Counselor Toolbox Podcast with Dr. Dawn-Elise Snipes produces 2 episodes each week and offers CEUs based on the podcast at AllCEUs.com/counselortoolbox
Coimbatore Call Girls in Coimbatore 7427069034 genuine Escort Service Girl 10...
Adjustment disorder case study
1. Adjustment Disorder Case Study
Using the PACER Method
Counselor Toolbox Podcast Episode 442
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs.com
Podcast Host: Counselor Toolbox and Case Management Toolbox
Copyright 2019 Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment 1
2. Objectives
Review a case study using the transdiagnostic,
transtheoretical PACER approach
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment 2
3. As they say on Law and Order…
The following story is fictional and does not depict any
actual person or event.”
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment 3
4. Case
Dana is a 18 year old freshman attending the
University of Gallifray. This is the first time she
has been away from home for any length of time.
She did not get a bid at the sorority she wanted to
join, does not like her roommates in the dorm and
is finding it difficult to attend classes and keep up
with her work.
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment 4
5. Physical
Sleep
On an average night how much sleep do you get? REM
_1__ Deep _.5__ Light _3___ Just can seem to sleep.
On an average night how many times do you wake up?
__1-2 (When roommates come home)
After an average night’s sleep how do you feel? Tired
_x__ Okay ___ Energetic ____
When you wake up feeling refreshed, how much sleep
do you get? REM __3_ Deep __2+_ Light __3+__
Sleep hygiene self assessment.
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment 5
6. Physical
Nutrition
Using a free app like SparkPeople, track your nutrition for a week.
Which nutrients do you get less than 75% the full RDA? Selenium
Which nutrients do you get less than 25% of the RDA? None
When was the last time you had a full panel blood test to examine
your kidney and liver function, thyroid and vitamin D levels?
Unknown
Describe your eating habits: I have been eating a lot of pizza and
Jimmy Johns lately
Do you eat due to stress or for comfort when you are upset? yes
Do you drink at least 64 ounces of noncaffeinated, nonalcoholic
beverages each day? yes
How much caffeine do you have on an average day? (100-150
mg/8oz of regular coffee; 35-50 mg/8oz of soda) ~600mg
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment
6
7. Physical
Nutrition
How much nicotine do you have on an average day? (1mg/1
cigarette; 6-24mg/vaping cartridges) __0___
Are you currently over or under fat? (Note: People can have
a lot of muscle and not be unhealthy) _no____
Have you recently had any problems with excessive thirst or
hunger? __no
Do you have problems with hypoglycemia (your blood sugar
dropping)? _no
Have you recently gained or lost a lot of weight? No
Has your doctor tested your blood sugar lately (fasting blood
test)? __no
Do you mainly gain weight around your belly? __no__
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment
7
8. Physical
Medication/Drug/Herb Reason for Taking
It
How Long Prescribing Doctor
(if any)
None
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment
8
9. Physical
Pain
Do you have any chronic pain? __no__
If so what causes it?_____ How long have you had it?
___
What makes it worse? ___________
What makes it better? _How has it impacted your
mood/relationships/energy/sleep/self-esteem? N/A
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment 9
10. Physical
Exercise/sedentariness
Do you exercise? ____yes______ If yes, how often
and for how long? ____daily 60-90 minutes_____
How is your energy, mood and appetite after you
exercise? ___good________________
Do you sleep better on days you exercise? __yes___
Does muscle soreness make it harder to sleep? __No___
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment 10
11. Physical
Energy
Which best describes your average energy level
Low__x_ I can get through the day___ Great! ___
Have you had your thyroid levels tested lately? __N__
If so were they in normal range? __?__
Using a pulse ox monitor: What is your resting heart
rate? __70_ What is your O2 saturation? __98___
Do you have high blood pressure? _N__ Heart
conditions? _N____ if so, what
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment 11
12. Physical
Libido/Sex hormones
How is your sex drive? Low __x___ Good _____
Incredible______
Has there been any change in your sex drive? __N___
If so when and what caused it? ____?__ Been low for a
couple years
If you are over 45 have you had your sex hormone
levels tested in the past year? ___N/A___
How often do you engage in sexual activity?
