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 tells you she feels ready to process her past, but whenever you ask her to share about her trauma experiences, she ends up resisting due to her disbelief that you are qualified to help her. How should you proceed?
(A): Re-label her reason for resistance as "fear"
(B): Review your credentials and experience
(C): Present the dilemma as only her decision to resolve
(D): Suggest that you refer her out

Correct Answer: Present the dilemma as only her decision to resolve
Explanation: Placing this conflict in Leah's hands empowers her to decide whether she wants to address her trauma with you, discuss other areas only, or see a new professional. Offering a referral to a higher-level professional may not be what Leah needs, and may be seen as "giving up" on her or "rejection"; quite possibly even seen as conceding to her claims that your credentials are not sufficient to treat her effectively. Recall that she has previous abandonment issues from her divorce; perhaps what will help Leah in multiple areas of her personality development is for you to remain in place unless she makes the request for another counselor. Answer b) can be seen as invalidating to her reported concerns or cause her to feel defensive if she is still not respecting your clinical perspective, although can be a good intervention to use once Leah is invested in sharing with you further. Answer c) is unnecessary unless she asks, and even then, removes the clinical focus from your client. Therefore, the correct answer is (D)
Competency: counseling skills and interventions