CASE 1

Case 1

Part One

Age: 16
Sex: Female
Gender: Female
Sexuality: Heterosexual
Ethnicity: Caucasian
Relationship Status: Single
Counseling Setting: Agency
Type of Counseling: Individual
Presenting Problem: School problems
Diagnosis: Social Anxiety Disorder

Presenting Problem: You are a counselor working in an agency. Your new female client is about to finish second semester of her junior year in high school. Her mother brought her in to see you because her daughter, normally an A and B student, has fallen behind in two of her classes and is in danger of failing them. The client reports that she starts shaking whenever she has to make class presentations.

Family History: The client has two siblings: an older brother with Down Syndrome, and an older sister who has finished college. Her parents are married, and both live at home with her and her brother in a middle-class community. Her sister lives independently a few hours away.

History of Condition: The client’s mother reports that she doesn’t understand why her daughter has begun skipping school. The client stopped going to youth group at church over the past summer, and rarely goes out with friends anymore. She spends a lot of time in her room and wants to look just right when she does go out.

Health History: The client had a check up with her pediatrician before trying out for the math team. Her mom and the doctor joked that schools need physicals for everything nowadays—even to join academic extracurriculars. The doctor found the client’s reflexes with ease, and stated that her blood pressure was normal for a girl her age. The client made sure she asked for a school slip on her way out to excuse her absence since she has already had a few warnings from the office for skipping class. The doctor’s office receptionist commended her on her level of responsibility, stating, “We normally get calls from the school and have to fax over things like this. Good for you for keeping us on our toes!” The client smiled shyly as she looked at the ground and followed her mom out to the car.

Academic History: She has always gotten A’s and B’s, and school has been relatively easy for her. She hasn’t ever had any disciplinary issues other than serving detention for the recent skipped days. Her mid-semester progress report noted that she had missed important presentations in both Speech and Geology, affecting her grades.
- - - - - - - -

Domain: Intake, Assessment, and Diagnosis

From a Logotherapy perspective, what could you say to engage this client at the start of therapy?
1. “Words are so important! As we work together, you will be learning powerful words and tools that will make all the difference for you.”
2. “Thoughts are so powerful. As we work together, you will learn how to control your thoughts, and by extension, your future.”
3. “Every life has its share of suffering. Your suffering matters. Together, we'll find your meaningful path through it.”
4. “I understand your struggle. Your life isn't working out the way you planned. Together, we can help you to refine your goals and to take steps to make them happen.”
Domain: Counseling Skills and Interventions

What would be an appropriate paradoxical intervention to suggest for this client?
1. “Drink caffeine before your next presentation. Since you’re already nervous, the caffeine will help you feel calm.”
2. “Focus on the people who did a bad presentation, so you aren’t intimidated by the competition.”
3. “Write affirmations to yourself on sticky notes and read them in class.”
4. “The next time you get up in front of the class, purposefully shake more than you’ve ever shaken before.”
Domain: Professional Practice and Ethics

You are educating one of your clients on their rights as a client. Which of the following are not considered part of standard client's rights?
1. The right to receive an appointment in a time slot that accommodates the client's schedule
2. The right to receive specific information about the counselor’s qualifications
3. The right to receive a copy of the counselor's code of ethics
4. The right to obtain copies of records and reports
Domain: Counseling Skills and Interventions

This client’s Social Anxiety Disorder would best be addressed by all of the following techniques except which?
1. Flooding
2. Thought records
3. Bibliotherapy
4. Behavioral experiments
Domain: Intake, Assessment, and Diagnosis

Criteria for Social Anxiety Disorder (Social Phobia) include all of the following except which?
1. Social situations are avoided or endured with intense fear or anxiety
2. Duration is for at least 6 months
3. In children, the anxiety must occur in peer settings and not just during interactions with adults
4. Fear or avoidance is due to thoughts that escape might be difficult
Part Two

