Case Study
Patient Demographic: Name: Dawn Clinical Issues: Maladaptive eating behaviors Diagnostic Category: Feeding and Eating Disorders Provisional Diagnosis: F50.01 Anorexia Nervosa, Restricting type Age: 17 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Single Modality: Individual Therapy Location of Therapy : University Counseling Center  
Mental Status Exam: The client presents as a female in her late teens who appears malnourished and underweight, dressed in loose, concealing clothing. She exhibits poor eye contact and a guarded, closed-off posture with arms protectively crossed. Her affect is tense and anxious. Speech is logical and goal-directed, with no evidence of hallucinations or delusions. She denies any suicidal or homicidal ideation. Cognition is grossly intact for person, place, and time. Her insight and judgment appear limited, as evidenced by unresolved conflict with her parents and changing college majors without considering long-term career goals. She reports a strained relationship with authoritarian parents who were often physically and emotionally absent, leaving her feelings of neglect. She exhibits low self-confidence and an inability to trust her thoughts and desires. She continues to seek parental approval but feels unable to assert her needs. Her mood is anxious and frustrated due to perceived external control and lack of autonomy.
Presenting Problem: First session You are a mental health counselor in a university counseling center. Dawn, a 17-year-old college student, is referred to you by her physician. The client's parents recently visited during their parents' weekend at the university campus and were very concerned when they saw their daughter, who appeared severely underweight. They had not seen her for several months and immediately contacted the family physician for guidance. After performing a complete physical exam, the physician could not determine any medical causes for the client's low weight. The physician noted, however, that the client expressed that she did not understand her parents' concern about her weight. During the physician's examination interview, she reported feeling intense anxiety about gaining weight and implied that she was unhappy with her appearance.  Dawn reported feeling stressed and anxious about her schoolwork, friendships, and body image concerns. She explained that she often skips meals or severely restricts her food intake in an effort to maintain control. Dawn acknowledged that her eating habits have become more disordered over time and expressed openness to learning new coping strategies.  While Dawn initially resisted her parents' efforts to intervene, their concern made an impression. She agreed to continue counseling to address the underlying issues driving her unhealthy behaviors. Dawn wants to improve her well-being despite lingering uncertainties.  In today's initial counseling session, you focus on establishing trust and providing the client with a safe space to share her feelings without fear of judgment or reprisal. You begin by asking the client how she feels today and if there are any particular topics she would like to discuss. You also explore her feelings about her parents and brother and ask targeted questions to better understand the family dynamics and how they have impacted her self-esteem. You provide the client with psychoeducation regarding healthy eating habits, body image, and the consequences of not caring for oneself. Lastly, you discuss possible resources and referrals that may be helpful for the client during this time.  Dawn seemed receptive to discussing her feelings and experiences in a judgment-free environment. She sometimes became emotional when describing her struggles but appeared relieved to openly share things she had kept private. Dawn stated the counseling session felt like a positive first step.  After reviewing healthy coping tools and strategies, Dawn agreed to keep a daily food and feelings journal. She also committed to reaching out for support if feeling triggered or unable to care for herself. Dawn left the session with referrals for a nutritionist and an eating disorder support group.  Fourth session You and the client have met twice weekly for therapy sessions on Monday and Thursday afternoons. This is your fourth session, and you begin to explore the client’s support network. She reports having a difficult time making friends at college and says that she feels very lonely. She shares a dorm room with two other female students who have been best friends since elementary school. The client says she feels like an “outsider” and struggles to share a living space with these two roommates.  Dawn shared that she often spends time alone in her dorm room on weekends while her roommates go out together. She said this makes her feel even more isolated. Dawn explained that she has tried reaching out to her roommates to get to know them better, but they seem uninterested in including her in their plans.  Dawn mentioned that her older brother is the only person she feels close with right now. However, since he lives so far away, they rarely see each other in person. Dawn said she misses having her brother around to talk to and confide in.  