Case Conceptualization

Introduction. Grace is a Caucasian female college student in her early twenties that attends

Kansas State University. She is currently a senior and is expected to graduate this academic

year. Grace is heterosexual and had a serious relationship end over the summer. Grace currently

works at Target in the fulfillment department. Grace lives in an apartment with one other

roommate. Her parents, who live in Lawrence, recently divorced over a homosexual affair her

father was having. She is also the oldest child in the family and has two younger sisters. Grace

is a kind woman of average size. She demonstrates good hygiene for our sessions. Grace is

talkative and social when in session. It does not take much prompting to get her to speak what is

on her mind. Grace is always polite and has even mentioned that is difficult to not ask me

friendly questions while in session because of her amiability. Grace identifies as a Christian,

and, until recently, has attended several ministries around campus and Manhattan.

Theoretical Components. The first theoretical component used in this case is that of Dialectical

Behavior Therapy (DBT), which sees the counselor searching to validate and support the client

and what they have gone through, as well as help them to cognitively analyze their situation and

presenting problem to come up with solutions (Hackney & Bernard, 2017). During my time with

Grace, we have challenged and analyzed many of her thoughts to change how she views and

feels about herself and her world. The second theoretical component used within this case is

Cognitive-Behavior Therapy (CBT), which is a form of counseling that focuses on changing a

client’s thoughts or behaviors in order to change their affect and response to given triggers or

events. During our time together, Grace has worked to develop coping thoughts she can use to
fight her irrational thoughts and learned tools to change her behaviors and responses to certain

troubling stimuli. The final theoretical component used in this case is Solution-Focused Brief

Therapy (SFBT), which focuses on maintaining that the client has the tools at their disposal to

resolve their own presenting problem while also maintaining a focus on searching for a solution

to their problems rather than dwelling too much on the past. Many of the questions and prompts

that Grace has been given in counseling revolve around helping her to view situations more

positively and take steps to achieve the solutions she desires.

Presenting Problem. In this case, the presenting problem is that of extreme anxiety. Grace has

been diagnosed with anxiety prior to meeting with me but does not take medication and has not

had substantial issues with anxiety in years. However, recent bouts of anxiety have been

significantly more difficult to handle and have caused Grace to have multiple panic attacks.

Grace’s motivations in coming to counseling are to find insight into where these panic attacks

are coming from and to develop skills in coping with the anxiety that causes them. She also

mentioned that she would like insight into how to move forward with her life due to three major

events that have occurred and will be detailed later in the background information section.

SMART Goals Statement. By the end of our time meeting together in December, Grace will

have significantly more days without a panic attack during two-week period (12 or more days)

than the present. During the same timeframe, Grace will also develop more coping skills to

manage her anxiety while learning to accept the life changes that have occurred recently.
Background Information Three events occurred in Grace’s life over a short period of time that

have caused the recent spike in anxiousness. The first occurred in last May, when she and her

younger sisters discovered that her father had been having an affair with a younger man. When

approached about the discovery, her father had made it seem like it was the girls’ fault and had

gotten angry with them. The end result of this discovery was the divorce of her parents.

Currently, her sisters (who are in high school) live with her father because they view their

mother as controlling. Grace struggles to see what her sisters see, since it appears to her that her

mother is looking out for their best interests and trying to keep them from engaging in risky

teenage behavior. To complicate matters more, her father’s boyfriend is only a few years older

than Grace is. This adds an extra layer of anxiety for Grace, as this makes her feel

uncomfortable to be around them due to viewing him as someone she could potentially meet in a

class at college. The second event that occurred took place over the months of June and July of

2021. Grace’s boyfriend spent this time at Camp War Eagle. Until this point, they had engaged

in regular communication and were fairly serious about each other. Grace mentioned that she

would even spend some nights at his place. While he was at camp, this communication and

physical closeness was cut off. The two had some disagreements, during which her boyfriend

made several remarks that hurt Grace deeply. The end result was a mutual break-up. The final

event occurred in August, when her friends rejected her, telling her they no longer wanted to be

her friends because they were tired of hearing about how difficult her life was. Together, these

three events have left Grace feeling lonely with no one to turn to.

As previously mentioned, Grace has been diagnosed with anxiety and ADHD in the past,

but until recently these two diagnoses were not inhibiting her functioning. Since the occurrence

of these events, Grace has had some difficulties functioning some days. On good days, she is
able to behave like a normal person. On bad days, sometimes all she can do is lay in bed. When

asked, Grace had not considered taking her own life or self-harm. The primary symptoms she

experiences are the panic attacks along with an inability to focus on things the way she used to

be able to.

Client Strengths/Diversity There are several strengths that Grace has exhibited through

counseling. As previously mentioned, Grace is highly sociable and amiable. While she feels she

has less of these traits than she did before her break-up, it is evident that she is able to hold

conversations with a diverse group of people easily and that she is a likeable person. This

strength will likely help her to cultivate new friendships, and even now has helped to start

planting some of those seeds.

Grace has also exhibited some resilience. She chooses to not go back to extremely

negative ways of thinking or acting that she previously experienced and refuses to take out her

emotions on those around her. This resilience bodes well for her work through therapy, as it

gives her hope for a better future and will help her to achieve that goal.

