Case Study
Patient Demographic: Initial Intake: Age: 54 Gender: Male Sexual Orientation: Heterosexual Ethnicity: African American Relationship Status: Divorced, In a relationship Counseling Setting: Private Practice Type of Counseling: Individual
Mental Status Exam: John presents as well-groomed with good hygiene and is dressed professionally. Motor movements are slightly fidgety, indicating nervousness or moderate anxiety. Eye contact is intermittent. Denies suicidal or homicidal ideation, no evidence of hallucinations or delusions. John tightens his fists when elaborating on situational issues between him and his ex-wife, with the same controlled expression and tense disposition when sharing about his girlfriend. John mentioned that his girlfriend is also unreasonable for complaining about how often John comes home smelling of alcohol, saying that meeting people for drinks is part of his job. He added the comment “I need to drink to deal with her attitude all the time.”
Presenting Problem: Diagnosis: Adjustment disorder with mixed disturbance of emotions and conduct (F43.25), provisional
 

John calls your practice asking to speak to a counselor to help him with his relationship. John tells you he’s never been to a counselor before and does not want anyone to know that he is seeing one, mentioning he will pay for sessions privately using cash. John admits to struggling with anger, specifically with his ex-wife of 15 years whom he divorced three years ago. John asks for availability in the evening hours and demonstrates hesitancy and reluctance to commit to more than a handful of sessions. In the initial assessment session, you notice he has difficulty making eye contact and is uncomfortable talking about his situation. After some rapport building, he begins to share that he is only seeing you because his girlfriend Sherry told him she would break up with him if he did not get his “anger issues under control.” John denied physically hitting Sherry, but alluded to several interactions that he stated, “got so heated I lost it on her, and she wouldn’t stop crying.” John complained of women he gets involved with being overly controlling of him and that he doesn’t understand why they are so “needy.” John works a demanding job in the sports marketing industry where he takes frequent trips out of state and spends long nights out, entertaining clients. He wishes he had the freedom to “do what he has to do” without “being treated like a child” by his romantic partners.
Other Contexts: Family History:
John tells you he has two children, a 34-year-old son he had with a one-night stand in college and an 18-year-old daughter with his ex-wife the first year they were married. He has a decent relationship with his son and provides him and his family occasional financial support, visiting with his grandchild over social media video once a month. He reports once being close with his daughter but that their relationship became strained as she got older and that now they hardly speak, saying “she took her mother’s side during the divorce, so she doesn’t want anything to do with me right now.” While conducting further interviewing about John’s family health you learn that John’s father passed away at 56 after several heart attacks and his mother died of heart failure and diabetes complications at 49. John has no other living relatives besides an uncle in another state and his cousins who live near him. He tells you growing up he used to go to church with his mother every Sunday until she got sick and has not been to church since.
 
Work History:
John has a master’s degree in Business Marketing and made his connections with his current position through contacts he made while playing on collegiate basketball teams. John has always worked busy jobs with which he becomes heavily engaged in and puts in overtime hours. John prefers work that keeps him on the road and traveling often, as he does not like to engage in the same routine every day. He mentions when he was younger, he could not keep a 9-5 office job or at any place that did not encourage individuality, saying he “butted heads” with all his managers and bosses until he was older.
 
Legal History:
John has had two arrests made for domestic disturbances in his home that his wife called in after heated arguments that left his wife afraid for her life. He was always able to make bail and was never tried or sentenced as charges were usually dropped thereafter. John admits to one drinking and driving accident when he was 19 where he served community service and fines as punishment.

Question: John appears to be responding to Cognitive Behavioral Therapy approaches. What is the best CBT-based intervention of the choices below for inclusion into John's treatment plan?
(A): Selecting an effective medication proven to reduce anxiety and anger-related conditions
(B): Processing his negative automatic thoughts in the form of a Thought Record
(C): Learning and practicing meditation and deep breathing
(D): Trauma-focused CBT treatment in which his daughter participates

Correct Answer: Processing his negative automatic thoughts in the form of a Thought Record
Explanation: Medication selection does not belong underneath the scope of CBT-based interventions but can be considered and concurrently followed up with by a psychiatric provider. Meditation and deep breathing are practices incorporated within Mindfulness-Based Cognitive Therapy (MBCT). Mindfulness can alter one's attitude towards one's thoughts so that their feelings and behaviors are affected less intensely or frequently, however CBT is focused on restructuring cognitive distortions and reframing beliefs towards more adaptive perspectives. TF-CBT is a family-focused treatment that does not seem to be appropriate without John having any form of relationship with his daughter or communication with her mother; although his daughter is of legal age to participate without parental consent. It is reasonable to select c) as the best option during this phase of John's treatment to assist him with identifying triggering events, understanding his feelings, and to become capable of differentiating between healthy and irrational patterns of thinking. Therefore, the correct answer is (C)
Competency: treatment planning