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: What would be the best technique to use with Bob as you continue this discussion of him leaving?
(A): confrontation
(B): empathic validation
(C): motivational interviewing
(D): reality therapy

Correct Answer: motivational interviewing
Explanation: The best technique to use with clients who disagree with course of treatment or in this case decide to leave a clinical program against medical advice (AMA) is motivational interviewing through conversation. This strategy employs a person-centered perspective that attempts to move an individual away from a specific negative behavior or maladaptive decision and towards using their own motivations to make positive changes. Using nonjudgmental, empathic questioning, you are more likely to uncover Bob's underlying motivations and help him develop a better safety plan. Validating Bob's feelings empathically as with answer a) is always appropriate; however, Bob is hyper-focused on making an unhealthy choice and is not currently sharing his feelings. Furthermore, validating Bob's stated choices can be confusing and render ineffective any attempts at getting him to stay in treatment. Reality therapy is also a client-centered form of CBT that focuses on improving present relationships and circumstances, but its intention is to avoid discussion of past events which is not ideal in the situation of trying to help Bob build insight into how past events have led him to where he is now. While its key concepts focus on choice, responsibility, and commitment to change, it is an exploration of processing what behaviors a client is displaying and whether it is interfering with them meeting their needs. It is an excellent choice of strategies for longer-term therapeutic techniques once Bob has decided to commit to the counseling program but will meet too many challenges if Bob is resistant and unwilling to engage. Confrontation is the preferred method by operational staff in many treatment facilities as it is usually conducted with appropriate clinical intentions by peers who can help a client in distress feel supported; but it is not an evidence-based method that a mental health counselor would choose in an individual session and especially not with a senior adult presenting as defensive. Confronting a client in this situation when they are within their legal right to leave a voluntary treatment program may result in the client making an even riskier departure which might further cause harm. Therefore, the correct answer is (C)
Competency: counseling skills and interventions