Case Study
Patient Demographic: Name: Denise Clinical Issues: Hopelessness/depression Diagnostic Category: Bipolar and Related Disorders Provisional Diagnosis: F34.0 Cyclothymic Disorder Age: 38 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Divorced Modality: Individual Therapy Location of Therapy : Private Practice  
Mental Status Exam: The client is appropriately dressed. She is overweight and appears edgy and irritable. Her attention wanders during the intake. She is articulate and able to communicate her thoughts logically. The client focuses on the negative aspects of life and appears to have a strong external locus of control. Insight is low, and judgment is strong.
Presenting Problem: First session You are a mental health counselor in a community agency. The client is a 38-year-old White female teacher referred to you by her principal. The client is experiencing difficulty with her school colleagues. She wants to keep her job and is motivated to improve her social skills. Since she was a young adult, she has had tumultuous relationships with co-workers, friends, and family. She tells you she has periods of highs and lows. During the high periods, she is overly talkative, impulsive, and insensitive to others. However, during the low periods, she withdraws from social contact, feels hopeless and helpless, and has trouble concentrating. She expresses a desire to be liked, but people see her as an "emotional roller coaster" and avoid her. She is very talkative throughout the session and changes the topic frequently. You raise your hand periodically to summarize what she is telling you.    Early on during the session, the client says, "Please help me. I know something is wrong, but I don't know what to do. Can you fix me?" You discuss the scope of your practice and explore options for treatment with her. You explain that one of your responsibilities as a therapist is to provide a safe space where she can express her thoughts and feelings without fear of judgement or criticism. You explain that through understanding and integrating different aspects of herself, she has the potential to develop healthier relationships both in and outside of work. You emphasize the importance of building self-awareness and developing effective coping skills as part of her journey towards healing. Ultimately, you focus on empowering the client by providing support, guidance, and skills that will enable her to make positive changes in herself so she can function more effectively in life moving forward.    You discuss the importance of the client taking an active role in her treatment process and explore methods she can use to become more mindful of her thoughts, feelings, and behavior. You suggest that this will help her gain better insight into the sources of her distress, which will enable her to take more control over how she copes with difficult situations in the future. The client appears relieved that there is something constructive she can do. You end the session by scheduling another appointment for next week and encourage the client to focus on self-care in between sessions. You also reassure her that you will be there as a supportive resource throughout the therapeutic journey ahead. The client leaves feeling empowered and energized to take the first steps towards change.  Fourth session During the previous two sessions, you spent the majority of the time listening to the client describing her conflicted relationships. You asked her to start keeping a mood diary, and while you review it together today, you notice that entries involving her father always precipitate a depressive mood. While you try to bring her attention to this trigger, she says, "I bet my dad enjoys watching this from the grave," and laughs. She tells you that she never felt like her father really loved her, and she believes that he blamed her for her mother's death. You demonstrate empathy and unconditional positive regard in response to her feelings. You begin to explore the client's thoughts about her father's suicide. Her demeanor changes, and she begins to talk about finding his body and the pain he must have gone through. She has "an epiphany" as she describes how she feels and realizes that he must have suffered a lot.    Following the client's disclosure, you take the time to normalize her feelings and process her experience. You acknowledge the immense amount of pain and suffering she has endured, both from her father's death, as well as his emotionally distant behavior during life. Through your therapeutic dialogue, you emphasize that it is natural for a person to feel overwhelmed and disconnected in such circumstances, and that these feelings are not a source of shame or weakness. You prompt her to think of new ways in which she can build healthier relationships with others, including developing more meaningful connections through open and honest communication. Finally, you ask her to brainstorm different activities and interests that she finds joy in doing so she can incorporate them into daily life as a way for her to find balance amidst the chaos.    At the end of the session, the client mentions that she is going to be visiting a friend who lives on the other side of the country. They are planning to explore one of the national parks for a few days and spend the remainder of the time "just chilling" at her friend's house. She tells you that she is looking forward to spending some time in nature. The client does not want to miss her weekly appointment with you and asks if you can meet with her for a virtual session next week instead of your usual in-person counseling session.  Sixth session The client has not been following through with her mood journal. She says that she "got bored and didn't feel like writing in it anymore." During this session, a month and a half into therapy, she relays an incident that happened with the friend she went to visit out-of-state. They argued due to political differences and are currently not talking to each other. The client now considers her friend "a drunk who doesn't know what she's talking about." You suggest that the client's anger and judgment may be a defense that she uses to avoid feeling rejected as she did with her father. You state, "It seems that in an attempt to avoid feeling hurt and rejected, you use anger and alcohol to push people away." The client responds with reflective silence and begins to tear up.    You guide the client to examine her defensive behavior and understand why she relies on it when faced with difficult emotions. You emphasize that her feelings of hurt, rejection, and anger are valid, however, they can be managed in healthier ways. You suggest that part of processing these feelings is to recognize them and make attempts at reconnecting with her friend. Additionally, you recommend cultivating self-care practices. The client acknowledges the importance of looking after herself during this difficult time, understanding that if she is able to take care of herself first she will be in a better position to address her relationships.    You remind the client that it is important to take steps to move forward, even if those steps are small. You highlight her willingness to talk through her emotions and gain insight into her reactions as an opportunity to grow in self-awareness. You explain that having knowledge of one’s own feelings helps them to make better decisions and boundaries, which can lead to healthier relationships with others and ultimately, more peace within oneself. With this understanding, you create a plan of action together for how she will move forward between now and your next session. You close the session by telling the client that she has made progress today by having gained insight into her feelings, and that will lead to exploration of how to respond to them more productively. You conclude by encouraging her to keep exploring new methods of self-care and to bring up any additional topics she wants to discuss in the next session.
Other Contexts: The client's mother was diagnosed with Bipolar I Disorder. The client's mother passed away ten years ago in a car accident. The client reported constant criticism from her father when she was growing up. When the client's mother was not depressed, she acted as a buffer between the client and her father. The client reports getting married immediately after graduating high school to an abusive man who was similar to her father in many ways. The couple divorced two years ago after the client wound up in the emergency room after reporting that she "slipped on the last step of the staircase and fell into a door jam." She got full custody of their son and went to live with her father until he passed away a year ago from suicide. He was chronically ill with cancer. The client is currently a science teacher. For the past three years, every school she has worked at has declined to renew her contract. The client's father left his house and all of his financial assets to her, so she does not have to make a mortgage payment. She has savings, but she is burning through it quickly. Previous Counseling: The client sought grief counseling at the time of her mother's death. She felt the therapist was "not spiritual enough" to deal with the client's beliefs. The client knew she needed help, and her pastor recommended a group. She attended four group sessions before leaving the group due to interpersonal conflicts with some of the group members. She tells you that she is not interested in participating in any group therapy. 

Question: Which defense mechanism is the client demonstrating in her interaction with her friend?
(A): Sublimation
(B): Reaction formation
(C): Intellectualization
(D): Projection

Correct Answer: Projection
Explanation: Projection is an unconscious defense mechanism stemming from the ego. An individual takes an unacceptable part of him or herself, such as feelings, thoughts, tendencies, or fears, and then disowns it by placing it on someone else. That is what is being demonstrated in the client's interaction with her friend. Therefore, the correct answer is (D)
Competency: intake, assessment, and diagnosis