Case Study
Patient Demographic: Client Age: 48 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Separated Counseling Setting: Private practice Type of Counseling: Individual Presenting Problem: Alcohol use Diagnosis: Alcohol Use Disorder, Moderate, Provisional (F10.20)
Mental Status Exam: Mental Status Exam: The client’s hands tremble, and she becomes tearful on several occasions. There is mild perspiration on her forehead. She endorses feeling hopeless about the future but denies suicidal ideation. The client shows no signs of intoxication or impairment. She presents as well-dressed with good hygiene. Both affect and mood are dysphoric. She apologizes several times for crying and states she has been “a mess” lately due to not sleeping for the last several days. Her demeanor becomes somewhat defensive when asked about her drinking, and she appears to minimize the impact this has had on her life. Fam
Presenting Problem: You are a counselor working in private practice evaluating a 48-year-old female with a history of alcohol misuse. Three weeks ago, the client was hospitalized due to alcohol poisoning. She explains that she was in a blackout before waking up in the hospital and was told her BAC was 0.26, just over three times the legal limit. This occurred on the evening she discovered that her husband was having an affair. The client briefly attended a drug and alcohol intensive outpatient program (IOP) but felt she was not improving with group therapy and would like to try individual therapy instead. She admits that there are times in her life when she has abused alcohol but does not believe she is an alcoholic. The client experiences frequent anxiety and admits to using alcohol “just to take the edge off” and to help her fall asleep. Her alcohol intake increased nearly six months ago when her youngest child left for college. During this time, her husband of 25 years announced he was leaving and filing for divorce. She struggles with being an “empty nester” and is mourning the loss of the life she and her husband built together.
Other Contexts: During the previous session, the client committed to controlled drinking and agreed on a limit of two drinks per night. She admits to having limited success with this goal and concedes to over-indulging when feeling “stressed out.” You learn she ran into a woman from her church who she discovered was a recovering alcoholic. She agreed to meet the woman at an AA meeting, and the client was surprised she could relate to other alcoholics. The client’s affect brightened as she reported that she has had seven days of continuous sobriety. She continues to have a strained relationship with her now ex-husband. Her youngest child is home on spring break, which has helped improve her mood and kept her accountable for staying sober. She is able to use relaxation and mindfulness techniques for insomnia, which have been effective at times at improving her sleep pattern.  Your client states, “I can’t do anything right anymore; I’ve failed as a parent

Question: Your client states, “I can’t do anything right anymore; I’ve failed as a parent.” Using Rational-Emotive Behavioral Therapy (REBT), you respond with the following:
(A): “You told me you were a stay-at-home mother. Would a failed parent make that sacrifice?”
(B): “All parents feel like that every so often. It’s just part of the human condition.”
(C): “What evidence is there that indicates you haven’t failed but instead succeeded as a parent?”
(D): “You felt criticized by your ex-husband and your automatic thought was that you can’t do anything right, including parenting.”

Correct Answer: “What evidence is there that indicates you haven’t failed but instead succeeded as a parent?”
Explanation: Rational-Emotive Behavioral Therapy (REBT) takes the ABC model used in CBT and adds two more elements—D and E—with D representing disputing irrational thoughts and E representing the newly formed alternative thoughts. Counselors using the technique of forceful disputing ask the client to review evidence that supports or does not support the client’s irrational thought. Answer A is an example of cognitive behavioral therapy rather than REBT. The activating event would be the ex-husbands criticism. The dysfunctional automatic thought is the statement about her inability to do anything right, including parenting. The potential consequences are frustration, hopelessness, depression. If you state that every parent feels like a failure every so often (Answer B), you might leave the client thinking their feelings are invalid. Answer C uses a closed-ended question and does not enable the client to engage in the forceful disputing of an irrational belief. Therefore, the correct answer is (D)
Competency: counseling skills and interventions