Case Study
Patient Demographic: Name: Camron Clinical Issues: Worry and anxiety Diagnostic Category: Anxiety Disorders Provisional Diagnosis: F40.10 Social Anxiety Disorder Age: 20 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Never married Modality: Individual Therapy Location of Therapy : University Counseling Center  
Mental Status Exam: The client looks anxious and uneasy, presenting with a "nervous" laugh. He twirls his thumbs and shakes his legs while seated. Mood is anxious and frustrated. He feels isolated and misunderstood by his family and peers. Speech is soft and hesitant. Eye contact is sporadic. Thought process is concrete and linear. He has some difficulty with abstract concepts. Thought content reveals fear of social interactions, feeling judged by others, and feeling inadequate. He seems to recognize the negative consequences associated with his anxiety and behavior, but he has limited insight with regard to recognizing the source of his anxiety. He reports difficulty recalling past experiences or conversations due to anxiety levels. No suicidal or homicidal ideation noted.
Presenting Problem: First session Your client is a 20-year-old male who has been seeing your colleague at the university counseling center where you both work as mental health therapists. The client requested to be transferred to another therapist because his former therapist reminded him too much of his father and therapeutic progress could not be made. The client's former therapist contacted you as a referral, and you agreed to transfer the client to your caseload. When you meet with the client today, he seems very anxious and laughs nervously. You can see he is shaking his legs as he sits, twirling his thumbs, and making little eye contact with you. You explain the therapy process and that you need to go over some intake questions. You ask him who his ICE (in case of emergency) contact is, and he says it is his roommate. You continue with your assessment, gathering information about his presenting problem and what he would like to accomplish in counseling.    He continues by telling you, "I thought that going to college would alleviate my social anxiety, but I'm not doing well here. I want to be social, but I can't." The client feels frustrated and overwhelmed by his fears of interacting with others. He tells you that when he is feeling anxious, he punches bathroom mirrors to try to distract himself from the anxiety. He notes that the anxiety is crippling, preventing him from doing the things he loves, and has resulted in him feeling isolated. He is afraid that others are judging him and is constantly worried that he will make a mistake and feel embarrassed.  Fourth session It has been three weeks since the initial counseling session with your client. The client comes to your office for his weekly session and says, "I tripped on my way here when I got off the subway, and I felt so embarrassed. I'm going to take a cab back to campus. What if people who saw me fall are still in the subway by the time we finish?" You ask your client to explain this embarrassment and why he thinks people who saw him fall this morning would still be in the station an hour later. He tells you that when he was little, his father always told him, "Don't do this, don't do that. People are going to think you're stupid. I still hear his voice in my head, telling me what to do. I've spent my whole life trying to live up to his expectations, and I'm tired of it!" You explore this with your client and use guided imagery to ask him to return to that little boy in his memory. He tells you, "I can't concentrate right now. The anxiety of remembering my childhood is stressing me out."    You switch to using behavioral techniques as a way to help him manage his anxiety. You explain that it is important for him not only to challenge his anxieties but also recognize his successes. To ensure that he feels successful and rewarded, you come up with a plan so he can realize progress and be able to measure it. In order for you and your client to monitor his progress, you create charts that will document any positive changes he experiences during the therapy sessions. As part of the plan, your client will commit to engaging in activities outside of the counseling session which are designed with the purpose of calming him down and helping him practice his newly-acquired skills to manage his anxiety.
Other Contexts: The client grew up in an authoritarian house where all of his actions and behaviors were scrutinized by his father. His father demanded obedience from his son and would not accept anything but perfection from him. He graduated from high school at the top of his class and has been waiting to attend college to get out from "under the thumb" of his father. The client's parents are paying all of his college expenses. The client is experiencing difficulties adapting to college life. He states that he stays in his room because he believes he always says and does the wrong thing, and everyone can see what a "loser" he is. He further states that he rarely leaves his dorm room except to go to his work-study position. The client has experienced two panic attacks; one occurred when he was required to give a presentation in class, and the second happened when he was required to meet with a small group to discuss his input for their group project. The client has missed many classes in which he is expected to participate or present projects. He is currently failing three classes. The client is in danger of losing his work-study job on campus due to frequent absences. He is competent and conscientious when his job does not require customer interaction. Personal/Social Relationships: The client is interested in exploring social relationships but is anxious as his father never allowed him to interact with his peers. As a result, his level of social functioning is relatively low. He has talked with a few students in his dorm and classes when required, but he feels extremely uncomfortable and inept. The client has not developed any friendships because of his anxiety. 

Question: The client is upset about his father's unrealistic expectations and says the pressure to live up to his father's standards is almost impossible to manage. How would you accurately reflect the client's feelings?
(A): "It's natural for your father to want the best for you, but it sounds like he has taken his concerns about your performance to the extreme."
(B): "Your feelings of frustration make sense to me, especially given what you have told me about your father."
(C): "It's completely understandable that you're feeling overwhelmed by your father's high expectations."
(D): "You're feeling overwhelmed by the pressure you're under trying to meet your father's expectations."

Correct Answer: "You're feeling overwhelmed by the pressure you're under trying to meet your father's expectations."
Explanation: This response accurately reflects the client's feelings by acknowledging the pressure and frustration he is feeling because of a family member's expectations. Therefore, the correct answer is (B)
Competency: counseling skills and interventions