Case Study
Patient Demographic: Name: Deb Clinical Issues: Worry and anxiety Diagnostic Category: Other Mental Disorders and Additional Codes Provisional Diagnosis: 300.9 Unspecified Mental Disorder Age: 40 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Divorced Modality: Individual Therapy Location of Therapy : Private Practice  
Mental Status Exam: The general appearance is of a 40-year-old female of average height and obese weight. Her hygiene is within normal limits. The client seems a bit nervous when you begin your initial interview. She says, "It's 'wine Wednesday' right? I wish I had a glass of wine right now to steady my nerves. A couple of glasses would really help right about now." The client is alert and oriented x4, cooperating fully with the exam. Motor activity is within normal limits. Speech is within normal limits for rate, articulation, verbosity, and coherence. There are no signs of impairment in attention, concentration, or memory. There are some signs during the exam of deficits in impulse control.
Presenting Problem: First session You are a mental health therapist in a private practice setting. The client, a 40-year-old female, arrives for the intake and discloses concerns about her physical health. She has felt that the "doctors are missing something" for years. She "feels sick all the time" but cannot describe specific symptoms other than general fatigue. The client reports feeling incredibly frustrated by the "lack of care" she receives. She was provided with a referral to contact you and is asking for your help in determining what steps she should take to ensure her health and safety. You notice that the client is becoming tearful as she describes her situation.    You complete a biopsychosocial assessment and explore various aspects of the client's life and history, including her family dynamics, current living situation, lifestyle habits, and any stressors in her environment. The client indicates that she has a supportive family and has been open with them about her concerns regarding her health. She is also actively working to improve her diet and exercise, but has found this process to be challenging due to lack of motivation. Although she does not have any diagnosable mental illnesses, the client reports feeling anxious and overwhelmed lately, particularly when it comes to work. The client discloses feeling overwhelmed by her new role as charge nurse and is worried that she might not be able to manage all of her responsibilities effectively. She also expresses concern over how her weight may affect her ability to be successful in her career.  Fifth session The client missed last week's appointment and rescheduled to see you today. Before she sits down in the chair, she hands you a file with her medical records and blood work. She explains that she made copies for you to review. You discuss how she has felt since meeting with you. She uses various clinical terminology when describing her feelings and reports "battling anhedonia." It is difficult for her to enjoy going anywhere as she is constantly worried that she will contract a disease. She states that her anxiety has caused her to make some mistakes at work which she is very upset about. You notice that the client is wringing her hands together and biting her lips.    You state to the client, "It sounds like you're really struggling with your anxiety. I noticed that you were talking about some of the mistakes you feel like you make at work because of your anxiety. Can you tell me more about that?" The client replies, "Yeah, it's so embarrassing and frustrating. Whenever I go out, and especially when I'm at work, I feel like everyone is judging me for my weight. It's like they think I'm not good enough because of it. I start to question myself and mess something up." You ask the client, "Have people actually said anything to you about your weight?" She responds, "No, but I can tell they're thinking it." As the therapist, you are able to observe how the client's cognitive biases may be contributing to her distress. You acknowledge her emotions, while also highlighting that she is facing challenges associated with being in a demanding role at work. You utilize cognitive-behavioral strategies with an emphasis on mindfulness practices to help her manage her feelings. You also discuss possible coping mechanisms that could help her manage the stress of her job. At the end of the session, you summarize what you have worked on and schedule her next appointment.  Tenth session It's been two and a half months since you first started seeing the client for weekly therapy sessions. Today, your client appears calm and relaxed. You review her progress and highlight her areas of growth since the start of therapy. The client states that she feels more empowered to challenge her negative thoughts and is able to recognize when her anxiety is beginning to spiral. She has been using the coping skills she learned in the previous sessions to manage her stress levels more effectively. The client also reports a weight loss of 5 pounds since beginning therapy, which she is pleased with and attributes to the mindfulness techniques she has been practicing. You discuss her weight loss and the importance of mindful eating practices. You explain to the client that weight loss is a secondary outcome of therapy and that it is more important to focus on living a healthy lifestyle than a number on a scale. The client expresses her understanding and appreciation for the guidance.    When you ask her to rate her level of anxiety, she indicates that she is much less anxious than when she first started therapy. Her preoccupation with illness has decreased, though it has not gone away completely. She reports that her colleagues have noticed the change in her attitude and confidence. She is able to stay present and focus on her job, without constantly worrying about negative judgement from her co-workers. She tells you that she has been keeping up with the journaling homework that you assigned in a previous session and it has been a helpful outlet for her to express her thoughts. She has also been practicing progressive muscle relaxation during her breaks at work and after she gets home in the evenings. The client is still drinking wine to help her relax, but you have determined that her alcohol use does not warrant clinical intervention. You discuss spacing out your sessions and she agrees to try meeting with you twice a month. At the end of the session, she asks if you could email her a copy of her therapy records so that she can refer back to them periodically in order to continue making progress.
Other Contexts: The client has a strong support network. She says that she is especially close with her mother, aunt, and two older sisters. The client goes on to explain that growing up she was close with her sisters, but because they were so far apart in age, they did not always get along. She remembers feeling like the black sheep amongst her older sisters since she was the youngest and had different interests from them. Her father was often away for work, which meant that her mother was the primary caretaker. Despite this, she speaks fondly of her parents and credits them for providing a stable home life.    She indicates that her father was recently admitted to a nursing home for dementia. The client reflects on how her father's illness has been hard to process. She remembers when he began to forget familiar places and people, as well as not being able to recognize himself in the mirror. His illness has been difficult for the family to accept, but they are working on a schedule to make sure that a family member sees him every day. The client has been working in the healthcare profession for over 15 years, and she currently works as a nurse at a local hospital. She discloses that she recently received a promotion to a "charge nurse." She has mixed feelings about the promotion. She states that she loves nursing, but sometimes worries about how she is perceived by her colleagues due to her weight. She fears being seen as lazy and unmotivated because of her appearance, which she believes is not in line with the expectations of a charge nurse. Overall, she experiences low self-esteem and difficulty feeling confident in her professional role due to her weight. She is also concerned that her co-workers may find out that she is seeing a therapist and will think less of her. Pre-existing Conditions: The client states that she is 75 pounds overweight according to her physician. She has been preoccupied with having an illness for several years and has seen multiple medical specialists. She is concerned that she has cancer or a heart condition "because those issues run in my family." There is no medical evidence to support any of her concerns, and during her last annual check-up, her primary care physician made a referral for her to see you. 

Question: How would you best demonstrate active listening skills in this session?
(A): "From what you have told me and what I've observed in our sessions, you've made some significant progress in therapy. How would you feel about spacing out our sessions?"
(B): "It sounds like you're doing really well. You must be proud of yourself for all of your hard work!"
(C): "That's great that you've lost weight. I know it's been a struggle for you, and I'm glad the mindfulness exercises have been so helpful."
(D): "I'm glad to hear that your anxiety has decreased and that you've been able to stay present at work. You sound relieved that you can focus on your job without worrying about judgement from others."

Correct Answer: "I'm glad to hear that your anxiety has decreased and that you've been able to stay present at work. You sound relieved that you can focus on your job without worrying about judgement from others."
Explanation: Active listening is an important part of any therapeutic session. It involves showing empathy, understanding and respect for the client by actively attending to their verbal and non-verbal communication. When using active listening, the therapist paraphrases what the client has said, mirrors their emotions and shows non-judgmental interest in their experience. Therefore, the correct answer is (C)
Competency: counseling skills and interventions