Case Study
Patient Demographic: Initial Intake: Age: 40 Sex: Female Gender: Female Sexuality: Lesbian Ethnicity: African American Relationship Status: Partnered Counseling Setting: Community Agency Type of Counseling: Individual
Mental Status Exam: The client appears to be slightly older than stated and demonstrates positive signs of self-care in her hygiene and dress. She states her mood fluctuates between “sad and okay.” Her affect is labile and mirrors topics discussed in session. She smiles when describing her children and her relationship with her former oncology team. She cries easily when discussing cancer, moving, instability, and fears. The client is cooperative and forthcoming, with easily understood speech. She offers insight into her thoughts and behaviors, is attentive, and shows no difficulties with memory or judgement. She acknowledges one episode of suicidal ideation, without plan, during her adolescence when she desperately missed her mother while on a custodial visit with her father. She has had no thoughts of harming herself since then and has no thoughts of harming others.
Presenting Problem: You are a counselor in a community agency. Your client presents with concerns about her lifelong history of being “anxious and emotional” since her parent’s divorce when she was 12. She tells you her feelings of “anxiety and feeling badly about myself” intensified when she was diagnosed with breast cancer four years ago and then again when her family moved to the area last year. She tells you that she thinks she managed her emotions well during her treatment because her focus was on getting through the crisis. She also was taking Klonopin twice a day for anxiety.  She says she feels that she has let her family down by having cancer because it costs them monetarily and emotionally; she wonders sometimes if her cancer is a punishment for something she’s done. She reports that she does not discuss these concerns and emotional fears with her partner because “she has become the breadwinner and I feel like I need to protect her from my negativity.” On intake forms, she endorses crying daily, trouble sleeping, concentrating on things, has been losing weight without trying, and constantly worrying about her health and the family’s finances. She tells you that her partner says she “runs around like a chicken with my head cut off because I start stuff like cleaning or cooking and then stop right in the middle of it. I just get restless and sometimes I just can’t stop fidgeting when I should be paying attention.” She notes that she is in menopause due to her cancer treatments, which included a removal of her ovaries three years ago and a hysterectomy one year ago. She tells you people often refer to her as a “cancer survivor” but she doesn’t feel like she has survived it because every surgery makes her feel like she “is losing another piece of me.” Additionally, she says that having to have body scans every six months and not being able to look in the mirror and see a “complete woman” makes her feel that she is still trying to survive, rather than putting it in the past.
Other Contexts: Family History:
Your client reports a four-year history of treatment for breast cancer. She has had 16 months of chemotherapy and 27 rounds of radiation, as well as a double mastectomy three years ago. She has completed reconstructive surgery for her breasts but has not yet added nipple tattooing for a more realistic image. She reports that she has three close female relatives with breast cancer, but no relapses after treatment. She states that she has been in a relationship with her partner for 17 years and they share two children, ages 12 and 8. She describes her partner as a “good person” and the relationship as “good.” She tells you that they moved to the area one year ago when her partner had an unexpected promotion. She reports this has been good but that their oldest child is “anxious, emotional, and just angry sometimes.”

Question: Based on the information provided, which of the following is true about this client?
(A): This client's most accurate diagnosis is Body Dysmorphic Disorder
(B): Cognitive behavioral theory is likely to be helpful in addressing this client's concerns
(C): A cancer support group will likely be unhelpful for the client due to her sexuality
(D): This client's prognosis in this area is poor because cancer is a medical condition, not emotional

Correct Answer: Cognitive behavioral theory is likely to be helpful in addressing this client's concerns
Explanation: Negative self-esteem and body image are best addressed with cognitive behavioral theory and having the client identify cognitive distortions and negative core beliefs about herself and her post-cancer body. This process allows her to develop more positive core beliefs and view herself in a more healthy and loving way. The diagnosis of body dysmorphic disorder (BDD) does not apply to this client as her post-cancer scars and body changes would not be viewed as minor imperfections to others. Additionally, she does not engage in repetitive behaviors such as mirror checking, skin picking, or mental acts in response to her concerns. BDD is a disorder related to obsessive compulsive disorders and this is not evident in the client's behaviors. Cancer impacts people across all cultural spectrums and the client's sexuality is not likely to impact how a cancer support group could benefit her. The client's prognosis in the area of body image and self-esteem is quite good because she has been successful already in counseling and while cancer is a medical condition, the diagnosis leads to many emotional issues such as anger, sadness, worry, and loss. Therefore, the correct answer is (C)
Competency: counseling skills and interventions