Case 3

Case 3

Part One

Age: 25
Sex: Female
Gender: Female
Sexuality: Heterosexual
Ethnicity: Caucasian
Relationship Status: Single
Counseling Setting: Community clinic
Type of Counseling: Individual
Presenting Problem: Uncontrolled eating
Diagnosis: Binge-Eating Disorder

Presenting Problem: Client is a 25 year-old Caucasian female who has been referred to you by her primary care physician after the client gained 35 pounds in less than one year. Client describes that for the last nine months, she has been eating large amounts of food after work. The client works as a software developer at a start up advertising company. Since work has started to get more stressful, the client has noticed her eating getting more and more unhealthy. She expresses concern that a lot of the time she isn’t even hungry when she starts eating, but she can’t get herself to stop. She tends to eat quickly during these periods of time, and feels guilty afterward. She states that she gets so uncomfortably full that she does not feel like doing anything for the rest of the night. She hopes that you can help her feel better about herself.

Mental Status Exam: The client is oriented to person, place, and time. She shows up early to her appointment and is tearful during session. Thought content is normal, absent of hallucinations and flight of ideas. The client’s speech is normal. The client demonstrates guarded body language. She denies suicidal and homicidal ideation.

Relationship History: At the age of 19, the client was one of the first in her group of friends to get engaged. The boy she dated all through high school finally asked her to marry him the summer after their graduation. She was elated at the thought of spending the rest of her life with him. They liked the same kinds of movies, restaurants, and enjoyed walking in parks together. She ended up calling off the engagement, however, after four years because she felt like it wasn’t going anywhere. Despite having an engagement ring, she felt as though there was a lack of serious commitment. She broke it off in a public place and encouraged her ex to not reach out to her. She hasn’t heard from him since, but still thinks about him from time to time and wonders what her life would be like had they stayed together.

Health History: The client has always been generally healthy. She went to the doctor two weeks ago with complaints of shortness of breath. The client also asked for her thyroid to be checked because she noticed significant weight gain in the past year. All of the tests the doctor ran were normal, aside from an elevated HgA1C, meaning that the client could potentially be at risk for type two diabetes. The client is not on medications and does not have a surgical history. She hopes that you can help her get her eating under control before she develops a chronic condition.
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Domain: Intake, Assessment, and Diagnosis

You decide to begin by administering a Mental Status Exam. Thought blocking, fusion, and loosening of associations are all part of which MSE Domain?
1. Thought Content
2. Cognition
3. Thought Process
4. Perceptions
Domain: Counseling Skills and Interventions

You say to the client, “You know yourself best, and I wouldn’t want to make assumptions about how you’re feeling, however it seems like you are carrying some strongly negative self perceptions.” What is the primary purpose of this statement?
1. Demonstrating to the client that you have the appropriate training to address their symptomology
2. Facilitate goal setting
3. Understand cultural differences
4. To build therapeutic alliance
Domain: Professional Practice and Ethics

As you work with the client, if over time you need to modify the client's diagnosis, what would be the best course of action?
1. Use white out to change the diagnosis in all prior notes
2. Use white out to change the diagnosis in all prior notes. Sign and date the revision
3. Update the diagnosis in today's record. Sign and date
4. Rewrite all prior notes with the proper diagnosis
Domain: Treatment Planning

From a Cognitive Behavioral Therapy perspective, which of the following would you say to build a therapeutic alliance with this client?
1. “It sounds like eating has become a form of self punishment. Let's explore that.”
2. “I can hear that you want to address this need before it gets any worse. Together, I'm sure we can figure this out.”
3. “Everything you say to me stays between us unless it involves hurting yourself, hurting someone else, or if someone is hurting you.”
4. “Thank-you for your honesty. I know this must be difficult for you. I know that you have the strength within to overcome this.”
Domain: Counseling Skills and Interventions

You are finishing up a session with a different client who is an adult client from West Africa. You remember reading something about how West Africans tend to include their family and spiritual leaders in decisions about health. Which of the below statements would be most beneficial in this situation?
1. “I saw you brought your parents with you today. Let me go get them from the waiting room so they can hear this last part about diagnosis and treatment.”
2. “Would you like to call someone to see if it’s okay that we set up a second appointment?”
3. “How would you like to proceed with treatment? We can set up another appointment now, or you can give me a call if you would like to set one up later.”
4. “I took the liberty of filling out a release of information form for your pastor. I know it will help to involve as many people as possible in this. All you have to do is sign.”
Part Two

