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: Based on the information provided, which of the following skills will be most appropriate for the counselor to teach during this session?
(A): Active listening and attending skills
(B): Conflict resolution
(C): Relaxation techniques
(D): Boundaries

Correct Answer: Boundaries
Explanation: The client has demonstrated that she uses rigid boundaries to control others, yet struggles and becomes angry when others attempt to control her. Explaining the concept of boundaries and how these can provide protection from others' overcontrol, while learning to recognize when the client is trying to control others is a skill which will assist her in each of the relationships she has brought into the counseling sessions thus far. Conflict resolution is an important skill which will be shared under the concept of boundaries. Currently, the client avoids conflict while giving in to her friends and feeling angry. Teaching conflict resolutions skills will help resolve this problem but will not help her learn to deal with controlling and being controlled. Active listening and attending skills will help the client as she communicates more effectively with others, but will not help her address her anger at being controlled or when she controls others and they do not submit. Relaxation techniques will be helpful for this client to reduce her anger and help her interact with more patience when irritated. This symptom-specific skill is important but will not address the root of her anger, which is caused by the feeling of being controlled or controlling others without their agreement. Therefore, the correct answer is (B)
Competency: intake, assessment, and diagnosis