___celibate
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment 12
13. Physical
Do you tend to feel on edge and startle easily? ___N___
Do you have a history of trauma? ____N___
Do you have any autoimmune issues/inflammatory conditions like psoriasis,
rheumatoid arthritis, Chron’s disease, lupus etc.? ___N_
Have you ever had a concussion or other traumatic brain injury? ___N_____
How often do you have headaches? ____N__ What triggers them? __
What helps them go away? _________
Do you ever see spots or floaties when you get a headache? __
Do you get migraines? ___N_____
How often do you drink alcohol? _daily_ What do you drink? Beer/wine
_none_
Do you gamble or play the lottery? __N___ How much money do you
spend on it each week? _______
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment
13
14. Affective
For each of the following feelings, identify how often you feel
it each week, what triggers it and what makes it better.
I feel happy 0-3 days a week __x__ 4 or 5 days a week __ More
than 5 days a week __
What 5 things help you feel happy? _going home__
* What things used to make you happy or did you enjoy: My dog, working
out, my friends, planning for college, photography, hiking
I feel sad or depressed 0-3 days a week __0__ 4 or 5 days a week
_x___ More than 5 days a week ____
What triggers it? I’m just always “blah”
What helps you feel better? Nothing
I feel stressed or overwhelmed 0-3 days a week ____ 4 or 5 days a
week ____ More than 5 days a week _x____
What triggers it? _Class assignments, grades, scholarship
What helps you feel better? __nothing. Even when I get them done, there
will be more…they never stop
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment 14
15. Affective
I feel anxious or worried 0-3 days a week _x_ 4-5 days a week
_ >5 days a week __(see stressed)__
What triggers it? __
What helps you feel better? ______?____
I feel angry, resentful 0-3 days a week ___ 4 or 5 days a week
_X_ >5 days a week
What triggers it? My rude roommates, seeing girls from the sorority I
rushed, having to sit through class while the professor drones on
What helps you feel better? Nothing
I feel guilty 0-3 days a week __0_ 4 or 5 days a week __ >5
days a week
What triggers it? ___
What helps you feel better? _______
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment
15
16. Affective
In the past year, I have experienced the following losses which caused
me to feel grief: Not getting into the sorority. Breaking up with my HS
boyfriend. Moving to college.
What stressors are currently present? __school assignments, roommates,
no social support (Nobody at school. Parents not understanding. Feels
like a failure (sed to be big fish in a little pond))
What is different when you are happy? I can focus. I am more
responsible.
How long does it take for you to calm down after you get upset? _+/- 1hr
What helps you calm down? __I watch TV or go on a run___
Educate about HPA-Axis activation, biofeedback and relaxation techniques.
Discuss affective issues in counseling
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment
16
17. Cognitive
How is your attention/concentration? ___awful___
Have you ever been diagnosed with ADHD? _N____
Has there been a change in your ability to concentrate lately? _Y__
How long? ___3 months___
If so, what is causing it? __lack of sleep? Depression? I don’t know.
Does it seem to be taking longer to process information? _Y_
How is your memory? __awful______ Have you been more forgetful
than usual? ___y_____
If so, when did your forgetfulness start? A couple weeks after I got here.
When you think about yourself, your life, the world, other people, do
you tend to feel angry, suspicious or hopeless? ___Y___
If yes, have you always felt this way or did something happen to
change your feelings? __Came to college…It is not what I thought it
would be. My friends got into sororities and I didn’t. I don’t think I
did well on my midterms.
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment 17
18. Cognitive
Negative self-talk
Do you frequently judge or criticize yourself? ___Yes
Do you hold yourself to a higher standard than you hold other
people? ____N______
Do you think you are lovable/likeable only if you are perfect
(or almost perfect)? ___N*____
Where did you learn your negative self talk? __My family is
very successful. My parents always achieved anything they
put their mind to. When I fail I disappoint them
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment 18
19. Cognitive
Pay attention to your thoughts for a week. Place a check by the thinking
errors which are most common for you and contribute to your unhappiness.