Second session, two weeks after the original intake session

The client comes to session eager to discuss some coping skills the client can put in place to help her eating habits. You start by helping the client list some of the thoughts she has about herself. After looking over the list, she realizes that most of them have to do with feelings of inadequacy. She discusses the ways she has compared herself to her coworkers. She states, “My manager says I'm doing well, but I feel like she just doesn't want to hurt my feelings”. You help the client identify evidence that supports the idea that she is competent to do her job and fit in with her coworkers. She brings up a recent time in which her coworkers decided to go to the midnight showing of a new movie that just came out. She heard some of her coworkers discussing the plans, and was convinced no one would ask her to go. At the end of the night, one of her team members was organizing rides, and put your client on a list for one of the cars. She shares that she was surprised that it wasn’t even a question of whether she would go or not, but she was already included in the plans. On the other hand, she notes a time when her manager wrote her up for making too many mistakes in one day, however she was successful in completing the improvement plan that was set up with her. The plan involved setting up more concrete goals for herself, asking for help, and taking two online trainings, which she completed faster than the allocated time. She discusses her professional accomplishments and unique skills she brings to the team. You reinforce the client’s positivity with statements that promote self-esteem.
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Domain: Counseling Skills and Interventions

The client's statement in Part Two is an example of which Thinking Error?
1. Minimizing
2. Mental Filter
3. Disqualifying the Positive
4. Emotional Reasoning
Domain: Intake, Assessment, and Diagnosis

What statement would reflect the use of cognitive reframing in addressing the client's feelings of inadequacy?
1. “Feeling inadequate doesn't have to be self bashing, instead it can be a way of challenging self growth.”
2. “Feeling inadequate is all about comparison and comparison is a dead end road.”
3. “Feelings of inadequacy come when our inner child takes over.”
4. “Who says you aren't as good as anyone else? You're amazing!”
Domain: Core Counseling Attributes

You ask your client about her spirituality. Your client becomes tearful, stating that she does not want to discuss spirituality at this time. Which is the best course of action?
1. Use immediacy by stating, “I notice that you became tearful. What is behind that?”
2. Give the client a clinical questionnaire that helps gather information about the client’s cultural background, spiritual beliefs, and socioeconomic status.
3. Explain that, “This must be a difficult topic for you. You are brave for seeking out help. I need to get an idea about your spiritual beliefs so I can help you.”
4. Move on to another topic.
Domain: Professional Practice and Ethics

As part of your practice, you agree to begin supervising a recent graduate. Which of the following does not describe proper ethics of supervision?
1. The supervisor provides a manageable amount of feedback in each session
2. The supervisor aims to alter the supervisee's theoretical model
3. The supervisor chooses interventions that will help the supervisee work toward his/her learning goals
4. The supervisor encourages the supervisee to work outside her/his comfort zone by taking clinically appropriate risks and expanding his/her counseling approaches
Part Three

Fifth session, six weeks after the original intake session

The client reports that she only had four episodes of unhealthy eating this week, as opposed to up to seven per week as in previous months. You praise the client for her mindfulness and for the improvement. You ask the client what led up to the four times this week in which she demonstrated disordered eating. She states that she is unsure what happened, which makes her feel embarrassment and shame. You walk the client through her evening step by step to help her understand what was happening before, during and after her binge-eating. You normalize the experience for the client and bring her attention back to the progress she reported in the beginning. After discussing her progress, she states that she is now aware of her train of thought leading up to the binge eating. She identifies extended periods of time in which her social media usage caused negative self talk to arise. She talks about one of the social media accounts she follows that is all about how to weigh and measure carbs and protein correctly that made her realize that she is not as engaged with her diet as she used to be. The thoughts that she identifies in session are “I’m ugly”, “I’m unlovable”, and “I’m permanently damaged.” You help her identify times in her life when these thoughts have come up, and make a list of more reality-based, non-biased self-talk that she can remember if the thoughts were to arise again. You help her identify other ways she can spend her time aside from engaging with social media.
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Domain: Intake, Assessment, and Diagnosis

Based on the Transtheoretical Model, and on the information revealed in Part 3, in which stage would you place this client?
1. Preparation
2. Movement
3. Action
4. Progress
Domain: Counseling Skills and Interventions

Which of the following would be the best choice for a brief assessment into potential comorbid diagnoses?
1. WHODAS 2.0
2. DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure
3. Patient Health Questionnaire 9
4. Composite International Diagnostic Interview
Domain: Intake, Assessment, and Diagnosis

You devise a plan with the client to in which she agrees to spend 30 minutes mopping her floors and cleaning her bathroom immediately following any episode of unhealthy eating. This is an example of _____
1. Exposure and Response Prevention
2. Paradoxical Intention
3. Systematic Desensitization
4. Operant Conditioning
Domain: Counseling Skills and Interventions

Your 'step by step' intervention from the fifth session after intake is an example of which of the following CBT techniques?
1. Behavioral Experiment
2. Functional Assessment
3. Cognitive Restructuring
4. SOLVED technique