Case Study
Patient Demographic: Client Age: 42 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Agency Type of Counseling: Individual and Group Presenting Problem: Social Anxiety Diagnosis: Social Anxiety Disorder (Social Phobia), Provisional 300.23 (F 40.10)
Mental Status Exam: Mental Status: The client is meticulously dressed and well groomed. She is cooperative and periodically exhibits a nervous smile. The client is fidgety and frequently repositions herself when seated. Her mood is anxious, and she becomes tearful when discussing feeling “stupid” during job interviews. She exhibits cohesive thinking, and her insight and judgment are intact. The client is oriented to person, place, situation, and time. Her affect is reserved. She denies suicidal and homicidal ideation as well as audio/visual hallucinations.
Presenting Problem: You are a certified mental health counselor working in a community mental health center. Your client is a 42-year-old white female who presents today with symptoms of social anxiety disorder. The client reports debilitating anxiety when interacting with others, particularly when meeting unfamiliar people or going somewhere for the first time. She states that she cannot sleep and has a poor appetite on the days leading up to social events. When encountering anxiety-provoking situations, she says that her hands shake, she sweats excessively, and her voice trembles. The client is recently divorced and, after more than 15 years of being out of the workforce, she is seeking employment. She explains that job interviews have been “humiliating” because of what she perceives as an “inherent lack of knowledge and a substantially impaired skill set.”
Other Contexts:     History of Condition: The client first noticed symptoms of social anxiety when her family moved north during the summer of her 8th-grade school year. When she began high school, she received unwanted attention for being the “new girl.” She explains that she was often teased because of her Southern accent and was labeled “country” and “ignorant.” Before meeting her husband, the client remembers drinking before going on a date stating, “It just helped settle my nerves.” Her social anxiety lessened after becoming a stay-at-home mom to her two now-teenage children. However, she noticed a sharp increase in social anxiety after her divorce, particularly when attempting to reenter the job force and trying to find new social circles. She denies current drug use and states that she is a social drinker. Family History: The client’s parents both live out of town and run a business together. The client’s father has been treated for alcohol use disorder and is now in recovery. Her mother takes medication for anxiety and depression. The client has two teenage girls. Both girls have had a difficult time with the divorce. Her youngest child is seeing a therapist for depression. The client’s ex-husband is a prominent attorney in their town. This is the client’s first experience with counseling, and she asks many questions when filling out the intake paperwork.  The client is resistant to engage in the self-affirmation exercise, exclaiming that “It just seems silly

Question: The client is resistant to engage in the self-affirmation exercise, exclaiming that “It just seems silly.” Using motivational interviewing, which response would best increase her compliance with this activity?
(A): “There are now studies showing that positive affirmations activate neural reward pathways in the brain.”
(B): “This way of decreasing anxiety seems foreign to you.”
(C): “Change is really hard for you, but I think you’ll be pleased with the results.”
(D): “You feel like I don’t understand you or can’t help you.”

Correct Answer: “This way of decreasing anxiety seems foreign to you.”
Explanation: Stating “This way of decreasing anxiety seems foreign to you” would best increase compliance with engaging in the self-affirmation exercise. Rolling with resistance is a motivational interviewing strategy used to improve a client’s desire to change. Statements that focus on the problem and not the person are used when rolling with resistance. The counselor’s statement is a simple reflection. The statement “Change is really hard for you, but I think you’ll be pleased with the results” focuses on the person rather than the problem and uses persuasion, which motivational interviewing discourages. The statement “There are now studies showing that positive affirmations activate neural reward pathways in the brain” is also an attempt at persuasion. Finally, the statement “You feel as if I don’t understand you or can’t help you” is a failed attempt at providing empathy because it does not accurately reflect the client’s underlying feelings or beliefs. Therefore, the correct answer is (D)
Competency: counseling skills and interventions