Case Study
Patient Demographic: Name: Candy Clinical Issues: Anxiety and relationship distress Diagnostic Category: Personality Disorders Provisional Diagnosis: F60.03 Borderline Personality Disorder Age: 29 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Married Modality: Individual Therapy Location of Therapy : Private Practice  
Mental Status Exam: The client presented as a well-groomed female who appeared her stated age. She was appropriately dressed in casual attire. Her speech was marked by a slow rate and low volume overall, though, at times, her rate and loudness increased spontaneously. Her tone was muffled and difficult to hear clearly at times. The client's mood appeared depressed and confused. She displayed emotional lability during the evaluation, with shifts between expressing elation, fear, and distrust of this clinician and the treatment environment. Despite her affective instability, she was oriented to person, place, and time. Her attention and concentration waxed and waned throughout the session, with some difficulty tracking questions and sustaining focus on topics. She denied current homicidal ideation or intent. However, the client endorsed chronic passive suicidal ideation that intensifies during times of high personal stress. She also reported a remote history of hospitalization due to engaging in self-injurious cutting behaviors when feeling extremely distressed.
Presenting Problem: First session You are a clinical mental health counselor working in a private practice setting. The client, a 29-year-old female, presents to the intake session expressing that she has trouble controlling impulsive acts and is constantly worried. She speaks about her marriage, describing it as up and down. She looks down tearfully and says, "I keep hurting him. One day I love him, and the next day I can't look at him." She pauses and asks, "What if he leaves me? I can't deal with that." She further reveals that after she fights with her husband, she goes into their bedroom and cuts her thighs. At first, she feels relief, but this is followed by profound sadness and a feeling of worthlessness.    The client's lack of a stable parental figure resulted in her having difficulty forming healthy attachments with others. She feels isolated and disconnected from the world around her and has difficulty appropriately expressing her emotions. Her relationships are often strained, and she finds it difficult to trust others or herself. She has difficulty setting healthy boundaries and repeatedly emotionally abuses herself and others.    She reports feeling overwhelmed by her emotions and finds it difficult to regulate them. She states that she experiences intense guilt and shame following her impulsive acts and is often worried that her husband may leave her due to her behaviors. The client has struggled to control her emotions, which has been a source of significant distress in her life.    The client's self-destructive behavior has become increasingly frequent and intense. She has been unable to find a way to cope with her emotions and has resorted to self-harm as a way to manage her distress. She has become increasingly isolated and withdrawn, and her relationships have suffered as a result. She has become increasingly dependent on her husband, and her fear of abandonment has become a source of significant distress.  Third session You are in your office waiting for the client to arrive for her weekly session when suddenly you hear screaming. You run out into the hallway and see the client crying hysterically. After guiding her into your office, she lies on the couch, crying. She begins to punch the pillows on the sofa. You indicate you are here to listen when she is ready to talk. The client is in a heightened emotional state and says, "He. Left. Me." You maintain a calm demeanor and encourage the client to tell you what happened. She said she arrived home after work and noticed her husband's car was gone. He had left her a note indicating he was leaving and wanted a divorce.    The client expresses feelings of shock and betrayal as she discusses how she had been blindsided by her husband's sudden decision to end the marriage. She reports feeling overwhelmed by a range of emotions, including fear, anger, sadness, and confusion. The client expresses hopelessness and despair, believing her situation is beyond repair. She ruminates on the idea that her marriage is irrevocably broken and that her life will never be the same. She expresses feelings of helplessness and fear of the unknown, feeling overwhelmed by the magnitude of the situation. The client struggles to make sense of her husband's decision and appears overwhelmed by the potential consequences. She is particularly concerned about how her husband's decision will affect their children and their family's future. The client stares at you with a blank expression and states, "I might as well give up. There's no point anymore."    You further assess her current mental health state and determine that she is suffering from an acute stress reaction. You provide empathy and validation while creating a safe space for the client to process her thoughts and feelings. You encourage her to talk openly and honestly about her experience, allowing her to express her emotions without judgment.
Other Contexts: The client's father died when she was very young. She describes her mother as having a "difficult time raising me and my brother as a single mother." The client's mother worked three jobs and could not spend much time with her children. The client remembers having several babysitters as a child, but they never lasted long. Currently, the only relative the client speaks with is her mother. She lists her husband and mother as her emergency contacts on the intake form. The client reports feeling isolated and alone, especially since her father's death. Personal/Social Relationships: The client has a long history of attempting suicide. She has been in and out of emergency rooms nearly every week. She is persistently angry, needs attention and recognition, and has difficulty trusting others. She has had numerous affairs in an attempt to feel worthy. The client compensates for her guilt by buying her husband expensive gifts. She grapples with maintaining healthy relationships and controlling her rage and violent behaviors when she feels threatened. She has struggled to form meaningful relationships with her peers and has few friends. Although she does not lack socialization skills, the client finds it difficult to get close to people. Previous Counseling: The client is currently taking Paxil for her underlying depressive symptoms. She has expressed concern about her ability to manage her mental health with her current treatment. She worries that her erratic adherence to her medication regimen and lack of follow-up with her psychiatrist could lead to a termination of services. She has reported increased anxiety and stress as a result of this fear. She reports that her mood swings are more extreme, and she is having difficulty concentrating and staying focused. She reports that her friends and family have noticed her behavior change and expressed concern.  

Question: After assessing the client, you determine that her "feeling of giving up" does not require hospitalization or will lead to self mutilation. You do need to address her current emotive crisis. What feelings do you identify as the most significant to address in this session?
(A): Grief
(B): Shock and betrayal
(C): Sadness and anger
(D): Fear of the future

Correct Answer: Shock and betrayal
Explanation: It is important to address the feelings of betrayal and abandonment the client feels, as these will have a much more significant impact on the client's emotional state. Betrayal can devastate a person's emotional state, particularly when it comes to the dissolution of a marriage. The client in question has been dealt a heavy blow, as her husband has unexpectedly left her without warning. For the client, the betrayal of trust and feeling of abandonment can be overwhelming and deeply painful. The client already has trust issues and may find it difficult to trust anyone again or to see relationships in the same light as before. Therefore, the correct answer is (A)
Competency: counseling skills and interventions