Case Study
Patient Demographic:  Initial Intake: Age: 37 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/non-Hispanic Relationship Status: Married Counseling Setting: Mental health counseling agency Type of Counseling: Individual telemedicine
Mental Status Exam: Leah is casually dressed, presenting with anxious mood and affect. Speech is of fast rate but with normal tone. Breathing is shallow from speaking fast, you note she stops to take deep breaths before continuing. Leah denies SI/HI, reports many protective factors, and admits that nothing in her life is “really that wrong.” Leah demonstrates good insight and judgment into the nature of her concerns.
Presenting Problem: Diagnosis: Generalized Anxiety Disorder (F41.1), Adjustment disorder with mixed anxiety and depressed mood (F43.23)
 

Leah is referred to your counseling agency by the U.S. Department of Veterans Affairs (VA) mental health program due to their inability to accommodate her because of their high caseloads. Leah is a 37-year-old married woman with a 2-year-old child and is a disabled combat veteran who served 8 years in active-duty Air Force service. Both you and Leah work full-time as mental health counseling interns in your respective practices. Leah struggles to manage her own anxiety which causes both interpersonal and professional problems for her. Leah reports experiencing trauma related to deployments, past divorce, death of a pet and birth trauma with her daughter. Leah tells you she needs someone to process everything with regularly as she does not want to exhaust members of her family with her stress. Leah’s biggest problem, she shares, is that she knows how to resolve her negative thoughts that lead her to act impulsively but cannot apply her skills when she feels overwhelmed.
Other Contexts:  
Education and Work History:
Prior to military life Leah worked several different jobs since the age of 13. Leah joined the Air Force at age 21, worked overseas as well as in the states, and had several deployments including one year in Kabul, Afghanistan as a Staff Sergeant during her fifth year of service. Leah obtained her bachelor’s degree right after separation, and then returned to Afghanistan as a contractor. Following this experience, she completed her master’s degree in counseling. She admits she is “skeptical” working with someone who has the same amount of experience as herself.
 
Family History:
Leah grew up with two younger siblings, and her parents divorced when she was 11. Due to joint custody, her and her siblings moved back and forth weekly every Friday until she originally left home for college at 18. Both of Leah’s parents remarried; her father having three more children with her stepmother, and Leah inheriting a stepsister when her mother married her stepfather. Leah was also previously married to an Army Sergeant while active duty, but her husband had an affair and left her prior to her military separation.

Question: Which response would help Leah regulate her emotions while accepting her situation?
(A): Explain that feeling anxious is unhelpful if she cannot change anything.
(B): Remind her of her counseling skills and challenge her to use them.
(C): Validate her feelings and acknowledge her virtues as a mother.
(D): Deliver a list of possible solutions to her problems.

Correct Answer: Validate her feelings and acknowledge her virtues as a mother.
Explanation: Regardless of Leah's knowledge and competency as a clinician, she is in the vulnerable position of needing to feel supported just like any other clients in your caseload. Therefore, using the same strategies as you would with a client who does not already possess prior knowledge of anxiety reduction skills will offer the most effective delivery of emotional comfort. Normalizing or validating her distressing thoughts has been proven in behavioral therapy techniques to actively reduce a person's momentary suffering because it allows them to feel the way they do without challenging them to fight against it which can often be more anxiety-provoking. Using strengths-based and positive psychology strategies of reflecting her virtues as a mother who prioritizes her child is a way of motivating her out of her own value system and hopefully leading her into a discussion about accepting her temporary, unchangeable position. Reminding her of coping skills, offering her solutions, or even attempting to have her rationalize, are all secondary supportive techniques to helping Leah feel heard, understood, valued, and accepted. If she were momentarily able to use her coping skills, she would have. Reviewing them and challenging her at this moment could increase her feelings of shame she has already expressed that she is not able to put into practice things she knows she should do. Trying to solve her problems for her will not help her as much as regulating her disposition in session for her to be able to find solutions to her own problems. Therefore, the correct answer is (D)
Competency: counseling skills and interventions