One of her classmates invited her to have lunch on campus, but she was so anxious about eating in public that she declined the offer. Although she would like to have friends, she is worried that, eventually, she will end up in a social situation involving food; this idea creates intense anxiety for her. She believes that it is easier to avoid social situations altogether. The client begins to cry and says she often thinks about moving back home but does not feel like she belongs there anymore, especially since her parents repurposed her old bedroom. She continues crying and says, “I don’t have any friends at school, and I don’t even have a room at home. I feel like I don’t belong anywhere. I really miss my brother.”  Dawn tearfully explained that she feels caught between missing her previous life and feeling unable to adjust to her new environment at college. She is longing for connection but finds it challenging to put herself out there socially.  Crying, Dawn shared that she feels like she has no place where she truly belongs right now. She misses the security and familiarity of high school and being with her brother but also recognizes that things have changed there as well. Overall, Dawn conveyed profound feelings of loneliness and isolation.  Eighth session You continue to work with the client in outpatient therapy. During a previous session, the client identified a few sources of support and was able to tell her parents that she switched her major. Today, the client arrives for her appointment 20 minutes early. She appears eager to see you and excited to talk with you. When she sits down, she pulls several cookbooks out of her backpack. She tells you that she plans to go home during spring break and has collected recipes for a large meal she wants to make for her family. During this session, while exploring the client's relationship with food, you discover that she spends many hours in the library reading through cookbooks and watching baking shows on her computer. She says that she has an apple for breakfast, picks up a small salad "to go" from the campus cafeteria every day at exactly 12:00 p.m., and bakes a sweet potato for dinner in the microwave in her room at 6:00 p.m. She looks forward to her meals and plans her day around them. She says she is envious of other people who "can eat anything whenever they want." She tells you she is worried that if she eats extra food, she will become obese overnight and never stop eating.  You continue to explore the client's relationship with food by asking, "What do you think would happen if you ate whatever you wanted?" She replies, "I'm afraid that if I eat extra food, I'll gain weight and never be able to stop eating. I'll keep getting bigger and bigger and turn into a severely obese person." After taking a moment to think, the client shares, "I'm scared that if I gain weight, no one will love me or care about me. Then I'll be completely alone, and it will be all my fault because I couldn't control my eating!" You listen compassionately as the client shares her fear. You also emphasize that this is an extreme outcome and unlikely to occur. You encourage her to think realistically about the potential consequences of eating additional food and acknowledge that there may be some negative outcomes, but they are not guaranteed or irreversible.
Other Contexts: The client has a 25-year-old brother who is a Navy Seal. The client's parents have government jobs and frequently travel to foreign countries for work. When the client moved away to live on campus, her parents immediately turned her old bedroom into a home gym, which the client found unsettling. The client says that while she knows her parents love her, they have never been very affectionate or spent much time with her. When she was younger, the client traveled with her family for a few weeks during the summer but was often left alone during their trips. She describes her relationship with her parents as "strained" but states that she does have a positive relationship with her brother. She plans to see him when he is on leave from the Navy. The client is a freshman at the university and has already changed her major from pre-med to music history. She is anxious about telling her parents that she switched majors and is worried they will be disappointed. She reports that she has always felt a lot of pressure from her parents to excel in school as her brother did. Since she was a child, her parents have expressed their desire to see her become a physician. Her parents have always set high expectations for her academic performance. Their authoritarian parenting style has left her doubting her confidence in her own capabilities. She is frustrated by this dynamic because she does not feel like she can think for herself or pursue her own goals without outside approval. 

Question: In consideration of the client's mood swings, what would be the most effective way to continue to maintain a supportive, positive therapeutic alliance with this client?
(A): Allow the client to share her thoughts, feelings, and actions without critique
(B): Provide bibliotherapy to the client regarding the course and progression of eating disorders
(C): Guide the client to realizing how her anxiety regarding her parents is contributing to her unhealthy eating patterns
(D): Assist the client in identifying past and present sources of support, discussing the qualities of these relationships

Correct Answer: Allow the client to share her thoughts, feelings, and actions without critique
Explanation: Unconditional positive regard, developed by Carl Rogers, is one of the tenets of client-centered therapy wherein the therapist maintains an accepting and caring attitude toward the client. The therapist provides acceptance and support to the client, regardless of what is said or done. Therefore, the correct answer is (C)
Competency: counseling skills and interventions