Case 6

Part One

Age: 58
Sex: Male
Gender: Male
Sexuality: Heterosexual
Ethnicity: Caucasian
Relationship Status: Single
Counseling Setting: Community Clinic
Type of Counseling: Individual
Presenting Problem: Unemployment, depression
Diagnosis: Bipolar II Disorder, Inadequate Housing (V60.1 living in a trailer without electricity)

Presenting Problem: You are a clinical counselor in a community mental health clinic. A 58 year-old male comes in seeking services to reduce depressive symptoms. He expresses that he is newly unemployed and is having trouble with his worth and self-esteem. The client states that he spent the last three days in bed, and has periods of up to two weeks where he has a depressed mood and a lack of interest in activities that normally interest him. Currently he sleeps nearly all day, and explains that he simply does not have the energy to do anything. He has been unemployed for a month and has not filled out any job applications or started looking for openings. Client affirms that he has been struggling for several years and states, “I'll never get my life together”.

Mental Status Exam: The client comes to session disheveled with poor hygiene. His affect is flat with slowed speech. He denies current suicidal ideation, however he states that he had severe suicidal ideation about six months ago, but never acted on it. The client demonstrates lack of energy in session, as well as psychomotor retardation throughout the diagnostic interview. Client denies psychotic symptoms and denies having a history of psychosis.

Current Living Situation: The client moved to the area three years ago. A family member told the client that he could live in a trailer on their land for free, but he just had to pay for the electric company to run a line out to the trailer. The client states that he never had the money to do so, so he has been living without electricity for the past three years. He states that winter is a particularly difficult time for him as he has trouble sleeping in the sub-zero temperatures. He has been hospitalized numerous times for pneumonia. He states that the investment to hook the trailer up to electricity is too much for him to afford. The client lives alone and only sees the family member who owns his trailer occasionally.

Work History: The client was working at a grocery store where he had a good relationship with the manager, who was very understanding of client’s absences due to depression. One day, the client found himself restocking the cereal aisle when he had an amazing idea for a new cereal. He spent the next five days researching formulas and recipes for cereal and researching what kinds of machinery he would need to start production. He charged $1,000 on his credit card to buy baking supplies and kitchen tools. He states, “I swear I stayed up for several days straight getting together everything I needed to run a successful company. I didn’t feel like I needed to sleep. I was so invested in the whole thing that I just kept working on it every evening after work.” The client states that after a week or two, the “cereal passion” faded and his depressive symptoms returned.

Medical History: Client denies having ever been hospitalized for mental health reasons. The client states, however, that he has been hospitalized twice over the past six months due to pneumonia. He has lost a considerable amount of weight over the past month, but is unsure why.
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From a Rational Emotive Behavioral Therapy perspective, what would you say to build therapeutic alliance with this client?
1. “Thank-you for being willing to share. It sure sounds like you have been on a roller coaster. That must be very difficult.”
2. “When you say, 'I'll never get my life together', 'never' is such heavy and hopeless word. How can you be sure of that? I think that together, we can help you find a path forward.”
3. “I can hear that you have had your share of ups and downs. The key is in finding what builds on the ups. Let's explore that together.”
4. “When you say, 'I'll never get my life together', 'never' is such heavy and hopeless word. All life has meaning and hope. Let's find it together.”
Which symptom most affirms the client's Bipolar II diagnosis?
1. The client's history of severe suicidal ideation
2. The client's psychomotor retardation
3. The client's “Cereal passion” episode
4. The client's denial of psychotic symptoms
What is the most likely alternative diagnosis?
1. Major Depressive Disorder
2. Bipolar I Disorder
3. Phase of Life
4. Persistent Depressive Disorder
From a Reality Therapy perspective, what would you focus on to help this client?
1. Empowering the client to set and attain positive goals
2. Helping the client to transform their unrealistic thought patterns
3. Helping the client to identify and release the real trauma bonds that are tying them down
4. Empowering the client to embrace and move through their current struggles
From an Acceptance and Commitment Therapy perspective, how would you summarize the client's struggle?
1. I hear how you see yourself as being doomed to never get better. You have accepted those thoughts as being your truth. Until you commit to challenging those thoughts, you will stay stuck.
2. I hear how guilty you feel about all this. But feeling guilty is actually a form of avoidance. Until you commit to embracing your struggle and moving through it, you will stay stuck.
3. I hear how hopeless you feel. Hopelessness is a sickness. Until you commit to finding your own personal reasons for getting up each day, you will stay stuck.
4. I hear how stuck you feel. You are stuck in an unending loop of self-defeating behaviors. If you commit to changing those behaviors, you will certainly get unstuck.
Part Two

