As I hear the material many questions come to mind. Most of which I would keep to myself until I learned more about him. I notice that he tells you that he found you from a directory rather than from a referral through someone he trusts. I don't have enough information yet to be able to determine what to make of it but it alerts me to several possibilities. For one I would wonder about his self esteem - it might be hard for him to take himself and his problems seriously enough to ask for help getting to a good doctor. He might have issues of shame which would make it hard to ask another for help. It could be because the therapy process is very new to him and he was unfamiliar with having any option other than using a directory. It is also presented in such a way that he could be inviting the therapist to feel unimportant, insulted and put down as you were only chosen due to your proximity to his all important work. If this was the case I would consider it an early test of the therapist's ability to comfortably handle aggressive and assertive statements from the patient. I would be on the look out for collaborative material. The material that follows make me feel that this will in fact be a crucial issue for this patient. This would orient me to watch for a pull to feel attacked or humiliated. I will be looking to see if this is a central issue for him. I notice his anger at not being seen and heard by his girlfriend and will look to see if this is a reoccurring theme for him. I wonder about how comfortable he is talking with her about his concerns as he describes a hostile discussion. I would ask him about how they talk about meeting each others needs. We learn that he is very upset at the event with his girlfriend and the man. "stewing" to such a point that he is having an anxiety reaction and can't perform sexually. His description of the event is very explicit. You discribe him as very uncomfortable with the language, Why? I wonder what that is related to. It is a strikingly way to describe the material. I would wonder how he thinks I will react to the sexual nature of the material. He is clearly concerned about the power of his anger and his potential to harm others as he almost did in the past. I would ask him about the previous incident with his ex-wife. Questions I would I have for him include learning more about the itching - has it ever occurred before, was it related to feeling rageful ? Was the impotency also reoccurring? Had he ruled out any medical or drug problem? I would want to learn what was interfering with his sexuality. I would wonder if he was afraid of hurting his girlfriend or acting out his anger with the rude man. At this point in the interview I would ask him what he thought was keeping him awake and making him so anxious. I would want details about his fears and anxieties. I would try to learn about his family and how anger and aggression were dealt with. There is a desperate feel to this man. I would try to slow him down and try to get to know him.