Case Study
Patient Demographic: Initial Intake: Age: 31 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Widowed Counseling Setting: Private Practice Type of Counseling: Individual
Mental Status Exam: The client appears her stated age, dressed appropriately for the circumstances. Her mood is identified as sad and frustrated and her affect is restricted and flat. Her primary emotion in the session is anger, though it is expressed in a tempered manner. She demonstrates limited insight, and appropriate judgment, memory, and orientation. She reports having considered suicide when she was in high school but made no attempt and would now never consider harming herself or anyone else.
Presenting Problem: You are a counselor in a private practice setting.  Your client is a 31 year-old female who reports that she is very impatient and feels angry all the time, and is taking it out on her children and others with angry outbursts. She says that her children are good but they don’t pick up when she tells them to and often, they put their toys away in the wrong places. The client states that her husband died while the family was on a vacation. She tells you that they had stopped for a break and her husband was hit by a car.  She says that it happened in front of her and the children, who are now 6 and 7 years old. She endorses feeling angry, restless, and having trouble making decisions. She tells you that she is having trouble falling asleep, is anxious and overwhelmed. The client tells you that her husband was a good man and “very much my opposite.” She has high expectations for neatness and being on time, he was often messy and ran late. She tells you that sometimes she felt like the whole activity they were doing was “ruined” because he made them late or the kids didn’t follow the rules. She states that she was the “controller” in their relationship, which worked well for both of them, except when she got angry with him for not doing what she wanted, when she wanted, or how she wanted it. She acknowledges that she was often angry and frustrated with his casual way of going through life but now regrets it because he’s gone. She states that her goals for counseling are to be more patient and decrease her anger.
Other Contexts: Family History:
The client reports a significant family history with her mother diagnosed with schizophrenia, with catatonia and was not medicated. She describes her mother as a “zombie” who loved her children but never told them because she was “absent.” The client describes her father as verbally abusive and involved with drugs and alcohol, often yelling, screaming, and throwing things. She states he often told the client that any mistakes she made were the reason that their life was so bad. She has no siblings but her husband has two sisters, with whom the client does not engage. She states one of his sisters is living with her boyfriend and the other asked to borrow money from her and her husband, which made the client angry. She identifies her support system as her church and a group of couples whom she and her husband were friends with prior to his death, most of whom attended the client and her husband’s high school and college. The client says she tends to be drawn to overly controlling people and her church, though fundamentalist and legalistic, became like family to her in high school.  She tells you that the couple’s closest friends are her husband’s best friend, whom the client dated in high school, and his wife. She says that while dating, her then boyfriend was very attentive, “almost smothering,” but also very demanding by leaving her notes with things or work he wanted her to do for him. She states they dated for several years and then she met and married his best friend, who was her husband. She tells you that their best friend’s wife is her best friend, although “she irritates me all the time, and I don’t really like her that much.” She says her friend has a strong personality, is controlling, and wants to make all the decisions and plans in their relationship.

Question: Which of the following interventions would be the most effective in helping the client with her anxiety about the holidays?
(A): Have the client invite her friend to a counseling session for better communication.
(B): Teach the client a grounding technique for when her anger overwhelms her.
(C): Provide the client with a book on setting boundaries.
(D): Role play conversations between the client, her in-laws, and her friend.

Correct Answer: Role play conversations between the client, her in-laws, and her friend.
Explanation: Roleplay provides an opportunity for the client to observe the counselor communicating in a way that models the ideas that the client wishes to communicate to others. By playing the role of the in-laws and friend, the client can listen to new ways of responding to those individuals so that she can feel comfortable imitating the counselor in actual conversations. Providing the client with a book on boundaries can be very helpful, if the client follows through with the reading. Clients do not always complete homework, so assigning a book to read may not provide the outcome that the counselor had hoped. Having the client invite her friend to a session may or may not be effective. While it can provide an opportunity for the client to feel safe confronting her friend, her friend may feel uncomfortable and a rupture in the relationship may occur. Teaching the client a grounding technique when her anger overwhelms her is a good intervention to use when the client's emotions are out of control. In most situations, it is best to help clients be proactive in working on their issues rather than concentrating on reactive remedies. Therefore, the correct answer is (C)
Competency: counseling skills and interventions