Second session, two weeks after the initial intake session

The client discloses that she is upset about the bad grades but just can’t get up in front of the classes to speak. Last year she had done a presentation on Hamlet in English, and some friends had teased her about it afterward, calling it lame and boring. This was very hurtful for her, especially since she worked extra hard on creating props and visual aids for the presentation. She was ashamed that she lugged additional art supplies to, from, and around school so that she could work on this project during all of her study halls, and it didn’t amount to much. Her teacher even wrote on the rubric that she was excited to see her presentation, but it fell short of her expectations. A lot of the kids in her class say that this teacher is hard to please, but at the same time most of the kids got good grades, while your client fell behind despite her efforts. She tells you that hardly anyone else planned out their projects as much as she did, and no one was seen carrying around near the amount of supplies she had. She was sure that her visual aids would push her project over the top. This year, she also worked hard on her presentations. She expressed feeling very nervous for days before they were due, almost panicky. She couldn’t eat or sleep and had a strong fear of how others would respond to her presentations. She was worried about being judged or mocked, especially if they noticed how shaky she was or if she choked on her words. Skipping class seemed like her only option. You express understanding of how hard and scary these situations must feel and ask her if she has any tools she uses to try to help herself when she feels so anxious.
- - - - - - - -

Domain: Core Counseling Attributes

During a session, you state, “I will always be real with you and tell you the truth.” What is the purpose of this?
1. To provide informed consent in the counseling relationship
2. To demonstrate congruence in the counseling relationship
3. To demonstrate empathy to the client, or in other words to treat the client as you would like to be treated
4. To open the door for future instances of self-disclosure
Domain: Core Counseling Attributes

How would you reflect the meaning of the client’s recounting of her fears of public speaking?
1. “Giving a presentation is only one of many areas of your life affected by anxiety.”
2. “You are concerned about judgment and mocking. Others’ opinions are important to you.”
3. “These are only thoughts. Imagine that they’re clouds just floating by, meaning that they’ll eventually subside.”
4. “Public speaking seems so easy for other people, but the more you practice, the easier it gets.”
Domain: Intake, Assessment, and Diagnosis

Based on the client's new disclosures from Part Two, which of her symptoms are most indicative of Social Anxiety Disorder?
1. Her decision to skip class
2. Her fear of being judged
3. Her fear of getting shaky or choking on words
4. The intense anxiety that she experiences in front of a class
Domain: Counseling Skills and Interventions

How would you use empathy to engage with the client about what happened in her English class last year?
1. “I know that really affected you, and it’ll make it hard to get back up in front of your class.”
2. “I bet your brother could relate since he must feel different from others. What would he say to you about what happened?”
3. “You felt embarrassed when they were so harsh on you after your presentation.”
4. “You say you felt ‘upset,’ but that’s not an actual emotion. Were you more sad or anxious?”
Part Three

Fifth session, five weeks after the initial intake session

The client reports that she has started noticing what happens in her body when she is anxious. Her heart begins to beat quickly, she gets flushed and breaks out in a sweat. She thinks about others judging her or somehow offending someone unintentionally. You go over cognitive distortions with her and ask her to self-report which of these she does most often. She chooses jumping to conclusions, mental filter and labeling as thinking patterns. You help her identify the recent times that she has jumped to conclusions, and she talked about a time that she was working on a math problem at the board in front of the class, when she heard a group of boys laughing behind her. She was convinced that they were laughing at the black and red plaid shirt she was wearing, which caused her to reach back and tug on the back of her shirt to make sure it was in place. She then looked down to smooth out the front of her shirt, and noticed that there was taco sauce on the front of it. “They must be laughing at me,” she thought. She felt her face turn red and looked back at the board, only to realize that she had lost her train of thought. The teacher’s timer went off, and she walked backwards to her seat so no one would see the stain on the front of her shirt. She sat down to watch the teacher complete the problem as the students graded each other’s homework assignments.
- - - - - - - -

Domain: Treatment Planning

Which of the following questions is most important when establishing a treatment plan?
1. “What are your presenting concerns?”
2. “Does anyone else in your family experience the same type of symptoms?”
3. “What was your past therapy experience like?”
4. “How will you know when you don’t need therapy anymore?”
Domain: Treatment Planning

You decide to schedule a team meeting for the client. Which of the following individuals is least likely to be included in this meeting?
1. Client’s teacher
2. School guidance counselor
3. School principal
4. Client’s parent/guardian
Domain: Intake, Assessment, and Diagnosis

Based on the client's disclosures in Part Three, what is the most likely alternative diagnosis for consideration?
1. Agoraphobia
2. Panic Disorder
3. Specific Phobia
4. Generalized Anxiety Disorder
Domain: Intake, Assessment, and Diagnosis

The client describes how during her periods of intense anxiety, she sometimes gets a strange 'pins and needles' feeling in her extremities. This is called ______
1. Paresthesia
2. Pseudo-anesthesia
3. Psoriatic nerves
4. Parasympathetic response