First session, 4 weeks after the initial intake:

This session was supposed to happen two weeks after the initial intake, but client did not show up for the session. This session the client apologized, stating that he did not remember he had an appointment due to being busy writing a novel. He states that he has since given up on the novel due to lack of energy. He commented, “When I started writing, I felt like I was onto the next great American classic. I wrote for four days straight, and then one day I woke up and couldn’t bring myself to touch my notebooks. Fail, fail, fail, that's all I ever do.” The client was visibly depressed in session as evidenced by lack of energy and tearfulness. You provide psychoeducation about his disorder and refer him to a social worker and case manager in your agency to get him in touch with the county housing authority.
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Which of the following symptoms would preclude a diagnosis of Bipolar II Disorder
1. If the client were to say that he was planning on killing himself
2. If the client continues to be unable to secure employment
3. If the client develops psychosis
4. If the client's depression resolves
From a Cognitive-Behavioral Therapy perspective, how would you respond to the client's statement of, “Fail, fail, fail, that's all I ever do”?
1. “Can you tell me what failure means to you?”
2. “Let's look at the ABCs, the activating event, beliefs, and consequences of your 'great American novel episode'.”
3. “Let's try something new. Tomorrow, I want you to see how little you can accomplish. Then write about how it felt.”
4. “Failure isn't real. Tell me one positive thing that came out of the 'novel episode'.
How would you respond to the client's statement of, “Fail, fail, fail, that's all I ever do” in a non-judgmental way?
1. “I feel your pain.”
2. “Everyone fails sometimes.”
3. “Who says that was a failure?”
4. “I can see how difficult that episode was for you.”
From a Solutions-Focused Brief Therapy perspective, what technique would be appropriate to address the client's depression?
1. Ask the client, “What would your life look like if you got free from these cycles?”
2. Ask the client, “If there were a purpose or meaning to life that could lift you out of this, what would that be?”
3. Help the client to make a list of past hurts that are holding him back.
4. Help the client to identify their wants and needs.
Part Three

Second session, 6 weeks after the initial intake:

The client comes to session very enthusiastic, discussing all of the people he has met through his social worker and case manager, and that he will be moving soon. He provides an update on his job situation which “looks promising.” He states that counseling has been helpful for him and he has been researching going to medical school to become a psychiatrist. So far he has filled out 3 applications for schools and has spent over $500 on the applications. He states that over the past three days he has spent almost eight hours a day at the library working on the applications. He states that he would have completed more applications, but he keeps making typos and every time he makes a typo, he has to start the application over, or else his 'application will surely be denied'. You make a timeline with the client charting his past projects as well as depressive experiences. He wonders out loud at the end of the session if all of these applications are another cereal company or novel experience. “I guess I’ll find out soon, but I have so many ideas!” he states on the way out of your office.
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Based on the new information from Part Three, what is the client's most likely comorbid diagnosis?
1. Histrionic Personality Disorder
2. Delusional Disorder
3. Obsessive Compulsive Disorder
4. Adjustment Disorder
From a Logotherapy perspective, what type of homework would be appropriate for addressing the client's depression?
1. Make a list of pleasurable activities and choose to do one each day
2. Give the client a workbook on understanding depression
3. Assign a mindfulness exercise
4. Have the client write a paragraph about what really matters to them
You ask the client to identify one of their irrational thoughts, plan an experiment to test it, and execute the experiment. After the experiment is complete, they will describe their experience, how they felt, and how their original thought has changed. This is called a _____?
1. Thought Experiment
2. Behavior activation
3. Behavioral experiment
4. Cognitive restructuring
The client's reasoning regarding the need to restart his applications after a typo is an example of ____
1. Disqualifying the Positive
2. Jumping to Conclusions
3. Emotional Reasoning
4. Catastrophizing