Case 7

Part One

Age: 21
Sex: Male
Gender: Gender-fluid
Sexuality: Pansexual
Ethnicity: Caucasian
Relationship Status: Single
Counseling Setting: Community clinic
Type of Counseling: Individual
Presenting Problem: Heightened anxiety in performance settings
Diagnosis: Social Anxiety Disorder, Performance Only

Presenting Problem: You are a recently licensed therapist working in a community clinic that serves an inner city population with a mixed and diverse clientele. The client has recently graduated with a Bachelor in Performing Arts degree from a competitive college with a strong arts program. The client informs you that the Performing Arts Department was so impressive that they had a difficult time choosing between dance and vocal arts. The client states that in the end, “I had this, like, insane opportunity to tour on CRASH for Charli, she just loved me, so I went with dance”. Soon after graduation, client was hired by a local dance troupe. Client describes that while college was a very supportive and collaborative environment, they are finding the dance troupe to be aggressively competitive. “Everyone needs to calm down. It’s a freaking dance, not a tracheotomy. No one dies if your point is an inch off. And what makes it worse is that they all pretend to be your friend and the director acted all thrilled to have an enby dancer but suddenly can’t find parts that fit my body type. It’s all bull, honestly”. Client explains that in college, performing was “euphoric”, but in this new environment, they are struggling with extreme nerves before every performance. “I'm sure the 'hyenas' are going to devour me after each show for each little misstep I make. It's getting to where I can barely make myself perform. I don't want to get out of bed on show nights, I don't want to be around people, it’s kind of a gag but I feel traumatized even watching dance TikToks!” Client clarifies that they love being in public but that the performance environment is becoming intolerable.

Mental Status Exam: Client presents well groomed with excellent hygiene. Their attire is coordinated, form fitting and appropriate for climate. They make good eye contact throughout the session and function within a normal emotive band. They do manifest heightened activation while recounting their performance anxiety. Client's thought process, content, speech, perceptions and insights all appear within normal limits.

Living Situation: Client lives in a small rental apartment with two other young adults. Client explains that they roomed with other performance majors during college, but everyone moved away after graduation, so they elected to room with strangers. Client explains, “Actually, this is working better for me, because my old roommates used to borrow my clothes all the time without asking. Like, pop off commie queen but don’t touch my Gucci slides, hahaha.” Client reports that they rarely see their roommates due to the fact that the roommates work during the day and the client is a 'night owl'. Client denies any significant conflict or issues with the roommates, saying, “They basically dress from The Gap, I don’t think they’d know what to do with my wardrobe.”

Relationship History: Client reports that they date often and “fiercely”. They are comfortable dating people of “any, all, or no” gender. They self describe as gender-fluid and pansexual. Relationship durations vary, according to the client. “A couple times I thought I found my person and we were together for, like ages. Other-times, it's more like a meteor, you know, a beautiful bright flash that was never meant to last long”, client explains. Client reports that they are comfortable in all dating settings, from intimate wine bars to “Horsemeat disco”.

History of Substance Use and Addictive Behavior: Client reports that they have been a 'social drinker' since early teens. They admit to occasional heavy drinking, but “only when stars are just right, and I never blackout or drive drunk”. Client reports that they have used recreational marijuana since their teens, but since joining the dance troupe, they are needing to smoke on performance nights in order to motivate themselves to leave their apartment. “Pot helps me get out the door, but I still feel all wound up about the show, like I'm going to screw up and get filleted. I love dance, but I don't know how much longer I can take this”, client states.
- - - - - - -

Domain: Intake, Assessment, and Diagnosis

Which of the following symptoms revealed in Part One most affirms this client's diagnosis?
1. Their difficulty leaving the home on performance nights
2. Their pre-performance anxiety
3. Their dread of being ridiculed by the other dancers
4. Their dependence on Marijuana to face performances
Domain: Counseling Skills and Interventions

From an Adlerian perspective, how would you reflect the client's statement of “I'm sure the 'hyenas' are going to devour me after each show for each little misstep I make. It's getting to where I can barely make myself perform.”?
1. I hear that the thought of being ridiculed makes you want to avoid performing.
2. I hear that criticism from the other dances makes you doubt yourself.
3. I hear that you expect the other troupe members to criticize you, but what is the evidence of this?
4. I hear that criticism from the other dancers causes your emotions to become significantly heightened.
Domain: Counseling Skills and Interventions

You begin to work with the client to help them understand their 'Window of Tolerance'. This refers to:
1. The level of arousal that one can comfortably tolerate
2. The amount of adversity that one can tolerate
3. The degree of acceptance that one has towards people who are different from oneself
4. The level of emotional pain that one can tolerate
Domain: Counseling Skills and Interventions

From an Emotion-focused Therapy perspective, how would you reflect the client's statement of “I love dance, but I don't know how much longer I can take this”?
1. “What emotions does their criticism evoke?”
2. “I hear you saying that dance makes you feel alive.”
3. “I hear you doubting your ability to keep performing.”
4. “I hear that while you love dance, you don't know if you can keep experiencing the level of pain caused by their criticisms.”
Domain: Intake, Assessment, and Diagnosis

Which of the following is not a potential component of the Performance Only specifier?
1. The anxiety is most likely to manifest in non-professional settings.
2. The specifier can apply to public speaking situations.
3. The specifier can apply to fear of making public presentations in work or academic settings.
4. People with Performance Only Social Anxiety do not fear nonperformance social situations.
Part Two

