Case Study
Patient Demographic:  Age: 27 Sex: Female Gender: Female Sexuality: Declined Ethnicity: Hispanic/African American Relationship Status: Single Counseling Setting: Community Agency Type of Counseling: Individual
Mental Status Exam: The client presents as her stated age with positive signs of self-care related to hygiene and dress. She appears overweight for height as noted in her intake. Her mood and affect are congruent and she appears to be cooperative and forthcoming in her responses. She demonstrates no retardation, spasticity, or hyperactivity of motor activity. She is oriented and demonstrates no unusual thought processes or patterns. Her insight is intact and she identifies goals for therapy. She reports no suicidal ideations, thoughts of harm to self or others, or difficulties with memory, judgement, or concentration. 
Presenting Problem: You are a counselor in a community agency that provides counseling.  Your client presents with a history of convictions for felony criminal offenses in her early 20s, of weight loss and gains since college, and currently rates herself as approximately 50 pounds overweight. She describes herself in years past as “fat,” “ugly,” and “grotesque.” She reports one long term relationship during high school and college, with a male she tells you was “manipulative, controlling, and emotionally abusive. She reports not “dating-dating” since their break up six years ago. She does report that recently she has engaged in self-destructive behaviors with different people in the context of online relationships. She states that in several cases, she has met men and women online and used elaborate methods, including using multiple telephone numbers and creating false names and life events to establish relationships with these individuals. Several relationships ended abruptly when the individuals, both male and female, made concerted efforts to meet the client, at which time she disclosed the truth to them. She tells you that she feels very badly about what she did, particularly because she had been helping each of the people with different problems in their lives, including one of the women with an abusive spouse, and she believes now these people will have no help.  She attended counseling for several months three years ago but reports she did not tell the counselor everything. Today she tells you that she is now in a professional graduate program for counseling and wants to be open about everything so she can “finally get her life in order.”
Other Contexts: Family History:
The client reports her support system as several male and female friends. She feels close to these people though she says they sometimes irritate her. She describes her father as distant and her mother as strict and controlling. She states she and her siblings were punished frequently for not following their mother’s strict expectations for “how young women and young men should act.” She states she and her siblings were required to engage in daily exercise; always dress in “their Sunday best” during childhood; and focus on dieting, food intake, and weight ideals. She tells you she daily engaged in binging and purging from age 13 to age 20, but never told anyone or saw a doctor for this. She tells you that she has not binge/purged for the past five years. She states that her sister did the same and still struggles with it, and two other siblings are in treatment for alcohol and methamphetamine addiction. Additionally, the client tells you that both of her maternal and paternal grandparents have histories of alcoholism, and she smiles when telling you that one of her grandparents was imprisoned for criminal behavior and “is connected.” She says that several other maternal and paternal relatives have criminal convictions.

Question: Using the information provided, which of the following represents the client's current struggle?
(A): Lack of support
(B): Lack of boundaries
(C): Desire for control
(D): Desire for approval

Correct Answer: Desire for control
Explanation: The client's narrative focuses on her desire to control herself by controlling others. She required her parents to buy and eat the way she is eating. She became angry at her brother for not acquiescing to her demands and at her father when he ignored them and ate a doughnut. She tells you she is aware of her mother's attempts to control her but shows no recognition of her own attempts to control others. The client demonstrates rigid boundaries for how others should act around her so while they are not appropriate, she is not lacking boundaries. Her family's actions, as narrated, do not show a lack of support for the client but instead show some resistance to her desires to control them. The client likely does desire her mother's approval but is currently engaged in a power struggle with her mother to determine who ultimately will control the client. Therefore, the correct answer is (C)
Competency: intake, assessment, and diagnosis