Case Study
Patient Demographic: Initial Intake:  Age: 23 Gender: Male     Sexual Orientation: Heterosexual Ethnicity: Indian American Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual
Mental Status Exam: Shawn is slightly unkempt, completes ADLs and has good hygiene. His motor movements are fidgety and tense, and he consistently averts eye contact and darts his eyes around the room and towards the door every time he hears a noise. He appears to be sensitive to the lighting in the office as evidenced by fluttering his eyes when he looks up and commenting about its brightness. Shawn speaks within normal rate and tone, however low volume and often mutters under his breath. He denies any past suicidal or homicidal ideation and denies hallucinations or delusions. Shawn also denies history of trauma.
Presenting Problem: Diagnosis: Social Phobia, unspecified (F40.10) provisional; Alcohol Use Disorder, moderate, in early remission (F10.10)
 

Rishaan is a 23-year-old heterosexual male of Indian origin and is being referred to you by his parents for counseling in your private practice who are telling you Rishaan is at risk for going back to his drinking because he “never does anything constructive.” Further complaints by Rishaan’s parents include that “all he does is play video games and watch TV,” that he “never has money to pay for anything himself” and is constantly asking them for money. His parents offer to self-pay for Rishaan’s sessions. You welcome Rishaan to your office for an initial assessment. He respectfully requests that you refer to him as “Shawn,” which he explains is his preferred American name, and remarks that his parents really want him to talk to you. Shawn has agreed to counseling because he shares with you that he “has stuff to talk about anyway” and does not think he can go to his parents.
Other Contexts: Substance Use History:
Shawn entered treatment and rehabilitation five months ago after his ex-girlfriend’s family had an intervention with him about his abusive drinking and he has now been through all phases of treatment for Alcohol use disorder. Shawn tells you he is ashamed that his parents found out about his problem through his ex-girlfriend’s parents, because he had been lying to his own parents about his well-being for several years since he left home for college at 18 years old. Shawn is currently five months sober but is not engaged in any post-treatment recovery program nor has he continued counseling.
 
Family History:
Shawn has two older siblings, both of whom he shares are “successful and have families.” Shawn says, “my parents always want me to be like them and are constantly comparing me to them, it’s so annoying.” Shawn’s father is a dermatologist, and his mother is his father’s secretary in their medical practice. Both parents observe traditional Indian cultural practices in their social lives and with respect to Hinduism.
 
Work History:
Shawn has attempted part-time work following his graduation from his alcohol rehabilitation treatment program but was unable to make his shifts on time and was let go from his job. He tried another job selling products by cold calls but could not keep up with the volume required to make a viable salary. When asked what Shawn would like to do for a living, he says “I’d like to be a gaming coder or tester, something like that.”

Question: You teach Shawn the cognitive strategy of labeling his negative thoughts while they are occurring in his mind in an emotionally detached manner and guide him in applying mindful observations without judging himself. This is an example of?
(A): Thought Responding
(B): Thought defusion
(C): Oral Cognitive Restructuring
(D): Paradoxical Repetition

Correct Answer: Thought defusion
Explanation: Thought defusion is applying mindful observation of your negative thoughts, then labeling your negative thoughts while they are occurring in your mind and reflecting on them unemotionally and without judgment ("For the moment, I'm having an anxious feeling, but it will pass eventually"). Then, instead of trying to restructure the negative thought, you redirect your attention to an activity or person in the moment as a "thought interruption" technique, avoiding self-criticism. This is a gentler approach to helping someone learn how to identify their thoughts and become used to managing them in an un-intimidating and passive way. A person who is constantly being told they must change may be resistant to the criticism. The other methods listed would be useful as brief cognitive strategies for change, but are not thought defusion as described in the question. Therefore, the correct answer is (C)
Competency: counseling skills and interventions