Case Study
Patient Demographic: Client Age: 30 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Agency Type of Counseling: Outpatient Presenting Problem: Recent Hospital Discharge Diagnosis: Borderline Personality Disorder (BPD) 301.83 (F60.3)
Mental Status Exam: Mental Status Exam: The client is wearing a low-cut blouse and short shorts. Her affect and mood are labile, and her speech is pressured. She is fidgety at times and sits with her arms crossed. The client states that she has had three previous suicide attempts and has been cutting since her late twenties. Her last suicide attempt was an overdose, which resulted in her recent hospitalization. She stated that this was the result of her last boyfriend “ghosting” her. The client denies audiovisual hallucinations but states that she often feels that others are conspiring against her. She says that she continues to have suicidal thoughts but denies having a current plan. Fam
Presenting Problem: You are a mental health counselor in an outpatient setting. Your client is a 30-year-old white female who was released from the hospital 48 hours ago. The client presents today for a postdischarge follow-up appointment. The hospital clinician diagnosed the client with borderline personality disorder(BPD) and substance use disorder. The client has a history of suicidality, impulsivity, and relational instability. She explains that she has a “quick temper,” which occurs when she is feeling rejected. She explains that she has a long history of being treated poorly by others, including her last boyfriend, former employers, and family members. During these times, the client admits to substance misuse and self-mutilation (i.e., cutting). She states that there are times when she drinks to black out and that she is more inclined to do so when her feelings become intolerable. The client has had multiple hospital admissions and has been in the care of several counselors. She questions your credentials and your ability to “work with someone like (her).”
Other Contexts: The client no-showed for her last session without calling to cancel. She arrives today, appearing disheveled and irritable. The client states that she has not been sleeping well. She explains that she was talking to someone on an online dating site and had planned a face-to-face meeting this past weekend. She says she waited at the bar for more than an hour and finally realized that her date had stood her up. She explained that she was in so much shame after the incident that she engaged in self-harm. The client reveals superficial razor cuts on her thigh and upper arm. She says she feels like she is a failure and undeserving of love.  The client has difficulty identifying and differentiating overwhelming emotions

Question: The client has difficulty identifying and differentiating overwhelming emotions. What technique could help her experience gradations of feeling?
(A): Mood monitoring
(B): Affect labeling
(C): Cue identification
(D): Escalation point recognition

Correct Answer: Affect labeling
Explanation: Affect regulation consists of affect labeling, recognition of escalation points, mood monitoring, and cue identification. Affect labeling helps clients experience gradations of feeling by identifying and differentiating overwhelming emotions. Because individuals with BPD experience black-and-white thinking, there is a tendency to label feelings using polarized terms (eg, “I’m either angry or calm”). Helping clients identify and articulate gradations of feeling (eg, irritated, relieved) allows for the acknowledgment of shades of gray and eventually the client learning to tolerate a range of emotions. Recognition of escalation points breaks down the client’s thinking, acting, and behaving before an unregulated emotional event. Mood monitoring is used to help clients keep track of patterns and changes in moods. Finally, cue identification helps identify problematic behaviors that can be altered. This is done by having the client identify internal cues rather than external triggers. Therefore, the correct answer is (C)
Competency: counseling skills and interventions