Case Study: Bob

Bob is a 42-year-old Caucasian male who presented for assessment and treatment for nervousness, anxiety, frustration, irritability, anger outbursts, and insomnia. Bob was somewhat disheveled in the initial assessment.

Bob married his wife at the age of 19. They divorced after 4 years because he had an affair. He has been married to his current wife, Anna, for 16 years and they have two children, James 14, and Teresa 12. The children are active in school extracurricular activities and both make better than average grades. James was diagnosed with ADHD and takes medication for that. Bob and Anna have recently had conflicts in their marriage and argue frequently.

Bob's mother and father are alive at the ages of 62 and 66, respectively, and he is the second of three children from his family of origin. Bob gets along well with his mother, older brother, and younger sister, but has a distant relationship with his father. His mother and father divorced when he was 10 and he lived with his mother until he graduated from high school. He later found out his father had affairs while married to his mother. He briefly attended collage where he met his first wife but dropped out to go to work so they could marry. He and Anna met several years later through a mutual friend, dated for about six months and married.

He reported no remarkable family history of psychiatric difficulties, alcohol or substance abuse, but said his cousin twice attempted suicide. He did not know much about his father's family. Bob reported no inpatient or outpatient mental health admissions or treatment with the exception of the two visits to a counselor.

He was diagnosed with Generalized Anxiety Disorder by a counselor. He saw the counselor twice but did not return for additional psychotherapy. He was prescribed Xanax 1 mg as needed, with a monthly quantity of 30, for anxiety by his PCP. He reported no other current medical conditions.

In the first assessment, he was given the Beck Anxiety Inventory and scored 21, placing him in the moderate anxiety category. He did not report any other symptoms at that time and said he was confused as to why his physician said he would not prescribe a higher dosage of Xanax. He addressed his anxiety and irritability in session and was educated on mindfulness techniques, controlled breathing, and guided imagery to help reduce his anxiety and irritability. He was educated and encouraged to use the components of the anger wheel of choice to initiate anger management cognitive awareness.

He returned for therapy one week later, reported he had implemented the interventions with only slightly noticeable improvement. He was re-educated on the techniques and encouraged to continue with them. He reported no anger outbursts but said his wife had "been nagging me to come here." During that session he was quiet and reserved with a low energy level. He was prompted several times for session continuity but reported no new problems or difficulties during the session. He was encouraged to continue implementing the interventions and given additional education and material on anger management techniques.

In the third session he was accompanied by his wife who came because she wanted to ensure complete communication. She reported domestic disharmony, said they have arguments frequently and have recently talked of divorce. His wife said he becomes angry and isolates himself after they argue. She also reported he cries often and tells her he cannot "stand the pressure at work." They seldom have sex and, when they do, he frequently is unable to engage satisfactorily. She reported suspicions of infidelity in the first few years of their marriage but there had been no specific evidence other than her suspicions based on his behavior of being gone without explanation at times. He stopped that behavior years ago and she reported no current suspicions of infidelity.

The client said little as his wife talked and he became more withdrawn. He volunteered little information in that session but said he will work with his wife to improve their marriage when she suggested that. She reported Bob's mother struggled with depression when he was young and his cousin attempted suicide twice. She also said his mood changes, oftentimes abruptly, moving from anxiousness and irritability to withdrawal from the family and isolation accompanied by crying spells. The client made no comment to her assertions.

When asked, he did not want to talk about his use of anxiety interventions and anger awareness communication and said he preferred to wait until the next session. Bob did not address his goal of reducing his anger and anxiety until his wife left the room. Bob then talked of his wife "nagging me to be happier and do more things around the house." He reported anger outbursts and said he has difficulty remaining pleasant to her. He commented on the stresses at his job and said people there "do not understand me." He reported instances of conflicts with others at his job but no major anger outbursts. He sometimes goes into the restroom to cry while at work.

• What ethical considerations should be included in the discussion with the client about medications? Describe the advisability of consultation with the original prescribing physician, topics for discussion and communication points. Describe concerns to be taken into consideration when speaking with the prescribing doctor about medications and related disease states. Describe how you will integrate the information presented by his wife, Anna. Include additional therapy topics to be addressed in the next session, possible assessment instruments to use, diagnoses to consider, and potential medication changes.