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: 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: You must assign Bob a category for the group therapy schedule. Which is the most appropriate?
(A): seniors 65 and up because he would benefit from a same-age peer group
(B): working professionals because he strongly identifies with his occupation
(C): adults 18-65 so he can view a wide range of perspectives
(D): faith-based 12-step track due to his identified spirituality

Correct Answer: faith-based 12-step track due to his identified spirituality
Explanation: In this case, a faith-based 12-step track would be the most appropriate to address his addiction due to Bob's spiritual belief that "only God can judge him". This group would focus on faith-based interventions helping Bob view his addiction through the perspective of originating from his Higher Power. The Big Book in Alcoholics Anonymous teaches that if you admit to being powerless over your addiction, then you need a higher power that is greater than you or your addiction to help you get clean. This attitude would be supportive of Bob's mental state as he seems to be rejecting clinical evidence of his need for recovery. Answer a) would likely trigger Bob since he was just relieved of his occupation and these groups focus around how to balance substance use recovery and an active professional career. A group where Bob would be the oldest adult as in answer b) might also not be helpful based on his presentation and attitude of disinterest in rehabilitation, which could be negatively influential on the others in the group. Answer c) would put Bob in a category where he would be the youngest in a group of seniors, which might deter him considering he presents as in denial over retiring in disgrace and reported feeling "too young to stop working". Therefore, the correct answer is (D)
Competency: treatment planning