Case Study
Patient Demographic: Name: Camron Clinical Issues: Worry and anxiety Diagnostic Category: Anxiety Disorders Provisional Diagnosis: F40.10 Social Anxiety Disorder Age: 20 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Never married Modality: Individual Therapy Location of Therapy : University Counseling Center  
Mental Status Exam: The client looks anxious and uneasy, presenting with a "nervous" laugh. He twirls his thumbs and shakes his legs while seated. Mood is anxious and frustrated. He feels isolated and misunderstood by his family and peers. Speech is soft and hesitant. Eye contact is sporadic. Thought process is concrete and linear. He has some difficulty with abstract concepts. Thought content reveals fear of social interactions, feeling judged by others, and feeling inadequate. He seems to recognize the negative consequences associated with his anxiety and behavior, but he has limited insight with regard to recognizing the source of his anxiety. He reports difficulty recalling past experiences or conversations due to anxiety levels. No suicidal or homicidal ideation noted.
Presenting Problem: First session Your client is a 20-year-old male who has been seeing your colleague at the university counseling center where you both work as mental health therapists. The client requested to be transferred to another therapist because his former therapist reminded him too much of his father and therapeutic progress could not be made. The client's former therapist contacted you as a referral, and you agreed to transfer the client to your caseload. When you meet with the client today, he seems very anxious and laughs nervously. You can see he is shaking his legs as he sits, twirling his thumbs, and making little eye contact with you. You explain the therapy process and that you need to go over some intake questions. You ask him who his ICE (in case of emergency) contact is, and he says it is his roommate. You continue with your assessment, gathering information about his presenting problem and what he would like to accomplish in counseling.    He continues by telling you, "I thought that going to college would alleviate my social anxiety, but I'm not doing well here. I want to be social, but I can't." The client feels frustrated and overwhelmed by his fears of interacting with others. He tells you that when he is feeling anxious, he punches bathroom mirrors to try to distract himself from the anxiety. He notes that the anxiety is crippling, preventing him from doing the things he loves, and has resulted in him feeling isolated. He is afraid that others are judging him and is constantly worried that he will make a mistake and feel embarrassed.  Fourth session It has been three weeks since the initial counseling session with your client. The client comes to your office for his weekly session and says, "I tripped on my way here when I got off the subway, and I felt so embarrassed. I'm going to take a cab back to campus. What if people who saw me fall are still in the subway by the time we finish?" You ask your client to explain this embarrassment and why he thinks people who saw him fall this morning would still be in the station an hour later. He tells you that when he was little, his father always told him, "Don't do this, don't do that. People are going to think you're stupid. I still hear his voice in my head, telling me what to do. I've spent my whole life trying to live up to his expectations, and I'm tired of it!" You explore this with your client and use guided imagery to ask him to return to that little boy in his memory. He tells you, "I can't concentrate right now. The anxiety of remembering my childhood is stressing me out."    You switch to using behavioral techniques as a way to help him manage his anxiety. You explain that it is important for him not only to challenge his anxieties but also recognize his successes. To ensure that he feels successful and rewarded, you come up with a plan so he can realize progress and be able to measure it. In order for you and your client to monitor his progress, you create charts that will document any positive changes he experiences during the therapy sessions. As part of the plan, your client will commit to engaging in activities outside of the counseling session which are designed with the purpose of calming him down and helping him practice his newly-acquired skills to manage his anxiety.  Eighth session It has been seven weeks since the client presented for the initial interview. Today, the client returns to your office for his weekly session. He admits that he has not been following through with any of the activities you have assigned as part of his systematic desensitization plan, and he continues to feels overwhelmed by anxiety. His facial expressions reveal a sense of defeat and disappointment as he shares his struggles with making progress. He says, "I just want to be a normal guy. What's wrong with me?" The client expresses feeling overwhelmed with fear and shame at being unable to make any changes. He asks if you know of anyone else who has experienced social anxiety before and if there is any hope for him to get better. You normalize his experience and briefly share a story about being afraid to wear glasses in high school out of fear that your classmates would make fun of you. You then explain to him that even though it may feel like he is alone in his experience and feels discouraged, recovery is possible. You emphasize the importance of being patient with himself and expressing self-compassion as he works through the process.    During the session, the client also mentions that his parents are having a difficult time in their relationship which has been causing additional distress for him. You explain that this could cause extra feelings of worry and insecurity, even when he is away from them. He acknowledges the connection between his parents’ relationship dynamics and his own struggles with anxiety. In order to address the additional stressors created by the distress in the client's parents' relationship, you explore ways he can work on managing his own emotions and reactions. You explain that building self-awareness of his feelings and responses may help empower him to have greater control over his anxiety symptoms. You discuss mindful breathing and visualization techniques. Afterwards, you provide examples of cognitive reappraisal strategies that can be used to challenge any irrational beliefs related to fear of failure or embarrassment that might be driving his avoidance behaviors. You explain the importance of consistently doing the practice in order for it to be effective and positive changes can be expected with consistent effort. You also give the client a homework assignment to read about social anxiety.    Toward the end of the session, you summarize what you have discussed during today's session, and you address his feelings of disappointment in his perceived lack of progress by saying, "I understand your frustration. It can seem like things are not changing but in reality, even small changes are a sign of progress. The most important thing for you to remember is that it takes time and effort to learn how to manage your anxiety and make meaningful change in your life. As you continue working on the strategies we have discussed, I want you to recognize any successes or moments of improvement as they occur; no matter how small they may be. This will help keep you motivated and encourage further growth."
Other Contexts: The client grew up in an authoritarian house where all of his actions and behaviors were scrutinized by his father. His father demanded obedience from his son and would not accept anything but perfection from him. He graduated from high school at the top of his class and has been waiting to attend college to get out from "under the thumb" of his father. The client's parents are paying all of his college expenses. The client is experiencing difficulties adapting to college life. He states that he stays in his room because he believes he always says and does the wrong thing, and everyone can see what a "loser" he is. He further states that he rarely leaves his dorm room except to go to his work-study position. The client has experienced two panic attacks; one occurred when he was required to give a presentation in class, and the second happened when he was required to meet with a small group to discuss his input for their group project. The client has missed many classes in which he is expected to participate or present projects. He is currently failing three classes. The client is in danger of losing his work-study job on campus due to frequent absences. He is competent and conscientious when his job does not require customer interaction. Personal/Social Relationships: The client is interested in exploring social relationships but is anxious as his father never allowed him to interact with his peers. As a result, his level of social functioning is relatively low. He has talked with a few students in his dorm and classes when required, but he feels extremely uncomfortable and inept. The client has not developed any friendships because of his anxiety. 

Question: Which of the following is considered an open-ended question?
(A): "What does it mean to you to be a 'normal' guy?"
(B): "Is feeling 'normal' important to you?"
(C): "Are there times that you feel like a 'normal' guy?"
(D): "Do you think you are 'normal?'"

Correct Answer: "What does it mean to you to be a 'normal' guy?"
Explanation: This is a form of an open-ended question. It requires more than a one- or two-word answer. Therefore, the correct answer is (D)
Competency: counseling skills and interventions