Case Study
Patient Demographic: Name: Alex Clinical Issues: Hopelessness/depression Diagnostic Category: Depressive Disorders Provisional Diagnosis: F34.1 Persistent Depressive Disorder, Severe Age: 65 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: Multiracial Marital Status: Married Modality: Individual Therapy Location of Therapy : Private Practice  
Mental Status Exam: Appearance: The client is dressed in a manner that can be described as casual, suggesting that they might not have made any special effort to dress up for the session. Additionally, he is unshaven, which you note might indicate either personal preference, a decline in grooming habits, or possibly, decreased motivation and energy.    Behavior: The client's overall behavior is withdrawn.    Mood and Affect: His stated mood is depressed, implying feelings of sadness, hopelessness, or desolation. His affect, the observable manifestation of his feelings, is flat.    Speech: His speech is both slowed and measured.    Thought Process and Content: The client's thought process is tangential. He tends to veer off-topic and does not consistently answer questions directly or stay on point. The content of his thoughts is notably negative and self-defeating.    Perceptual Disturbances: No delusions or hallucinations have been reported, indicating that the client has no gross misinterpretations of reality or perceptual disturbances.    Orientation: The client is oriented to person, place, and time.    Insight: It appears that the client has poor insight into his condition.    Attitude: His attitude towards the evaluator is compliant and cooperative.
Presenting Problem: First session You are a licensed mental health therapist. Today you are seeing a 65-year-old male via distance counseling. You introduce yourself and ask him what prompted him to schedule an appointment to see you. He reports that he has felt "down in the dumps" for several years, and as he gets older, he feels more depressed and is in constant pain. As he is talking, he shifts around in his seat, appearing to have difficulty staying in a comfortable position. He continues by saying he feels depressed most of the time, has lost interest in activities that he once found enjoyable, feels hopeless, and is fatigued all the time. He also says he has lost his appetite and has difficulty sleeping. He states that "no one wants me around." Then he looks down and says, "I don't really blame them. I wouldn't want to be around me either." At work, he has difficulty concentrating and making decisions and is distressed that his co-workers see him negatively. When you ask him about his relationship with his wife, he says that while they live together, they have "not been close for a long time now." They both sleep in separate bedrooms and they lead separate lives. He explains, "We just kind of grew apart. We still love each other and would never get divorced, but now we're more like roommates. She's very social and involved in the community. I'm more of a homebody."    After the client has shared why he is seeking counseling, you state, "I can hear that you are feeling very discouraged. It sounds like you have been going through a difficult time for quite some time now and it's taking a toll on your life. Let's explore what might be contributing to these feelings and how we can work together to help find solutions or ways to cope with the challenges you're facing." You use a solution-focused brief therapy technique and ask him visualize what successful treatment would look like. He contemplates it for some moments and says, "I'd feel better, I guess." You encourage the client to think more deeply about what successful treatment would look like and explain how this visualization process can help him gain clarity on his desired outcomes. He says, "Hmm, I'm not really sure. Can you give me some examples? This is my first time in therapy and I'm not really sure what to expect." You provide some examples of tangible goals that he might set for himself, such as improving sleep patterns, having better communication with family members and co-workers, and finding meaningful activities to engage in. The client is able to identify some areas that could be improved and formulates realistic, achievable goals. Together, you create an action plan for successful treatment, which includes specific steps he can take to reduce symptoms and increase positive outcomes. You schedule a follow-up appointment to meet with him next week.
Other Contexts: The client reports that his relationships with family members were strained growing up, with his father often away for work and his mother struggling with her own mental health. He reports that his mother drank a lot, which the client defends saying, "I guess I'd drink a lot if I had 5 kids by the time I was 22 years old. The client grew up feeling unsupported and unimportant, which led to a disconnect from the rest of his family. Of his four siblings, the client keeps in touch with one brother, but "my other two brothers and sister live in different states and have different lives. I think they've struggled with depression, too. We don't talk much." Despite this difficulty in connecting, the client has an adult daughter whom he "loves very much and tries to stay in contact with. He wishes he could have done better for her during his parenting years, and despite their rocky past, has a deep desire to maintain a healthy relationship. He says, "I don't want her to think the same way I do about family and relationships. I want her to have good ones." The client is currently employed as a corrections officer and feels his job has no potential for advancement. He has been working there for 20 years and is ready to retire in less than a year. He expresses that it has been challenging and physically and mentally exhausting. In addition, he is tired of "dealing with both the inmates and the administration." He tells you his co-workers consider him a "slacker" because he is always tired and takes as many breaks as he can get away with. He is also worried about "word getting back to his co-workers" that he is in therapy. The client expresses that he has some drinks, especially after work, to calm down. He reports that he will drink in social settings as well. He states that his preferred drink of choice is whiskey.

Question: What would you discuss first with the client based on his concerns and presentation during the intake?
(A): Suicidal ideation
(B): Method of dealing with conflict
(C): Pain management options
(D): Substance use history

Correct Answer: Suicidal ideation
Explanation: When discussing the client's concerns and presentation during intake, it would be best to discuss suicidal ideation first. The client has been dealing with depression for a long time. Additionally, he expresses feelings of loneliness, disconnect from family members, difficulty in maintaining relationships with others, and a reliance on alcohol to manage his emotions. These factors can increase the risk of suicidal ideation or attempts, so it is important for the clinician to assess this issue with the client first. Therefore, the correct answer is (D)
Competency: intake, assessment, and diagnosis