Case Study
Patient Demographic: Client Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Community Mental Health Agency Type of Counseling: Individual Presenting Problem: Hallucinations and Delusions Diagnosis: Schizophrenia 295.90 (F20.9)
Mental Status Exam: Mental Status Exam: The client displays an angry affect, and his mood is irritable. His speech is disorganized and pressured. He is oriented to person, place, time, and situation. He reports audiovisual hallucinations, which include seeing “the shadow man” and hearing voices others cannot hear. The client exhibits tangential and disconnected thinking. He is firm in his conviction that he is being poisoned and says he is exhausted from constantly trying to maintain vigilance. The client’s insight and judgment are poor. He denies suicidal ideation, homicidal ideation, and command hallucinations. The client first experienced symptoms of schizophrenia in his late teens but was misdiagnosed with bipolar disorder until rece
Presenting Problem: You are a counselor working in an outpatient community mental health center serving clients with severe psychiatric disorders. A 26-year-old male, accompanied by his caseworker, presents for counseling due to symptoms of schizophrenia. The caseworker reports that the client was doing well until he stopped taking his prescription medication. He resides in assisted living, where he was placed after being discharged from the hospital last month. The client claims someone he calls “the shadow man” is following him and putting poison in his food. The caseworker reports that the client has been more agitated recently and has engaged in verbal altercations with other residents. The client is refusing to take his medication because of the side effects. He had an initial therapeutic response to Haldol, an antipsychotic, but stopped taking it because it made him restless and nervous. He explains, “I felt like I constantly had to keep moving.” The client is adamant about his desire to stay off medication and becomes angry when his caseworker mentions the possibility of going back into the hospital.
Other Contexts: The client began a new medication, which has helped with his delusional thinking. He continues to hear voices but reiterates that he does not hear command hallucinations. The client is able to focus on interpersonal relationships and has shown interest in obtaining part-time employment. He reports that he continues to benefit from group therapy. He has identified decreasing maladaptive thoughts and improving social skills as long-term treatment plan goals

Question: Which cognitive-behavioral technique (CBT) can be used to investigate alternative explanations for the client’s delusions?
(A): Scaling questions
(B): Symptom analysis
(C): Peripheral questioning
(D): Unified detachment

Correct Answer: Peripheral questioning
Explanation: Peripheral questioning is used to investigate alternative explanations for the client’s delusions (eg, “How do you know the shadow man is poisoning your food?. What methods would he use to do this?”). This technique focuses on the client’s specific symptoms to understand their origins and plausibility. Slowly, incremental reality testing is used to present hypotheses for alternative explanations. This technique helps reduce blame and enhances the therapeutic alliance. Scaling questions are associated with solution-focused brief therapy and are used to help clients track progress towards identified goals. For example, “Where are you on a 1-10 scale concerning the resolution of your problem?” Unified detachment is a technique used in integrative behavioral couple therapy (IBCT) involving communication in a detached and non-accusatory manner. Symptom analysis is a Jungian therapy technique used to help individuals achieve a state of individuation and self-realization. Therefore, the correct answer is (C)
Competency: counseling skills and interventions