Case Study
Patient Demographic: Client Age: 51 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced and single Counseling Setting: Local government mental health agency Type of Counseling: Individual counseling Presenting Problem: The client is experiencing a recent separation from her last partner who was verbally and physically abusive, and she is currently living in a domestic violence home. Diagnosis: Major depressive disorder, recurrent episode, moderate (F33.1) and post-traumatic stress disorder (PTSD) (F43.10)
Mental Status Exam: Mental Status Exam: The client’s affect is flat, and she is hunched over in the chair. The client is oriented to person, place, time, and situation. She reports no hallucinations, paranoia, or depersonalization/dissocia
Presenting Problem: You are a licensed counselor working for a local government mental health agency in the counseling clinic. The client was referred to receive case management and counseling after experiencing homelessness due to leaving a physically and verbally abusive relationship with her last partner. The client is experiencing the following depressive symptoms: sadness more often than not, mental fogginess, suicidal ideation, insomnia, significant weight loss, feelings of worthlessness, and fatigue. The client experiences PTSD symptoms due to having experienced several abusive relationships, including recurrent distressing intrusive thoughts regarding the physical abuse, distressing dreams related to abuse, and physiological reactions (difficulty breathing, heart racing) when she goes near certain places that remind her of the abuse. She also explains that she has been avoiding triggers, believes that no one can be trusted, has an exaggerated startle response, and has had difficulty experiencing positive emotions. The client says that she does not know if therapy can help because she feels like these events have changed her and that she cannot get back to “normal,” but that she would like to make friends so she doesn’t feel so alone.
Other Contexts: The client comes into the session, sits down, and immediately begins to talk about one of her roommates in the domestic violence home that has been making her angry because the roommate comes into her room when the client is gone and borrows her personal hygiene items. The client continues to explain that she worries that the roommate might come in while she is sleeping, but that she has not done this yet. You process these feelings with the client and identify that when she was a child, her uncle would come into her room without her permission and sexually abuse her. The client also reported that one of her ex-husbands would enter their bedroom drunk at night and would often hit her while she was asleep. You and the client discuss how to make her environment feel safe and how to engage in cognitive reframing. You empathize with the client and validate her emotions

Question: Which one of the following statements would be the most beneficial cognitive reframe for the client’s beliefs about her roommate that would address an approach from a reality perspective?
(A): “My thoughts aren’t reality; therefore, I should distract myself using coping skills.”
(B): “My roommate may actually do something bad, so I need to set some boundaries with her regarding my room.”
(C): “I should talk with my roommate about boundaries.”
(D): “Currently, my roommate hasn’t done anything other than enter my space without permission and borrow things, so this isn’t the same as my past experiences.”

Correct Answer: “Currently, my roommate hasn’t done anything other than enter my space without permission and borrow things, so this isn’t the same as my past experiences.”
Explanation: Focusing on the current situation, in which the roommate has not done anything other than disrespect boundaries, and seeing how it is different from past events is the most helpful cognitive reframe. This focuses on the reality and helps the client refrain from blowing it out of proportion. Although focusing on enforcing boundaries is helpful, it is not a cognitive reframe. Identifying that it is a possibility that the roommate may sexually assault her is not helpful because this reinforces fear and irrational thinking. Identifying that the client’s thoughts are not reality is important, but this does not focus on the root of the thoughts, which stem from a fear of a past situation becoming the present reality. Therefore, the correct answer is (B)
Competency: counseling skills and interventions