Case Study
Patient Demographic: Initial Intake: Age: 48 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual
Mental Status Exam: The client appears to be his stated age and overweight for his height. He is dressed professionally and appropriately to the circumstances as he tells you he will see clients after your appointment. The client lays on the office couch with his hands behind his head and his feet on a cushion. He answers questions without pauses and often replies very casually with “sure” or “I don’t know,” demonstrating little insight into his thoughts, behaviors, and emotions. He estimates his mood as dissatisfied and unhappy though his affect suggests ambivalence. He presents with some complaints of forgetfulness but is oriented to time and place, and endorses no delusions or hallucinations. He acknowledges frequently feeling suspicious, especially when he’s feeling really stressed. He says he questions other people’s motives and what they are doing or saying when he’s not present. The client acknowledges using alcohol on weekends, and has used marijuana and cocaine regularly over the past ten years but admits it has increased over the last two years. He assures you he only drinks and uses drugs when not seeing clients. He has a prescription for pain medicine and states he uses it appropriately.
Presenting Problem: You are a counselor in a private practice setting.  Your client presents with complaints of not meeting his own expectations in his licensed, health care profession, and dealing with the business aspect of his work, difficulty meeting financial obligations, difficulty getting along with others, and problems with his ability to concentrate. He says his business partner used to be his best friend but now he can’t stand him because he sees the clients more often and leaves your client to do all the work. He tells you his concentration issues have always been present but have become progressively worse over the past eighteen months, as have his feelings of irritability, failure, fatigue, and lately he has pains in his chest and shoulder. He tells you that he thinks sometimes about what would happen if he died, but only as far as wondering how others would react. Later in the session, he says he is not suicidal and does not have a plan, but occasionally he just “gets tired of it all.” He tells you that sometimes he feels like “ending it” and has said that to women when the relationship isn’t going well and once or twice during breakups. He asserts that he has not actually tried to kill himself. He summarizes his relationships with others as “if they like me, they lose interest” and says that he finds himself “almost being manipulative” in how he chooses his words in his relationships with women and sometimes takes them on spontaneous “wildly expensive vacations” so they will not lose interest in him. The client tells you he has been in several relationships with women over the years, beginning with his high school sweetheart, then with his college sweetheart, but none of them have “worked out.” He states he was engaged to his college sweetheart at 24 for 6 months and then she married someone else. He tells you that another girlfriend was married and didn’t tell him, one “went crazy and threatened him with a gun,” and one broke up with him saying that he was “too needy” and “almost obsessive” in wanting to see her every day. He tells you that “all in all, I’m unhappy with how things are going and I need to make changes, but I just have no motivation to do it and I don’t know why I should have to.”
Other Contexts: Family History:
He states he is close to his sister who has never married but “always likes the deadbeat guys.” He tells you his father and mother never showed affection to him while growing up, were always bickering, and his mother was always obsessive about saving money and always complaining. He acknowledges loving his parents but sometimes getting so angry at them that he wishes he could just ignore them forever. He tells you both his maternal and paternal grandfathers were “mean as snakes,” while his paternal grandmother was a “saint.” He reports that one of his uncles committed suicide several years ago and that his cousin, whom he was very close to, committed suicide last year. He also says his best friend died five years ago due to a drug overdose.

Question: Which of the following actions will be most challenging when working with this client?
(A): Empathic responding
(B): Developing a safety plan
(C): Setting and maintaining strong boundaries
(D): Using active listening and attending skills

Correct Answer: Setting and maintaining strong boundaries
Explanation: Counselors who work with clients diagnosed with BPD are often challenged to set and maintain strong personal and professional boundaries with their client. The client's personality patterns include frantic efforts to avoid any imagined abandonment so changes in appointment times, not allowing the client to stay longer than their appointment time, or holding them to therapeutic discussion rather than casual conversation can appear as rejecting the client. Counselors working with this population are challenged to set, explain, and maintain their boundaries, often needing to repeat these to the client or set new boundaries as new circumstances occur with the client. Developing a safety plan for this client is important so that the client has a plan as well as allowing the counselor to maintain boundaries when not in the office or "on call". Empathic responding and active listening/attending skills are foundational counseling interventions that are used with all clients and should not be a challenge. Therefore, the correct answer is (B)
Competency: counseling skills and interventions