A final strength of Grace is her commitment. She sought out counseling as a way to heal

from the events that hurt her last summer. She is determined to get better and has faithfully and

openly tried every intervention that has been brought up in session. Many of those interventions

have been used by her out of session as well, and she has accomplished every homework

assignment she has been given in therapy.

From a diversity standpoint, Grace is a single woman in early adulthood. This could

possibly be helpful to her as she determines who she wishes to be in life, but it could also be a

limitation as she desires to have a deep connection with a man. She also has no friends from her
high school living nearby, so she often feels totally alone in Manhattan. Many times this has

been the cause of her negative affect for the day.

Systemic Assessment. When looking at the situation and family from a systems theory

standpoint, there are a couple of problems that have seemed to occur within the family. First, in

terms of triangulation and scapegoating, Grace mentioned that it was evident that her father had

tried to blame her mother for his own behavior. She predicts that his has occurred in her father’s

new home, as her sisters have also turned their mother into a scapegoat in attempts to get Grace

to come live with them. This patter on behavior has worried and frustrated her, because Grace

still loves both of her parents and cares about both of them. Grace has attempted to appease both

sides by splitting her time with them to show that no single parent is more important to her and

that both matter.

There are also imbalances in the hierarchies in these homes that concern Grace. There is

largely a standard hierarchy in her mother’s home, and she feels that her mother sets good

boundaries for the children living under her roof. In contrast, Grace feels that her father does not

set good boundaries for his daughters, which leads to a more incongruous hierarchy in his home.

As such, Grace has attempted to encourage her sisters to make good decisions while realizing

that they are not under her control.

Family Map/Influences. Largely, Grace’s family has been a focal point of her anxiety since the

divorce. Her parents’ divorce and distaste for each other has led to Grace feeling embattle and

caught between two warring fronts. With her sisters choosing to side with her father, Grace feels

partially obligated to take her mother’s side but feels this would betray her love for her father.
To avoid seeming like she is choosing sides, Grace has worked hard to split her time with her

parents as evenly as possible. She has even gone so far as to not spend the night at either

parent’s home since the divorce, opting instead to stay with her grandmother that lives nearby

her parents. Her sisters have also begun bullying her to some extent as well to pressure her to

side with her dad, which hurts Grace. This has caused more anxiety for Grace, as her sisters

have begun making decisions that Grace views as unwise since choosing to live with their dad.

Solution Assessment. The first solution that Grace attempted to implement in regard to these

stressors was to talk to her friends about her struggles. For a while, this seemed to work for her.

However, as previously mentioned, her friends eventually chose to leave her because they were

tired of what they considered to be whining. This moved to Grace to her second attempted

solution before counseling, which was avoiding any situation that could cause an adverse

reaction. She went home as little as possible to stay away from her family and avoided campus,

church, and other ministries at all costs to keep her ex-boyfriend’s memories from surfacing.

However, when school resumed, she was forced to come back to campus, which has caused her

to have more anxiety as she drives around town as well.

Since counseling, there have been several more attempts Grace has made to cope with her

symptoms and return to normal functioning. The first things she tried were the 5-senses or 5-4-

3-2-1 technique to calm her anxiety when it arrives while using thought stopping and coping

thought replacements to help keep herself from reaching the point of extreme anxiety that causes

panic attacks. These techniques worked well when she had the energy to use them and when she

was not already in crisis, but she felt she needed more to overcome her anxiety when she did not

have the energy to control her thoughts or focus to calm herself. For this reason, we began
implementing anxiety reducing relaxation techniques like grounding exercises and deep

breathing. These new interventions worked to her benefit when already in crisis, and even

helped her to calm some when not in crisis. Coupled with the previous two techniques, Grace

has seen a marked reduction in anxiety levels in recent sessions. A final intervention used in

sessions was cognitive restructuring, which helped Grace to view herself as more positively in

regard to how she recharges and makes it through the day.

Summary Statement. Before meeting with me, Grace had three major life events occur in

quick succession that caused her previously diagnosed to flare up again. This anxiety was

exhibited through panic attacks. Her family’s inner turmoil with the reveal of an affair and

embattlement of divorce only increase the internal strife that Grace felt, and when her serious

relationship with her boyfriend ended, and her friend walked out, Grace felt alone. When Grace

began coming to counseling, she came with the goal of gaining insight into how to move past the

struggles she was feeling and back to a normal level of functioning while also desiring new tools

to help her cope with and reduce the anxiety she was feeling. During our sessions, we utilized

components of DBT, CBT, and SFBT to help her challenge her irrational thoughts, cope with the

stressors of her anxiety, and develop action plans to begin taking small steps toward the solutions

she desires. Through the further application and practice of techniques such as thought-stopping,

anxiety reduction, and cognitive restructuring, Grace will be able to confidently move beyond

the challenges she is currently experiencing and manage her anxiety levels on her own.
 References

Hackney, H., & Bernard, J. M. (2017). Professional counseling: A process guide to helping.

Boston: Pearson.