X All or none thinking Find Exceptions
X Focusing on a small aspect instead of the bigger picture Consider alternate
explanations
X Expecting life to be fair Explore living in the AND
X Taking things too personally Consider alternate explanations
X Focusing on the negative and ignoring the positive Learn about radical acceptance
Taking something bad and blowing it out of proportion (catastrophizing)
Expecting people to be able to read your mind Evaluate how you communicated
what you wanted and practice assertive communication
Assuming/Jumping to conclusions without all the facts Get the facts
Assuming you know what others are thinking. Evaluate your evidence. Get the facts.
Educate about cognitive distortions and interventions. Provide worksheets to address
CDs.
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment
19
20. Cognitive: Hardiness
What parts of this relationship, experience or thing can you control?
Children
none
Parents
They just don’t understand. I feel worse after I talk with them.
Friend 1:
My BFF from HS. I could text her more
Friend 2:
I could try going to church or a bible study to see if I can make some friends here. I could start teaching
spin again to meet people. I could find somewhere to volunteer.
Friend 3:
Job/School
(graduation)
Force myself to go to class. Study at the library before going back to the dorm. Bring coffee to class to
make it more tolerable. (Sign up to get paid to take notes)
Dorm Try to transfer to a single. Get ear plugs and a sleep mask. Find a way to afford to live off campus next
semester.
Pets
Move off campus so I can have my dog with me
Money No problems
Volunteering
Health
I can start eating better, do what I can to improve my sleep, continue exercising.
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment
20
Educate about psychological flexibility and discuss how, how much and how often you intend on doing each of these
things and make a schedule or checklist for 1 week to remind you to do them. Repeat weekly.
21. Cognitive
Time management
How effective are you at managing your time? Bad. I used to do
4th period homework in 3rd period
Do you often take on too much and feel overwhelmed or rushed?
Yes
Are you a perfectionist? __Y___ If yes, how does that impact your
mood, sleep and relationships? I tend to get irritable
Do you procrastinate? __Y__ I just don’t have the desire to do
homework and laundry and stuff so I put it off until it is a crisis.
If yes, how does that impact your mood, sleep and relationships?
__When I am procrastinating I’m okay, but then I have to pull all
nighters to get my assignments done.
Develop a schedule that includes the “must dos” delegates and
simplifies when possible.
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment 21
22. Environmental
Do you feel safe most of the time? _____Y___ If no, where do
you not feel safe and why?
What helps you feel safe? __Campus feels safe
Are you able to have peace and quiet when you want it and
when you sleep? ___no If no, what can you do to reduce
unwanted noise? Move. Ear plugs/headphones.
During the day are you able to access natural light, or at least a
really bright working area? ___Yes walking to class
When you sleep, are you able to make your room totally dark or
block out the light? _N—Roommates in and out at all hours_
Do you eliminate blue light from television and electronic
devices at least 2 hours before bed? __N I play on my phone
until I fall asleep
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment
22
23. Environmental
What smells are you regularly exposed to?
Noxious/unpleasant/irritating __nothing.
Triggering (reminds you of something unpleasant)
_nothing_
Happy/relaxing/energizing __coffee. The gym. Air
fresheners
Are you able to keep your environments at a
temperature you find comfortable? __Yes
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment
23
24. Relationships
Do you feel you are capable, lovable and deserving? _not sure____ If
not, why not? __I used to be really confident. Since I got here—well it
is all just so different. Not what I expected._
Do you have healthy relationships or regularly fear abandonment?
____My parents won’t abandon me, they will just be disappointed if
Idon’t continue to be the best (valedictorian)______
Can you effectively identify and communicate feelings and thoughts
and get your needs met? ___apparently not_____
Do you have a social support system that can provide practical
assistance and emotional support? __No
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment 24
25. Summary
Dana is struggling to adjust to college. In high school she was the valedictorian, on the dance team and
very popular.
The study habits she had in high school are not helpful in college. She has difficulty budgeting her time to
study and do her assignments and experiences a great deal of anxiety over her grades being comprised of
just a couple tests/papers.
She anticipated college classes to be enthralling and college to be an adventure. She is disillusioned to find
that her freshman classes feel like a re-hash of high school. Part of her feels the work is so easy she can get
it done at the last minute and she has difficulty getting motivated to get started. Then she ends up pulling
all nighters to get the work done and turning in less than her best work.
