Case Study
Patient Demographic: Name: Ella Clinical Issues: Seeking help after experiencing a trauma Diagnostic Category: Trauma and Stressor Related Disorders Provisional Diagnosis: F43.0 Acute Stress Disorder Age: 35 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Married Modality: Individual Therapy Location of Therapy : Private Practice  
Mental Status Exam: The client is a 35-year-old white female with a slender build. She is wearing jeans and a t-shirt and appears to be clean and well groomed. Her posture is slumped, her facial expression is flat, her eyes are downcast, and she has been displaying signs of crying. She speaks softly in a monotone voice. The client appears depressed and anxious, with tearfulness and trembling. She seems overwhelmed by her current situation and is unable to control her emotions. She reports difficulty concentrating on day-to-day activities. Her thoughts are logical and organized with tangential moments. She reports feeling as if she is living in a dream-like state since the trauma occurred. She experiences frequent nightmares about people she loves being killed. She is able to recall her personal history accurately. She is able to understand and follow your instructions and questions. She recognizes that she needs help. She denies suicidal ideation or intent.
Presenting Problem: First session You are a mental health counselor working in a private practice setting while under supervision. The client is a 35-year-old white female who presents for therapy following a trauma. When you ask the client why she made an appointment to see you, she begins to cry and shake uncontrollably. She tells you that her friend was shot two weeks ago and the client saw it happen. Her friend is in the intensive care unit at the hospital. She cannot consciously recall the actual shooting. Since the assault, she cannot concentrate and feels anxious all the time. She does not want to talk to her friends, and she has been withdrawing from her family. The client tearfully tells you that "life has no meaning." She is seeking your help to find some relief.    You validate the client's emotions and begin processing her subjective experience. You help her to understand that witnessing such a traumatic event can lead to the physical and emotional symptoms that she is experiencing. She appears receptive to what you are saying and nods her head. You emphasize that she has taken a courageous step by seeking professional help. As you continue with the initial session, you focus on providing an empathetic space where she can explore her feelings without fear of being judged. You provide her with information about resources she can access for further help. You also discuss the principles of cognitive-behavioral therapy as a method to begin to process her traumatic experience. Before the session ends, you present relaxation exercises that she can practice at home in order to reduce distress and tell her that learning healthy coping skills will be an important part of her recovery.    Following the session with your client, your supervisor tells you that she has worked extensively with the client’s parents in the past and offers to give you their files so that you can understand more of the client's family history.  Second session After meeting with the client for the initial session, you thought it would be beneficial to meet with her again in a few days. She scheduled an appointment to meet with you via telehealth three days after her initial visit. You begin today's session by discussing potential avenues of treatment. The client reports not sleeping well because of vivid nightmares. She excessively worries about losing her parents but does not want to concern them. Since the assault, she has withdrawn from her family. She reports becoming angry when they suggest that she go for a walk outside to "get some fresh air". She now believes they do not care that she feels unsafe. The client denies suicidal ideation but sometimes feels she would be better off not waking up in the morning. During the first 10 minutes of the session, the client's two pet dogs continually draw her attention away from the session. You notice the distraction and acknowledge it. You ask the client if she would like to take a break and play with her dogs for a few minutes. The client agrees and takes a few minutes to interact with her animals. When she is finished, she escorts the dogs out into the hallway and returns to her room, closing the door behind her.    You sit with the client and share a compassionate space together, allowing her to share her vulnerable feelings. You notice that, as you talk, her two pet dogs are still being disruptive, barking in the hallway, and distracting her from the conversation. You bring her attention back to the session by reiterating your understanding of how she has been feeling since the assault. You then explain that these feelings may be compounded by the disruption caused by her pets during their sessions. You offer suggestions on ways to create a better environment for therapy such as having another family member manage the pets while they work together, or setting up a comfortable area in another room where she can work with you away from distractions. The client is appreciative of your suggestion and agrees to put some of these ideas into practice for their next session. From here, you move onto discussing potential treatment options for her recovery. You explain the benefits of cognitive behavioral therapy and how it can help her in managing her feelings more effectively. Additionally, you share relaxation techniques with the client to help reduce her physical symptoms of distress. Finally, you work collaboratively with your client on developing coping skills and increasing self-care practices in an effort to improve her overall well-being. You end the session feeling that progress has been made, both in terms of providing an understanding environment and suggesting ways to further address the trauma she experienced.
Other Contexts: The client's family has a long history of living in the Bronx, New York, as her great-great-grandparents immigrated from Italy. She currently lives with her parents in a house that has been in her family for generations. Her entire life she has always felt safe and secure living in her Italian neighborhood. The client has one older brother who is married and works as a paramedic. She is close to her parents and describes them as supportive, hardworking, and loving. Her father was diagnosed with cancer several years ago and she has tried to be there for him in every way possible. Stressors & Trauma: The client witnessed her friend being shot during a robbery. Since then, she cannot stop thinking about the event. As a result, she has insomnia and frequent nightmares about people she loves being killed. She is unable to stop shaking and crying when discussing the nightmares. In addition, the event has left the client feeling angry, confused, ashamed, depressed, and highly anxious in her day-to-day activities.  

Question: Which of the following is most impacted by the client's pets' drawing her attention away from the therapy session?
(A): The rapport between the client and therapist is impacted.
(B): The client’s mood is affected.
(C): The therapeutic process is impacted.
(D): The client's ability to commit to therapy is impacted.

Correct Answer: The therapeutic process is impacted.
Explanation: The therapeutic process is impacted when the client's pets draw her attention away from the therapy session. The setting is the most challenging part to control in online therapy and can hinder progress with the client. Therefore, the correct answer is (B)
Competency: counseling skills and interventions