Case Study
Patient Demographic: Initial Intake: Age: 20 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Community Mental Health Agency Type of Counseling: Individual
Mental Status Exam: The client presents appropriately dressed with evidence of positive self-care related to hygiene and appearance. Her mood is stated as anxious about being labeled as “crazy” though you note her affect appears to be angry.  Her movements and speech demonstrate no retardation; she is cooperative, engaged, and forthcoming. She reports past suicidal attempts using alcohol or pills when she was extremely angry at her boyfriend or her parents, but emphasizes she has no current suicidal ideations. She also states she has had past thoughts of hurting others but emphasizes she does not desire to or think about hurting others now.  Her short- and long-term memory appear to be intact, but demonstrates poor insight and judgement in choices.
Presenting Problem: You are a counselor in a community mental health agency.  The client presents for “an evaluation,” which she states is required by her parents before she is allowed to move back into their home. During the intake session, you learn that your client was married for 18 months and has been divorced for two years. The client states that her husband had an affair during their marriage, which led to the divorce. She states she has a daughter who is five years old and shares custody with her ex-husband, who is now remarried. She reports that she was living with her parents until recently and is now sleeping on a friend’s couch.  The client acknowledges that she has had several traffic incidents related to driving while intoxicated in the past few months. She reports she “totaled” her new car last week but was not arrested, likely because her companion had a felony warrant and the police arrested him at the scene and not her. It was at this time that she says her parents insisted she move out of the house and cannot return until she has sought counseling. She states she wants to “move on from my past,” she misses how things used to be, and wishes that her parents understood her better. The client reports that she drinks at least 20 alcoholic drinks per week and uses marijuana intermittently. She states she takes Adderall to help her clean the house quickly, uses cocaine, and has used Klonopin in the past, but stopped due to a “back experience.”  She states she does not have a problem with substance use but acknowledges it is a stressor in her relationship with her parents. She reports that using substances are the “only way to get to know people” and has found herself angry when attending parties where others were having fun but she was not drinking or high.
Other Contexts: Family History:
Client reports that she is the youngest of two children and that her family relationships were terrific until she turned 14 years old and then her parents “went crazy” when her grades in school declined and she was often grounded. She tells you that her parents didn’t like her after that and were always angry at her. On further discussion, the client says that she began dating a 19-year-old male when she was 14 but her parents decided he was too old for her and would not allow her to see him. She admits being furious at him for not taking her out after that and she called him daily to try to change his mind for over two months. She says she can’t stand him now and that he is currently in prison for aggravated assault on a police officer. She also tells you that at 15 years old, she began a long-term relationship with another man, who is now in prison for attempting to shoot someone. She states that he got involved with another girl and your client ended up getting arrested after she started a fight with the girl. Her third relationship was with her husband and with whom she became pregnant. At that time, her parents “kicked me out of the house and I couldn’t even come back inside to get my things.” They divorced two years ago after he called the police after “he said I attacked him when I found out he was cheating on me.”

Question: In working with this client to facilitate insight into her personality, emotions, and behaviors, which of the following would likely be the most helpful intervention?
(A): Values checklist
(B): Feeling wheel
(C): Empty chair exercises
(D): Family genogram

Correct Answer: Family genogram
Explanation: The main cause of BPD is childhood trauma and unhealthy family relationships. A family genogram, whether using CBT or DBT for treatment can help facilitate the client's understanding of historical patterns that have shaped her personality. This insight can be used to help the client identify negative core beliefs and skills that can be modified for improving distress tolerance and interpersonal relationships. Empty chair exercises are best used for clients who already possess insight and the ability to manage distress. Values checklists and feeling wheels are effective tools for helping clients identify the emotions they are feeling and the values that are most important to them. These are helpful in counseling but would not be as effective in facilitating insight as seeing familial patterns of interpersonal relationships. Therefore, the correct answer is (D)
Competency: counseling skills and interventions