Case Study
Patient Demographic: Client Age: 24 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Private practice counseling clinic Type of Counseling: Individual counseling Presenting Problem: The client comes to counseling for help in managing anxiety, workplace dissatisfaction, and a pornography addiction. Diagnosis: Generalized anxiety disorder (F41.1), other problem related to employment (Z56.9), religious or spiritual problems (Z65.8)
Mental Status Exam: Mental Status Exam: The client is oriented to person, place, time, and situation. The client appeared hesitant when talking about pornography
Presenting Problem: You are a professional counselor, and the client comes to counseling to work on anxiety, work dissatisfaction, and a pornography addiction. You and the client discuss his anxiety, and he identifies that he experiences anxiety at work, regarding daily tasks, and in social settings. The anxiety is characterized by restlessness, difficulty concentrating, muscle tension, and insomnia. The client states that at work he is often treated poorly by his supervisors, who often point out what he does wrong and do not acknowledge what he does right. He does not feel that he does as much wrong as they claim, and he often finds that their accusations do not accurately reflect his actions, which is frustrating. The client states that he has had many meetings with his supervisors and that they do not appear to try to understand his point of view. The client appears uncomfortable and begins to speak but stops for about a minute before saying that he also has a pornography addiction. The client says that he is a Christian and that he does not feel he should view any pornography, but also that he uses pornography a lot and does not feel like he has control over himself or the frequency at which he uses it. The client asks if you are a Christian, and you decide to disclose with him that you are, knowing this is an important part of the client’s life and perspective. The client states that his work problems and pornography use are his most pressing issues.
Other Contexts: The client comes into the session smiling and says that he is excited to share his log this week. The client shares that he masturbated an average of one to two times daily and that he even went a day without masturbating. You express your excitement for the client achieving his goals. Through processing, the client identifies that he refrained from masturbating most often by leaving his bedroom and finding something to structure his time late at night. The client says that he had difficulty refraining from masturbating mostly when he came home from a difficult day at work, or when he struggled to sleep. You and the client discuss calming techniques to use when he is stressed after work. You also recommend approaches to address difficulty sleeping. On days when the client masturbates, he explains that he often decides that since he already messed up, he can do it again. The client says that he is happy at his new place of employment and that it is just a hard job. You support the client in challenging his past cognitive distortion that his future employment experiences will be the same as his past experiences.  The client is engaging in all-or-nothing thinking with regard to his rationalization of masturbating again if he has already done so

Question: The client is engaging in all-or-nothing thinking with regard to his rationalization of masturbating again if he has already done so. Which of the following would be the most helpful reframe of this thought?
(A): “I didn’t meet my goal, but this doesn’t have to affect the rest of my day.”
(B): “I’ll take some time to do yoga to disconnect from this event and move forward with my day.”
(C): “I did mess up, but I’m only human, so I won’t beat myself up over it.”
(D): “What happened can’t be changed, so I’ll just continue to move forward.”

Correct Answer: “I didn’t meet my goal, but this doesn’t have to affect the rest of my day.”
Explanation: The best reframe in this case of all-or-nothing thinking is the client acknowledging that he did not meet his goal but that he has power over the rest of his day to make changes. This reframe helps the client see that one event in his day does not have to define the whole day. Acknowledging his humanity is helpful, but it does not address the client’s all-or-nothing thinking. The client saying that he “messed up” has a negative connotation, when the reality is that he is working toward a goal, which often involves setbacks. The client acknowledging that he cannot change what he did is a helpful technique, but it does not change his mindset for the rest of the day. Yoga or other calming activities also do not address all-or-nothing thinking when done in isolation (without a mental reframe); instead, these activities can be used as a diversion to avoid confronting the cognitive distortion completely. Therefore, the correct answer is (B)
Competency: counseling skills and interventions