Case Study
Patient Demographic: Initial Intake: Age: 68 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: African-American Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual
Mental Status Exam: The client appears older than his stated age, with weight appropriate for height. He demonstrates positive signs of self-care in his hygiene and dress. He appears to be open and cooperative, with some hesitancy noted in his speech pattern, due to age or possible alcohol use. The client endorsed several positive responses to alcohol dependence but states he has not used alcohol prior to this session. He states he does not take any medication. He identifies his mood as ambivalent and his affect is congruent with little lability. His responses to questions demonstrate appropriate insight, judgement, memory, concentration, and orientation. He does state that he has never considered harming himself, but acknowledges passive ideas such as, “what’s the point,” he would be “better off dead,” or he should “drink a lot of wine and go to sleep.” He acknowledges these as previously unrecognized suicidal ideations and states he does not have a wish or plan to follow through or harm himself.
Presenting Problem: You are a counselor in a private practice setting.  Your client is a 68-year old male who presents with difficulties stemming from his role as a caregiver to his wife of 26 years and who now has Parkinson’s disease and requires his full attention. He tells you that he has been providing care for the past 40 years, first for his parents and now for his wife.  The client endorses feelings of sadness, anger, guilt, irritability, and being overwhelmed. He states that he has difficulty concentrating, anxious, losing things, and having unwanted thoughts like that he might be better off dead. He tells you also that he has difficulty sleeping and can’t enjoy any hobbies or social activities because of caring for his spouse. The client states that he distracted himself from his negative feelings last year by preparing for the move to their new home and then getting settled in. The client and his wife moved into an assisted living facility, but live in independent housing. The client endorsed a history of alcohol use that includes drinking more than he intends, feeling the need to cut down, being preoccupied with drinking, and using alcohol to relieve emotional pain. He states he drinks one to two bottles of wine daily and has done so for the past 6 years. He acknowledges that he has not admitted the extent of his alcohol use to others and works diligently to hide it. He reports he is unwilling to attend AA or other alcohol support groups, but “lurks” on an online support group for alcoholics. The client tells you that he attended counseling twice: 15 years ago, related to depression about his wife’s diagnosis and 10 years ago related to depression and anxiety related to caregiving. On both occasions, he was prescribed antidepressants but said he refused to fill the prescriptions because he doesn’t like to take medicine.
Other Contexts: Family History:
The client describes his family history as containing a significant number of family members who use alcohol in great quantities and multiple, maternal, close relatives diagnosed with schizophrenia. Client states that two of his aunts have male children with schizophrenia and that one of these aunts has been diagnosed with Bipolar I disorder. The client’s father was diagnosed with Parkinson’s disease and was in an assisted living facility prior to his death while the client’s mother remained in their family home. The client was the main caregiver for both of his parents until their deaths. The client reports two siblings, one with an alcohol and drug use history who is a paraplegic following a motorcycle accident and one who identifies as “gay” with a history of alcohol dependence and hospitalizations for “nerves.”

Question: Which of the following will help the client identify barriers to attaining his goals?
(A): Processing the importance of antidepressants instead of a depressant like alcohol
(B): Processing how difficult it is to stop using the amount of alcohol he drinks
(C): Processing his ability to meet his wife's needs as her health continues to decline
(D): Processing the unconscious benefits the client gets from his depression

Correct Answer: Processing the unconscious benefits the client gets from his depression
Explanation: Secondary gains are the conscious or unconscious benefits that individuals get from their current way of responding to life. In this case, the client may continue to use ineffective coping skills because it is comfortable and familiar to him rather than experiencing the discomfort of change. Secondary gains include the interpersonal or social advantages that an individual may consciously or unconsciously experience because of their own illness or, in this case, the client's role as caregiver for his parents and now his wife. Identifying secondary gains is critical to determining if a client is willing to give these up to meet their stated goals. The difficulty the client will have in stopping his alcohol use may be a barrier for the client, not because of the amount he drinks, but because he uses it as a coping strategy. He has previously demonstrated the ability to stop drinking when he chooses and has noted the improvement in his thoughts and emotions. Processing the importance of antidepressants is not helpful for the client as he has previously stated his refusal to use antidepressants. Focusing on his ability to meet his wife's needs as her health declines is most likely to cause the client greater stress and increase his depressive symptoms, which will create a barrier to meeting his goals, rather than identifying the current barriers. Therefore, the correct answer is (C)
Competency: counseling skills and interventions