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: Leah has been sharing without pause for 30 straight minutes. It has been difficult to keep up with her changing topics and introducing new information. How do you help her to slow down?
(A): Calmly interject, encourage her to take a deep breath, and refocus the dialogue
(B): Interrupt with the observation and tell her to slow down
(C): When she takes her next pause, ask her to stop and review only the highlights
(D): Allow her to share however she needs to until she comes to a natural stop

Correct Answer: Calmly interject, encourage her to take a deep breath, and refocus the dialogue
Explanation: Modeling how to take a deep breath while she is sharing and helping her to refocus is the best choice for an intake and assessment session as you are specifically trying to organize your counseling strategies with her moving forward. This is a gentle and non-invasive intervention for helping Leah improve her session's quality. As her counselor, you are trying to get to know her and help her feel heard and understood at the same time; silently listening to her vent without being able to reflect, summarize, or ask questions to get to know her better is not necessarily more helpful for Leah. You are also responsible for completing this intake within a specific amount of time while honoring her VA benefit authorizations; while this does not take precedence over Leah's need for therapeutic engagement, it is an administrative aspect of professional counseling that is necessary for order and maintenance of boundaries. Answer a) projects a critical demeanor and may cause Leah to feel offended or stifled in her sharing, and answer d) is unnecessary as you are having her stop and repeat herself. Answer b) is not realistic if she has not taken a breath for 30 minutes and your intake is only scheduled to be 55 minutes. Therefore, the correct answer is (C)
Competency: counseling skills and interventions