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 of the following rational-emotive behavioral therapy (REBT) techniques is used to help identify the salient aspects of the client’s delusional belief system?
(A): Normalizing
(B): Emotion-based reasoning
(C): Inference chaining
(D): Linking

Correct Answer: Inference chaining
Explanation: Inference chaining is an REBT technique used to explore personal meanings associated with delusions. Inference chaining is used in rational-emotive therapy and is particularly effective for individuals experiencing delusions. The technique is used at the beginning of treatment to understand the underlying belief used to sustain the delusion. Linking is then used to gradually test reality by introducing other plausible explanations, with the overarching goal of decreasing distress created by the delusion. Normalizing is an effective cognitive-behavioral technique used to help process hallucinations. The stress-vulnerability model is used to normalize experiences associated with the onset of hallucinations and co-occurring stressors. Emotion-based reasoning was used by Aaron Beck, credited for developing cognitive-behavioral therapy. Emotional-based reasoning describes the maladaptive process in which delusions are categorized and involves believing that one’s emotional experiences dictate reality. Therefore, the correct answer is (A)
Competency: counseling skills and interventions