Case Study
Patient Demographic: Initial Intake: Age: 20 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Community Mental Health Agency Type of Counseling: Individual
Mental Status Exam: The client presents looking appropriate to stated age and with positive signs of self-care related to hygiene and dress.  Mood and affect are congruent, and motor activity is within normal limits. His interpersonal communication is cooperative, open, and forthcoming. His speech is within normal limits with respect to volume, tone, or rate. His thought processes appear within normal limits with insight into his thoughts and behaviors, including concerns others express about his situation. He demonstrates the ability to connect ideas with circumstances and choices. He reports no thoughts of suicide or self-harm.
Presenting Problem: You are a counselor in a community mental health agency setting.  Your client presents as a 20 year old man with feelings of sadness, discouragement, being overwhelmed, and anxious. These feelings have been present for the past 4 to 5 years. He reports that while in high school, he had planned to commit suicide but did not follow through with it as he did not want to hurt his family and friends. The client tells you that he has moved frequently with his family; living overseas during his last two years of high school then beginning college in the United States. He states that he moved here 8 months ago because he wanted to be independent of his family and start “a new life without so many ups and downs.”   He lives in a house that his paternal aunt left to his family when she died. His mother and father recently separated and his father provides him with financial support. Until recently, he reports having been employed as a server in a restaurant but was fired after being accused of disrespect to a coworker. Your client states that the coworker had never liked him and he had not been disrespectful of her; however, their manager chose to let him go. He is currently attending classes at the community college and is in a mechanical engineering program. He chose this program because he thought he would really like it but he has been struggling with his courses due to his work schedule and now his major concern is making a living so that he can stay in school. He says he’s beginning to doubt whether this is the right path for him. He reports having no friends or anyone to spend time with on his days off.
Other Contexts: Family History:
The client is an only child. His parents have moved frequently with his father’s job and have lived in different areas of the world. His mother currently lives across the country and his father lives in the Middle East due to his work. They formally separated three months ago. Prior to moving here, the client lived with his mother but was concerned that she was “spending all our money.” His mother is retired and is supported by his father. He states he doesn’t want to be like her and live off of his father’s wealth.

Question: Viewing this client through a cognitive behavioral theoretical (CBT) lens, which of the following best describes his current problem?
(A): Client is experiencing reactive attachment issues related to his frequent moves
(B): Client is experiencing an emotional cutoff because of family enmeshment
(C): Client holds a core belief that friendships should not be trusted
(D): Client holds a core belief that it is better to be lonely than to lose people

Correct Answer: Client holds a core belief that it is better to be lonely than to lose people
Explanation: CBT focuses on core beliefs that individuals hold and which may impact their emotional well-being. The client appears to believe that not attempting to make friends protects him from loss, although it leaves him lonely and without support. There is no information provided that suggests his past friends were hurtful or harmful to him and it is the loss of the friendship that is painful, rather than them being untrustworthy. Reactive attachment is a trauma-stressor related disorder often seen in children. The client evidences no history related to criteria of the disorder such as consistent emotional withdrawal from adult caregivers, social unresponsiveness or unexplained emotionality during unthreatening interactions with adult caregivers, or a history of social or emotional deprivation from caregivers, or frequent changes in caregivers limiting the opportunity to form stable emotional relationships with adult caregivers. Emotional cutoffs and family enmeshment are constructs from a family systems theoretical lens and are not used in CBT. Therefore, the correct answer is (D)
Competency: counseling skills and interventions