Case Study
Patient Demographic:  Initial Intake: Age: 65 Gender: Male Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Inpatient detox facility Type of Counseling: Individual
Mental Status Exam: William presents as irritable and quite anxious with congruent strained affect. William is casually dressed and with good hygiene. William’s rate and tone of speech are normal with motor movements appearing tense and agitated as evidenced by shifting of position and frequent crossing of arms. William avoids eye contact the entire visit. William denies any depression however his chart indicates that he reported having a history of depression with suicidal thoughts. He says, “Only God can judge me, and I know where I’m goin’ so I don’t have any worries about whether I go now or later.” You then notice in his intake he identified as Christian with active faith-based beliefs. He repeats several times that he plans to leave as soon as he meets with the doctor later today and receives “medical clearance” saying “I can’t stay the whole three weeks it’s just not possible, not going to happen.”
Presenting Problem: Alcoholism and late-stage medical complications with depression and anxiety
Diagnosis: Alcohol dependence (F10.20), Major depressive disorder, single episode, unspecified (F32.9)
 

You are a mental health counseling intern providing brief crisis intervention and counseling support for patients admitted to a substance use rehabilitation facility at the detox-level of care. Your clinical director schedules William to meet with you on his first Monday morning after being admitted the Friday night before for alcohol dependency. William tells you he had a “medical issue” last week that “freaked his wife out” and she said she would “kick him out of the house” if he did not come to your program. He notes that he has been drinking their entire marriage and does not understand why it is suddenly such an issue for her, but that he would have “nowhere to go” otherwise so he conceded to coming in. You learn from the overnight staff nurse that William had several bouts of delirium and vomiting with tremors over the weekend, and one instance of a seizure which required emergency interventions to have him stabilized. You ask what “medical issue” he was referring to and she tells you that his chart indicates he had a heart attack. William interjects, saying “She thought I had a stroke, but it wasn’t that big a deal I just had some bad indigestion.” He is now on a benzodiazepine regimen to help regulate his symptoms and stabilize his mood throughout his detox process until he can report a reduction in anxiety and be seen by the weekday psychiatrist.
Other Contexts: Work History:
William has worked has a construction company manager for almost 30 years until just before reaching retirement he was let go due to COVID-related company downsizing. He attempted to file a legal case against his company for wrongful actions that would in William’s words “rob him of his hard-earned retirement” however they cited his daily alcohol use on the job as an additional reason he was fired. He was informed due to his longevity with the company that they would offer him a generous severance package and not pursue administrative actions against him for breaking company policies. He adds that he was not planning on stopping working when retiring from his company, saying “I’m too young to just stop. I was going to start my own business.” He also retorts that no one calls him William but his wife and insists that you call him “Bob.”

Question: What information would be most helpful to collect that would support Bob's continued stay in rehab?
(A): protective factors
(B): mental health history
(C): education history
(D): wife's willingness to take him back

Correct Answer: protective factors
Explanation: Learning what protective factors Bob has for recovery will be crucial to helping support his continued rehabilitation. Finding close family members, children who might be willing to help him, friends who can reinforce his need for care, defining his spiritual beliefs, or even peer groups or activities he is involved with that can be an asset to understanding Bob and what he values would support your counseling of Bob. Learning his mental health and education history is important but does not necessarily help in maintaining Bob's attendance in rehab, and his wife's willingness to take him back if he leaves rehab early might even motivate him to leave. Therefore, the correct answer is (B)
Competency: intake, assessment, and diagnosis