Case Study
Patient Demographic: Initial Intake: Age: 48 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual
Mental Status Exam: The client appears to be his stated age and overweight for his height. He is dressed professionally and appropriately to the circumstances as he tells you he will see clients after your appointment. The client lays on the office couch with his hands behind his head and his feet on a cushion. He answers questions without pauses and often replies very casually with “sure” or “I don’t know,” demonstrating little insight into his thoughts, behaviors, and emotions. He estimates his mood as dissatisfied and unhappy though his affect suggests ambivalence. He presents with some complaints of forgetfulness but is oriented to time and place, and endorses no delusions or hallucinations. He acknowledges frequently feeling suspicious, especially when he’s feeling really stressed. He says he questions other people’s motives and what they are doing or saying when he’s not present. The client acknowledges using alcohol on weekends, and has used marijuana and cocaine regularly over the past ten years but admits it has increased over the last two years. He assures you he only drinks and uses drugs when not seeing clients. He has a prescription for pain medicine and states he uses it appropriately.
Presenting Problem: You are a counselor in a private practice setting.  Your client presents with complaints of not meeting his own expectations in his licensed, health care profession, and dealing with the business aspect of his work, difficulty meeting financial obligations, difficulty getting along with others, and problems with his ability to concentrate. He says his business partner used to be his best friend but now he can’t stand him because he sees the clients more often and leaves your client to do all the work. He tells you his concentration issues have always been present but have become progressively worse over the past eighteen months, as have his feelings of irritability, failure, fatigue, and lately he has pains in his chest and shoulder. He tells you that he thinks sometimes about what would happen if he died, but only as far as wondering how others would react. Later in the session, he says he is not suicidal and does not have a plan, but occasionally he just “gets tired of it all.” He tells you that sometimes he feels like “ending it” and has said that to women when the relationship isn’t going well and once or twice during breakups. He asserts that he has not actually tried to kill himself. He summarizes his relationships with others as “if they like me, they lose interest” and says that he finds himself “almost being manipulative” in how he chooses his words in his relationships with women and sometimes takes them on spontaneous “wildly expensive vacations” so they will not lose interest in him. The client tells you he has been in several relationships with women over the years, beginning with his high school sweetheart, then with his college sweetheart, but none of them have “worked out.” He states he was engaged to his college sweetheart at 24 for 6 months and then she married someone else. He tells you that another girlfriend was married and didn’t tell him, one “went crazy and threatened him with a gun,” and one broke up with him saying that he was “too needy” and “almost obsessive” in wanting to see her every day. He tells you that “all in all, I’m unhappy with how things are going and I need to make changes, but I just have no motivation to do it and I don’t know why I should have to.”
Other Contexts: Family History:
He states he is close to his sister who has never married but “always likes the deadbeat guys.” He tells you his father and mother never showed affection to him while growing up, were always bickering, and his mother was always obsessive about saving money and always complaining. He acknowledges loving his parents but sometimes getting so angry at them that he wishes he could just ignore them forever. He tells you both his maternal and paternal grandfathers were “mean as snakes,” while his paternal grandmother was a “saint.” He reports that one of his uncles committed suicide several years ago and that his cousin, whom he was very close to, committed suicide last year. He also says his best friend died five years ago due to a drug overdose.

Question: It would be most helpful to educate the client on which of the following topics?
(A): The differences between ambivalence and anxiousness
(B): The causes of Borderline Personality Disorder and the familial links
(C): The differences in manipulating others and making suicidal threats to prevent abandonment
(D): The research that shows Borderline Personality Disorder tends to decline with age

Correct Answer: The differences between ambivalence and anxiousness
Explanation: The client presents with ambivalent affect for a second time as well as a BPD diagnosis. BPD is a personality disorder that centers around the anxiety of being rejected and abandoned, which this client appears to have experienced often. Because the client shows little insight into himself and his thoughts, emotions, and behaviors, helping him to distinguish between when he doesn't care and when he doesn't actually care and when he feels too anxious to attempt caring, will help him better understanding his feelings. Teaching the client about the causes and familial links of BPD may influence him to focus on others and how he has been harmed, rather than on his own current problems. The fact that BPD tends to decline with age may be hopeful news but may also encourage ambivalence as the client is already unmotivated to make changes in himself. Finally, the BPD client may make suicidal threats to prevent abandonment, but the threats are also indicators of the pain the individual is experiencing. It will be helpful at some point to discuss his threats and manipulative behaviors, but this would not be a priority at the beginning of treatment and may make the client feel defensive. Therefore, the correct answer is (B)
Competency: counseling skills and interventions