Case Study
Patient Demographic: Client Age: 30 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Pacific Islander Relationship Status: Single Counseling Setting: Private practice counseling clinic Type of Counseling: Individual counseling Presenting Problem: The client and her boyfriend recently broke up, and she is “tired of being with the wrong guys.” She admits that she will often stay in relationships even if she knows they are wrong for her. Diagnosis: Provisional diagnosis: Dependent personality disorder (F60.7), personal history (past history) of spouse or partner violence, physical (Z69.11), and personal history (past history) of spouse or partner psychological abuse (Z91.411)
Mental Status Exam: Mental Status Exam: The client is oriented to person, place, time, and situation. No hallucinations, delusions, or paranoia are reported. The client was anxious at the start of the session, but she was able to calm herself down by easing into the counseling relation
Presenting Problem: You are a professional counselor working in a private practice clinic. The client comes in and sits quietly. The client appears nervous because she avoids eye contact and waits for you to initiate conversation. You ask why she is in counseling, and she responds that she is just tired. You ask more about this, and she says that she is not ready to talk about it yet. You decide to cover demographics and other less intimidating topics and then ask if she is comfortable talking yet. The client says that she feels a little more comfortable. She begins to state that she and her boyfriend broke up the previous week and that she was with him for 2 years. She explains that she has been “in this type of relationship before,” continually finds the “wrong guy,” and that she always goes “all in” with her relationships. Through processing, she identifies the following behaviors and beliefs: difficulty making daily decisions without the input of her partner, doing anything to gain support and affection even if she does not want to do the task or activity, quickly moving on to another relationship when a relationship ends, feeling that she cannot care for herself when she is not with someone else, and acknowledging that she needs others to take responsibility for major areas of her life. The client says that she has experienced physical and psychological abuse from partners, but that she is not ready to discuss this. The client identifies that her most important goal is to not end up in “the same relationship” again or rush into a relationship that is not right for her. Throughout the session, you provide empathetic and active listening. You suspect that the client has dependent personality disorder.
Other Contexts: You meet with the client, and she reports that she started dating someone. You and the client spend some time talking about the man who she is dating and agree that he sounds like a nice person that is not taking advantage of her personality. You and the client discuss her having an increased awareness of the behaviors that she has engaged in in the past that she did not like. The client identifies that she has engaged in behavior that worries her with this boyfriend. She went out for lunch and felt compelled to buy him lunch also, even though he was not there. After exploring why the client feels an obligation to buy her boyfriend lunch when he is not present with her, it becomes clear that it is motivated by the fear that he will be offended that she bought herself lunch without thinking of him. You support the client in identifying more helpful thoughts related to this and ask her to complete a behavioral experiment regarding this situation. The client becomes frustrated that she is still struggling with relationships and says, “I think I’ll just date who I want and how I want from here on out. It’s definitely the easiest choice instead of doing all of this.” You remind the client that therapy takes some time but can be really beneficial and you praise her for engaging fully so far

Question: Which of the following statements demonstrates the use of paradox in response to the client’s statement that she should just date who she wants?
(A): “Maybe you should date who you want and how you want, even though it can be frustrating for you. This process does seem like a really hard step for you.”
(B): “You can continue to date who and how you want to; that is your own choice.”
(C): “What if you decided to try things differently this time because you haven’t been happy in the past with dating.”
(D): “Only you can decide if you want to continue counseling; you can always take a break or wait until you’re ready to work on your relationships.”

Correct Answer: “Maybe you should date who you want and how you want, even though it can be frustrating for you. This process does seem like a really hard step for you.”
Explanation: Paradox is a counseling technique in which the counselor goes along with the client’s statement even if they do not agree with it to demonstrate a deeper empathy for the client’s underlying feelings. It must be used with care in the counseling relationship. The purpose of using paradox is to investigate the roots of the client’s motivation to continue a negative behavior. For instance, this client is frustrated that counseling is taking time and rather than focusing on the client’s statement of continuing negative behavior, you are empathizing with this feeling of frustration by agreeing with her statement as an expression of frustration. This statement can also support the client in identifying reasons to change her behavior. The client has the right to start or stop therapy if she wants, but you would want to support her in finding the motivation to participate. Encouraging the client to try new behavior that may have more positive results is a helpful technique, but it does not demonstrate the use of paradox. Therefore, the correct answer is (C)
Competency: counseling skills and interventions