She identifies that her mood and desire to do anything changed significantly when she was rejected from
the sorority. Her friends from HS are all in one. She doesn’t really know where she fits in.
She has 2 roommates. 1 is rushing a sorority. The other just stays out until all hours. They wake her up
when they come and go and she has very little in common with them.
She tried to talk to her parents, but they told her that everyone goes through an adjustment period and
blew her off. She is worried that they will be disappointed if she doesn’t get straight As
Her BF went to another college, so they broke up before the school year started. She thought she would be
so busy with stuff she wouldn’t care, but she cant stop thinking about it.
Currently she is not sleeping much, and when she does it is not well. She reports feeling exhausted,
“foggy” and generally apathetic.
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment 25
26. Tx. Plan Goals
Dana will figure out where she fits in and develop
social support
Dana will complete a compare and contrast of HS and
college to figure out what was different in HS that made her
happier and work toward recreating some of that.
Dana will enhance her social circle at college by exploring
volunteering (humane society?) and getting a job teaching
spin
Dana will make a plan for moving out of the dorm next
semester so she can have her dog at school with her and go
to the dog park
Dana will start texting her BFF from HS at least twice a
week
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment 26
27. Tx. Plan Goals
Dana will develop better study habits, rekindle her
enthusiasm for college and reduce her anxiety about
her grades.
Dana will make a master study schedule and post it over her
desk
Dana will learn about and practice “chinking”
Dana will sign up to start getting paid to take notes so she can
save money to get an apartment off campus (and it will
encourage her to go to class)
Dana will get involved in the undergraduate honor society for
her major to explore what upper division has to offer
Dana will find a study buddy to help her get motivated to do
work in a timely manner.
Dana will make use of her professor’s office hours to get
feedback on projects or papers before turning them in
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment
27
28. Tx. Plan Goals
Dana will improve her sleep
Dana will get ear plugs or noise cancelling headphones and a sleep
mask to help her stay asleep despite the noise in the dorm to
improve her energy and focus throughout the day
Dana will add a blue light filter to her phone to help with sleep
Dana will reduce her anxiety and depression
Dana will address cognitive distortions especially catastrophic
thinking, personalization and focusing on only a couple aspects of
a situation
Dana will start doing one thing each day that makes her happy
Dana will begin each day with positive forecasting and end each
day with positive reflection and radical acceptance
(Note: Family session is not currently a consideration due to
parents being in another state)
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment 28
29. Tx. Plan Goals
Dana will work through her grief issues in
counseling
Breakup
Not getting a sorority bid
Not being a “big fish”
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment 29
30. Reassessment
Dana made the school schedule and started “chunking” She found
that it helped her to get her work done if she made herself go to the
library instead of going back to the dorm
Dana has started using her professor’s office hours and feels more
confident in her ability to do her work.
Getting paid to take notes has significantly increased her motivation
to go to class and pay attention. She is not sure if it will help with
her grades, but she is not falling nearly as far behind and hasn’t
pulled an all nighter in 2 months.
Dana still hates the dorm, but she talked with her parents and they
have agreed to help her move off campus next semester and bring her
dog to school. This improved her outlook.
When comparing to high school, Dana realized that there she felt
noticed and appreciated. Dana has found a couple extracurricular
groups that she enjoys going to. She hasn’t met any real “friends”
yet, but she does feel a little more connected.
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment 30
31. Reassessment
Dana reports that she still hates her classes but she now sees them as
a way to pad her GPA before upper division.
Dana still holds some bitterness toward the sorority, but realizes that
holding on to that anger is not going to change anything. She does her
best to avoid those women right now and focus her attention on her
new activities.
She has worked through some of the grief related to her breakup. She
recognized that it represented another rejection (in addition to the
sorority) and was focusing on that because she thought it was
something she might be able to change.
Dana has found positive forecasting and reflection and radical
acceptance helps her to focus on the bigger picture which has also
reduced her catastrophizing.
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment 31
32. Summary
Unlike depression and anxiety disorders which generally
have no identifiable trigger, adjustment disorders
typically have a clear “cause”
When life changes (even for the better) it throws our
world out of balance and we have to adjust.
Dana recognized how college was more than just a
different school and identified ways to bring her
“world” back into balance.
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment
32