Case Study
Patient Demographic: Name: Gordon Clinical Issues: Mood instability and substance use leading to occupational impairment Diagnostic Category: Bipolar and Related Disorders;Substance Use Disorders Provisional Diagnosis: F31.0 Bipolar I Disorder with Rapid Cycling; F10.20 Alcohol Use Disorder, Severe Age: 33 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Never married Modality: Individual Therapy Location of Therapy : Agency  
Mental Status Exam: The client appears to the intake session disheveled and displaying a strong presence of body odor. He is inconsistently cooperative within the session. His mood and affect are anxious and labile. His attention and concentration are impaired, and he is easily distracted in the session. He admits to his recent suicidal ideations and hospitalization but minimizes the impact stating, "Everyone overreacts these days." He mentions that when he was in his 20s, he was prescribed Lithium. He denies any homicidal ideations and displays no acts of delusion or hallucination. The client's ability to abstract and generalize is slightly lower than average. The client grapples with his impulse control regarding alcohol. He has insight into the level of the illness with which he is struggling but lacks judgment when making healthy choices.
Presenting Problem: First session You are a mental health therapist in an agency. The client, a 33-year-old former cab driver, comes to see you per his hospitalization discharge. The client's speech is characterized by an increased rate of speech, tangentially, and circumstantiality. He reports feeling overwhelmed and out of control, often losing his temper and having difficulty regulating his emotions. He reports a history of alcohol abuse, as well as self-medicating to cope with his emotional distress. He states that he has lost his job due to his difficulty controlling his emotions, and he is hopeful that therapy can help him regain his job. He also reports a history of legal trouble and has been incarcerated multiple times in the past. His legal record shows a history of violent offenses and domestic abuse.    After the initial interview, you review the paperwork from the client. You recognize his last name and realize he is a distant cousin by marriage, although this is your first time meeting him. You consider the ethical implications of continuing to see him for therapy along with the possibility of transferring him to one of your colleagues.  Third session After determining that you would be able to remain objective with the client, you met with him for a session and continued your assessment. You recommended seeing him once a week for therapy sessions and asked him to check in with you between sessions. You also provided him with a referral for a psychiatric evaluation to determine if medication was warranted for mood stabilization. Today is your third counseling session, and the client arrives 10 minutes late. The client's behavior during the session was increasingly concerning. He appeared disheveled, and his speech was slurred and jumbled, indicating that his level of intoxication was likely high. The client exhibited bizarre behaviors and laughed inappropriately, indicating a potential manic or hypomanic episode. His attention span during the session was limited, and he could not focus on the topics at hand.    When asked, the client admits to drinking before the session and is unable to provide an accurate account of how much he has consumed. He reports going to the local bar down the street from his house to have "one drink." He is also unable to provide any information on the location of his emergency contact. This lack of insight and awareness of his current intoxication, combined with the inappropriate behaviors he is exhibiting, prompts you to assess for the next level of intervention that is needed.  Seventh session The client's attendance in weekly therapy sessions has been inconsistent. Today, he presents to his scheduled session, and he hands you a discharge summary from another recent hospitalization. The client states that he was on one of his "highs," went to a bar, and ended up fighting with one of the other customers. He says he has no recollection of how the fight started, but the person he was fighting with told him that "his life was useless and that he would be better off dead." The client states that having a few drinks and driving around in his car while listening to music helps him calm down. You validate the client's attempts to identify coping skills.    The client's depression is further evidenced by his lack of motivation and interest in activities he once found enjoyable. He reports feeling overwhelming hopelessness and expresses a pervasive feeling of worthlessness. His low self-esteem is apparent in his statements and is further evidenced by his inability to recall accurately the events leading up to the altercation.    The client's risk for self-harm is elevated, given his recent suicidal ideation. He reports feeling his life has no value and that he would be better off dead. His current safety plan is inadequate to address his risk for self-harm and is further exacerbated by his use of alcohol as a coping mechanism. The client has little insight into his current mental state and cannot accurately identify the signs of his deteriorating mental health. He lacks insight into his coping skills and their potential consequences and is unable to recognize the need for more comprehensive safety planning
Other Contexts:  The client had a history of alcohol abuse and had been warned multiple times by his employer to stop drinking while on the job. The client's boss tried to counsel him, but he refused to accept help or advice. Instead, he continued driving while under the influence, and his reckless behavior eventually led to an accident. As a result, the client was dismissed from his job and has struggled ever since.    The client has been unsuccessful in finding other employment due to his record of drinking on the job. He has been trying to seek help with his drinking but without any success. He believes that therapy may be his last hope for getting his job back, and he is desperate to change his life. The client tells you, "I started drinking years ago. I've tried to quit, but I can't do it." He further states, "It used to be a couple of beers, but that doesn't do it for me anymore. So now, I drink almost half a bottle of whiskey a day. I usually start in the morning because if I don't, I feel terrible; my hands shake, I feel clammy, and I get an upset stomach. For years, I used just to let the mood pass, but in the last year or so, the alcohol has helped."

Question: What would be the most beneficial referral for the client?
(A): Readmission to inpatient with referral to the discharge plan case manager
(B): Readmission to inpatient with referral to an Outpatient Program
(C): Readmission to inpatient with referral to Residential Treatment Program
(D): Readmission to inpatient with referral to Partial Hospital Program

Correct Answer: Readmission to inpatient with referral to Residential Treatment Program
Explanation: The client continues to pose a threat to himself and others with his continued drinking and driving while intoxicated. Therefore, immediate placement in a residential treatment program would be most beneficial for his safety at this time. Therefore, the correct answer is (C)
Competency: intake, assessment, and diagnosis