Case Study
Patient Demographic: Name: Jill Clinical Issues: Depression and recent death of a close friend Diagnostic Category: Depressive Disorders;Substance Use Disorders Provisional Diagnosis: F34.1 Persistent Depressive Disorder, with Anxious Distress, and F10.99 Unspecified Alcohol-Related Disorder Age: 26 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Eastern European Marital Status: Never married Modality: Individual Therapy Location of Therapy : Agency  
Mental Status Exam: The client is a 26-year-old female who appears slightly disheveled and unkempt with bags under her eyes, suggesting recent lack of sleep. Her affect is flat and her behavior is withdrawn. She speaks in a quiet monotone and is tearful at times. Her speech is coherent, though her thoughts are sometimes diffuse. She exhibits difficulty in focusing on topics and has some difficulty in supplying relevant details. The client reports that she has difficulty concentrating and recalling information, as well as making decisions. No perceptual distortions are reported. The client has limited insight into the cause of her distress, but appears to understand that her drinking is a problem. Her judgment appears impaired due to her drinking, as evidenced by her blackout episodes. The client expresses feeling overwhelmed and states that if counseling does not help, she is not sure she wants to go on living. She has also had thoughts of death and dying.
Presenting Problem: First session You practice as a mental health therapist at an agency. A 26-year-old female presents for therapy following a recent incident involving the death of her close friend. The client elaborates on her friend's death by saying, "He was beaten to death because he was transgender." The attack occurred a week ago, but the client states she has felt depressed for as long as she can remember. She says, "He was the only person who could actually put up with me. Now that he's gone, I feel like I have no one." She tells you that during the past few years, she has been drinking as a way to cope with her feelings. She states that she is usually able to control her drinking, but admits that lately it has "gotten out of hand." After her friend was killed, she went to a party and blacked out after drinking. She states that she cannot seem to find joy in anything and cannot stop thinking about her friend. You continue your assessment by exploring the client's history and current symptoms. After gathering more information, you determine that the client is experiencing a major depressive episode which has been compounded by her friend's death.    When asked what she is hoping to gain from therapy, she responds, "I just want to stop feeling so awful all the time." You validate her feelings and applaud her willingness to seek help. You share information about the counseling process and treatment options, including potential risks and benefits. You tell her that it is important to be open and honest during therapy and that she may need to talk about some difficult topics to make progress. After explaining the importance of developing a trusting relationship, you encourage her to ask questions and ask if she has any concerns. She asks if she can contact you outside of your counseling sessions. You review your agency's policies with her, including information about therapist availability.  Third session You and the client have agreed to meet for biweekly therapy sessions as she feels she needs extra support right now. This is your third session with the client, and she presents looking exhausted and can barely speak. You consider alcohol use, but there is no smell of alcohol, and the client's eyes do not seem dilated. She is neither slurring her words nor stumbling. You can sense that she is exhausted, both mentally and physically. She shares that she has not slept in 48 hours and is struggling with nightmares about her deceased friend.    She says, "Why did he have to die? I feel like it's my fault." Next, you ask her, "What do you think caused your friend's death?" but she looks away and shakes her head, unwilling to answer. You then try to explore the nightmares she has been experiencing, but she becomes irritable and angry. Finally, she breaks down and begins to cry. You allow her time to cry, knowing that it is a way for her to release some of the pain she is feeling. After a few minutes, you ask the client if she would like to talk about what is going on in her life. She agrees and starts talking about how overwhelmed she feels. She hates her job, her past, and her present. The client feels like everything is too much for her to handle. You listen patiently as she talks about her feelings.  Eighth session You have been seeing the client for a few months now, and she has consistently come to therapy and has made some progress, but some areas still need work. Regarding the death of her friend, she remains in the denial stage of his passing. She had been prescribed medication to help with her insomnia and depression, which seemed to be helping somewhat. In addition, she is limiting her alcohol intake, but she has not stopped drinking altogether. She had also been working on identifying her triggers for anxious distress, and you discussed several of them during previous sessions.    Today, you focus on the stress the client reports in relationship to her job. You ask, "What has been going on at work that has been making you feel stressed out?" She starts to talk about her boss and seems to be caught up in the details, getting lost in her story. You notice her becoming agitated. You ask her to explain what she is feeling and she says, "overwhelmed, frustrated, and like I can't keep up." She tells you that just talking about it makes her feel physically uncomfortable. You offer the client some grounding techniques to help her stay in the present moment. You suggest she take a few deep breaths and focus on her breathing. You then ask her to focus on her physical sensations, including any tension or tightness in her body and gently encourage her to release that tension. You suggest she identify something in the room that can help her stay grounded and focus on it if her mind starts to wander.    When she appears to be calm again, you ask her to describe the situation at work that is causing her the most distress in simple terms, without getting caught up in details. The client goes on to explain that her supervisor is often critical of her and she feels as though he does not appreciate the hard work she puts in. You listen to her and empathize, then encourage her to think about specific ways she can address the situation at work. You suggest that she start by making a list of her skills and competencies, so that she can remind herself of her worth when feeling attacked.    Throughout the session, you mirror the client's body language by following her lead. When she leans forward, you lean forward. When she furrows her brows or crosses her arms, you do the same. You also make eye contact with the client, giving her your undivided attention.
Other Contexts: The client grew up in a very chaotic household with five siblings. The client is a first-generation Eastern European whose family immigrated to the United States before her birth. Her parents never adapted to the culture. Her father committed suicide when she was in high school. She says, "It was like my dad leaving us just made everything worse." The client says she has no patience with her siblings when they call and has little desire to keep in touch with them. After completing her associate's degree, the client immediately started her job as a paralegal. She is a paralegal at a law firm where she has worked for two years. She describes her work as "okay, but not something I'm passionate about." She says that she has been feeling increasingly overwhelmed and stressed out. At work, she becomes easily annoyed, has trouble concentrating, and feels tense. She has difficulty getting along with her colleagues and tries to avoid them when she can. 

Question: What intervention would best enable you to accomplish the treatment objective of increasing the client's support network?
(A): Encourage the client to reconnect with her friends
(B): Suggest that the client reconnect with her siblings
(C): Recommend grief group for the client
(D): Explore the client's relationship with her father

Correct Answer: Recommend grief group for the client
Explanation: A group would provide good social support for the client to help her through her grief. Her best friend died, and she does not have a healthy family dynamic. Therefore, the correct answer is (C)
Competency: treatment planning