Case Study
Patient Demographic:  Initial Intake: Age: 37 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/non-Hispanic Relationship Status: Married Counseling Setting: Mental health counseling agency Type of Counseling: Individual telemedicine
Mental Status Exam: Leah is casually dressed, presenting with anxious mood and affect. Speech is of fast rate but with normal tone. Breathing is shallow from speaking fast, you note she stops to take deep breaths before continuing. Leah denies SI/HI, reports many protective factors, and admits that nothing in her life is “really that wrong.” Leah demonstrates good insight and judgment into the nature of her concerns.
Presenting Problem: Diagnosis: Generalized Anxiety Disorder (F41.1), Adjustment disorder with mixed anxiety and depressed mood (F43.23)
 

Leah is referred to your counseling agency by the U.S. Department of Veterans Affairs (VA) mental health program due to their inability to accommodate her because of their high caseloads. Leah is a 37-year-old married woman with a 2-year-old child and is a disabled combat veteran who served 8 years in active-duty Air Force service. Both you and Leah work full-time as mental health counseling interns in your respective practices. Leah struggles to manage her own anxiety which causes both interpersonal and professional problems for her. Leah reports experiencing trauma related to deployments, past divorce, death of a pet and birth trauma with her daughter. Leah tells you she needs someone to process everything with regularly as she does not want to exhaust members of her family with her stress. Leah’s biggest problem, she shares, is that she knows how to resolve her negative thoughts that lead her to act impulsively but cannot apply her skills when she feels overwhelmed.
Other Contexts:  
Education and Work History:
Prior to military life Leah worked several different jobs since the age of 13. Leah joined the Air Force at age 21, worked overseas as well as in the states, and had several deployments including one year in Kabul, Afghanistan as a Staff Sergeant during her fifth year of service. Leah obtained her bachelor’s degree right after separation, and then returned to Afghanistan as a contractor. Following this experience, she completed her master’s degree in counseling. She admits she is “skeptical” working with someone who has the same amount of experience as herself.
 
Family History:
Leah grew up with two younger siblings, and her parents divorced when she was 11. Due to joint custody, her and her siblings moved back and forth weekly every Friday until she originally left home for college at 18. Both of Leah’s parents remarried; her father having three more children with her stepmother, and Leah inheriting a stepsister when her mother married her stepfather. Leah was also previously married to an Army Sergeant while active duty, but her husband had an affair and left her prior to her military separation.

Question: Which of the following strategies is derived from a strengths-based approach?
(A): "Tell me about the last time you successfully got through a similar situation."
(B): "Explain what makes you think you will not get through this."
(C): "List the qualities you believe you will need to get through this."
(D): "Share with me how can I help you can get through this."

Correct Answer: "Tell me about the last time you successfully got through a similar situation."
Explanation: Strength-based interview questions or exhortations should be aimed at helping Leah consider what she has done that has worked in her past, based on her existing strengths, to give her the confidence that she can be successful again. Answer a) asks Leah to review a time she has come out of a similar difficult situation, review the things she did that helped, and consider herself to be someone who can conquer challenges. Asking her to list qualities she thinks will help her get through this is a good first step, but you would need to follow through with helping her reflect on the fact she already has those qualities. This could backfire in Leah not being able or willing to identify if she has what she believes it takes to get through her current problem. Explaining why she does not think she will resolve her issues can be part of a cognitive behavioral based approach at discovering her cognitive distortions and helping her reframe them and asking her how you can help is causing her to be dependent on you for her needs. Therefore, the correct answer is (A)
Competency: counseling skills and interventions