Fourth session, Four weeks after initial intake

The client has been coming for weekly sessions and appears to have settled into the therapeutic process. They comment, “Like, I really didn't know if you would 'get' me, but I shouldn't have prejudged you. I guess I did to you what I hate others doing to me. My bad.” The client is beginning to understand why other people's comments and criticisms can cause them so much pain. “I'm beginning to see how much power I give my coworkers and the director. Especially the director. It's like she knows how to trigger all my self-doubt.” The client has begun to explore what Power meant in their family of origin. Their mother loved them but was a 'metal b***h' who wouldn't tolerate any dissent. The client learned how to keep quiet and stay out of trouble. They describe an incident that occurred when they were in grade school where their mother was enraged because the client laughed when the mother accidentally dropped a platter of meat. The client's punishment for 'disrespect' was three hours of 'marching' around the perimeter of the house after dinner. The client's parents divorced when the client was in middle school with the mother receiving full custody. The client describes that after the divorce, the mother softened and began to focus on her self care. She even helped her children to open up and express their 'true selves' which was a major change. However, she still ran a strict house and expected complete obedience. The client began taking dance classes in 9th grade. The client begins to open up about an additional struggle they have been experiencing since college started. They explain, “Look at me. Can you see how ugly my body looks? My right side is so much bigger than my left. I feel like a poorly drawn cartoon. Symmetry is everything to a dancer. But nothing I have tried has worked to balance my body. I've tried every diet you can imagine, all kinds of exercises, massage programs, but nothing works. I feel like a freak!” The client describes a careful routine they follow involving measuring each limb twice a day in the morning and evening to check for symmetry.

Domain: Intake, Assessment, and Diagnosis

Based on the information revealed in Part Two, what is the most likely co-morbid diagnosis?
1. Obsessive-compulsive disorder
2. Body Dysmorphic Disorder
3. Generalized Anxiety Disorder
4. Unspecified Feeding or Eating Disorder
Domain:Core Counseling Attributes

Using empathetic atunement how would reflect the client’s statement of “I'm beginning to see how much power I give my coworkers and the director. Especially the director. It's like she knows how to trigger all my self-doubt.”
1. “I see that you are making important connections between how we retain power and how we give it away.”
2. “I hear that sometimes you blame yourself for allowing others to have power over you.”
3. “When they disparage you, you start disparaging yourself”.
4. “Their taunting and criticism makes you feel bad about yourself and doubt your ability as a dancer.”
Domain: Counseling Skills and Interventions

While addressing the client's performance anxiety, you teach them a relaxation technique that involves breathing from the abdomen. This is clinically called:
1. Core Breathing
2. Abdominal Breathing
3. Diaphragmatic Breathing
4. Deep Breathing
Domain: Intake, Assessment, and Diagnosis

How could you apply Externalization, from a Narrative Therapy perspective, to this client's situation?
1. Help the client to give their pre-performance fears and anxieties a name.
2. Help the client to see how they are giving their power away to others.
3. Teach the client how to remove themselves from upsetting situations.
4. Teach the client how to defend themselves from external attacks.
Part Three

Eighth session, Eight weeks after initial intake

The client presents extremely animated. They present wearing silk Versace-print shorts and a chiffon bathrobe with their signature Gucci slides and leaf green-tinted glasses. They inform you that they have been selected for the lead dance role in the company's upcoming premier. They will be dancing the part of a changeling who is on a path of self discovery. “How perfect is that! It's like the fates knew exactly what I needed at this time in my life! You should have seen me during the auditions. I tuned out all the haters in my head and let my inner muse take over. I practically flew across that stage!” The client expresses that since learning how to externalize their fear of criticism, they are feeling much more confident and empowered. They are still experiencing pre-performance jitters, but they are far less concerned about the snide remarks of their troupe mates. “It’s still surreal but it feels so right. This part is me! I’m a little changeling haha! I mean, this really says something about what I can do, right?” The client is still troubled about their body's 'asymmetry' and continues to do daily measurements. They report, however, that they are spending less time on diet and exercise regimens designed to correct the 'asymmetry'. “Honestly, I hardly have time to keep up rehearsals so I’ll just have to hope a reduced regimen still helps. I'm in almost every scene. And some scenes have two or even three costume changes! I just don't have time to fix my ugly arms and legs.” You affirm the client's progress and towards the end of the session and raise the possibility of moving to sessions every-other week.

Domain: Counseling Skills and Interventions

As you process with the client their successes, you have them identify the numerous positive steps that they have recently made. This CBT technique is referred to as a:
1. Goal Map
2. Credit List
3. Success Diary
4. Positive Step Chart
Domain: Counseling Skills and Interventions

From a Motivational Interviewing Therapy perspective, how would you use 'developing discrepancy' to address the client's Body Dysmorphic symptoms?
1. “A dancer's body is their temple. How are you treating your temple?”
2. “Have you measured other people's arms and legs? Is your 'asymmetry' really any different from everyone else's?”
3. “Who says your body is asymmetrical? Where is the evidence?”
4. “It looks to me like you strive to accept others as they are. Are you doing that for yourself in regards to your arms and legs?”
Domain: Intake, Assessment, and Diagnosis

When you raise the possibility of reducing session frequency, the client is upset and says, “You don't want to see me weekly anymore? Why? Are you rejecting me too?” From a Psychodynamic Therapy perspective, this dynamic is referred to as:
1. Introjection
2. Reaction Formation
3. Transference
4. Sublimation
Domain: Treatment Planning
What is the best clinical action to take when a client informs you that they are no longer able to afford your services?
1. Refer them to a no-cost local support group
2. Refer them to a community mental health clinic with a sliding scale that they could afford
3. Reduce your charge to one that would be affordable to the client
4. Inform client that therapy can wait until they are able to afford it