Case Study
Patient Demographic: Name: Tony Clinical Issues: Feeling alone and disconnected from children Diagnostic Category: V-codes Provisional Diagnosis: Z60.0 Phase of Life Problem Age: 66 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Divorced Modality: Individual Therapy Location of Therapy : Private Practice  
Mental Status Exam: The client is well dressed and well-groomed. He appears healthy for his stated age. Speech flow is normal, and eye contact is appropriate. The client is cooperative with adequate rapport. His thought process is logical. He expresses feeling angry, "even though there is nothing to be angry about." You do not observe any physical evidence of anger. When asked to describe a time when he felt angry recently, he mentions a road rage incident. His affect is more sad than angry.
Presenting Problem: First session You are a licensed mental health professional working in a private practice setting. The client is a 66-year-old male who is returning to therapy with you. When he called to schedule the appointment, he asked if he could meet with you for dinner beforehand and offered to pay. He presents for his session today, reporting that he has been experiencing what he labels "anger," but he cannot figure out where these feelings are coming from. He says he often talks to himself and ruminates over problems to find solutions. He is seeking your help to improve his relationship with his children. He felt that working with you in the past was helpful, and now that his children are all adults and he is financially secure, he has the time and resources to spend with them.    The client has a history of difficulty in forming and maintaining meaningful relationships, particularly with his children. He has a history of conflict with them and has difficulty with communication and boundaries. He has had difficulty constructively expressing his feelings and has frequently resorted to outbursts of anger and aggression. He has had difficulty positively expressing his needs and has often felt overwhelmed and frustrated by his inability to be heard or understood.    The client also has difficulty with impulse control and self-regulation, contributing to his difficulty managing his anger. He has frequently engaged in self-destructive behaviors to manage these feelings and has had difficulty finding effective coping strategies to control his emotions. He has also reported a pattern of avoidance, in which he avoids or withdraws from difficult situations rather than confront them.    At the end of today's session, the client asks if he can go ahead and schedule therapy appointments with you every Tuesday for the next month so that he is "guaranteed" a spot. You can accommodate his request and plan to see him again in one week.  Fourth session The client has been seeing you every Tuesday and likes to schedule his weekly appointments a month in advance. Last week, you asked him to bring in a list of the triggers for his anger and the strategies he has tried in the past to manage it. You explained that this would help you create an individualized treatment plan with specific goals and objectives to work on throughout therapy. Furthermore, you suggested coming up with potential coping strategies to employ if/when he finds himself in a situation in which he feels the need to withdraw or avoid. You also stressed the importance of identifying and addressing any underlying issues contributing to this behavior.    Today, you spend the session exploring his anger and constant road rage, and you help him identify his feelings. He recognizes that the rage comes from a sense of being disrespected and feeling taken advantage of. As you continue that discussion, the client has a revelation. He recognizes that he also feels insignificant, unappreciated, and taken advantage of by his adult children. He wonders aloud if they like him. You focus on providing a positive therapeutic empathic response to meet his need to connect in relationships.  Seventh session The client was a "no show" for his session last week. You did not hear from him and ended up reaching out to him to reschedule. He arrives at this session on time and is eager to talk about a situation that occurred with his daughter. He had reached out to her to talk about repairing the relationship, and after some convincing, she had agreed. She came to pick him up to go for lunch, and while they were in a car together, he used a term that is now considered politically incorrect to refer to one of her friends. His daughter got upset with him and would not speak with him any further. He attempted to defend himself by saying that the term he used was not derogatory.    He presents this as "yet another example" of his children not liking him, and "never giving him a chance". He does not know how to move forward. He tells you that he "can't do anything right" and is a failure where his children are concerned. He mentions that this episode was especially frustrating, because he has so happy at arranging this meeting. You disclose your own frustration with one of your family members and explain that sometimes that person only seems interested in connecting with you when they need help. You also incorporate a strengths-based approach to build the client's resilience.

Question: What is the best way to address the client's "no show" to his previously scheduled session?
(A): Remind the client about your cancellation policy
(B): Submit an invoice to the client for the "no show"
(C): Engage the client concerning the deeper motivation behind his absence.
(D): Overlook the "no show" and move on to the next session

Correct Answer: Remind the client about your cancellation policy
Explanation: It is best to remind the client of your cancellation policy. It benefits the client more to have the appropriate consequence as motivation for modifying his actions. Also, you deserve to have clients who respect and value your time and who can maintain their commitments. Therefore, the correct answer is (C)
Competency: professional practice and ethics