Case Study
Patient Demographic: Client Age: 41 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Behavioral Health Type of Counseling: Outpatient Presenting Problem: Fear and Panic Diagnosis: Agoraphobia 300.22 (F40.00)
Mental Status Exam: Mental Status Exam: The client appears her stated age, and she is dressed in casual attire. Her affect and mood are anxious. She is tearful and seems extremely distressed when recounting her panic attacks. The client denies suicidal or homicidal ideations but does endorse feeling hopeless about her condition. She is unsure if she will benefit from counseling and expresses mixed feelings about seeking help. The client denies audio and visual hallucinations. Fam
Presenting Problem: You work in a behavioral health outpatient center. Your client is a 41-year-old Caucasian female presenting with symptoms of fear and panic. The client has a history of anxiety and depression but explains that her anxiety has worsened within the last year and that she has begun to experience panic attacks. She states that she has an “overwhelming fear” of elevators and stairwells. When exposed to these situations, she has trouble breathing, begins to feel dizzy, and hyperventilates. The client remembers having her first panic attack while staying at a hotel one weekend. She was taking the stairs and suddenly felt intense fear and panic. On the same trip, she had a similar experience when taking the elevator. The client quit her last job due to travel requirements, and she is currently unemployed. She stays away from stairwells and elevators as much as she possibly can. When unable to do so, she asks her son to accompany her.
Other Contexts: The client’s son accompanies her to her appointment today. Since the initial intake, COVID-19 has become a global pandemic and has greatly impacted the client’s anxiety and fear. The client was visibly trembling when she spoke and requested that her son remain nearby. She explained that complying with the statewide mask mandate has been difficult, stating, “Wearing this mask makes me feel like I can’t breathe. It’s the same feeling I get when I’m walking up stairs or taking the elevator.” The client’s internist prescribes alprazolam (Xanax), which she has been taking for years. However, she thinks that it is no longer effective and asks if you can help her discontinue the medication. Given the COVID-19 outbreak, you discuss providing distance counseling to the client.  You search for randomized clinical trials to determine the efficacy of distance counseling for agoraphobia

Question: You search for randomized clinical trials to determine the efficacy of distance counseling for agoraphobia. Which one of the following best ensures that a study’s conclusions are free from bias?
(A): On-treatment analysis
(B): Intention-to-treat analysis
(C): Transactional analysis
(D): Per-protocol analysis

Correct Answer: Intention-to-treat analysis
Explanation: In addition to randomization, an intention-to-treat analysis best ensures that a study’s conclusions are free from bias. An intention-to-treat analysis uses conclusions based on keeping all subjects in the treatment group they were randomized to, independent of what occurs later in the experiment. In other words, for randomized clinical trials, if half of the subjects dropped out of the study or conditions changed that affected their participation, they were still counted despite deviation from the protocol. A per-protocol analysis is the opposite of an intention-to-treat analysis. A per-protocol analysis excludes subjects who deviated from the protocol. If conducted alone, this analysis is subject to attrition bias. Transactional analysis is a psychoanalytic counseling theory used to analyze social transactions to determine one’s ego state. Unlike intention-to-treat analysis, on-treatment analysis only includes data on subjects who received the treatment they were randomized to—those who deviated from the protocol were not counted. Therefore, the correct answer is (C)
Competency: professional practice and ethics