Case Study
Patient Demographic: Initial Intake: Age: 70 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/Non-Hispanic Relationship Status: Widowed Counseling Setting: Private Practice Telemedicine Type of Counseling: Virtual Individual
Mental Status Exam: Mary presents with anxious mood and congruent affect. Speech is normal rate and tone, motor movements within normal limits. Denies hallucinations, delusions, suicidal or homicidal ideation. Mary is well-dressed, adorned with makeup, jewelry, and stylish hairstyle. Mary frequently resists the urge to cry as evidenced by smiling and deflecting when becoming tearful. She tells you she wants to work on herself but appears mildly offended whenever given feedback or asked a personal question and then changes the subject.
Presenting Problem: Diagnosis: Anxiety disorder, unspecified (F41.9), Adjustment disorder, unspecified (F43.20)
 

You are an associate counselor and receive a new referral for a virtual client through your company’s telehealth practice. Mary is a 70-year-old widow who lives alone with her dog in a 55+ active living community. Mary moved to her town to live closer to her daughter and son-in-law when she lost her husband suddenly to cancer four years ago. Mary is struggling with feeling comfortable leaving the house or engaging in any social gatherings outside of being with her children. She wants to make friends her age and take local activity classes, but her anxiety prevents her from committing to plans. Mary has been widowed for four years but has not yet committed to counseling or attendance in grief support groups. She has felt insecure socially since her husband died, but reports being a “social butterfly” before his passing. She admitted to only visiting her husband’s grave on his birthday but is unable to do so any other time. Also, since the COVID-19 outbreak, Mary’s fears and concerns have increased as she is immunocompromised. She asks you for counseling but cannot define what she wants to get out of it.
Other Contexts:  
Family History:
Mary was married to her children’s father for 25 years until he had an affair and left her for the other woman. After a few years, Mary met her late husband and was married another 20 years until he became diagnosed with lymphoma and died within three months of being diagnosed. Mary has three older sisters, all of whom live in different states but come to visit seasonally. She celebrates her late mother’s birthday annually, expressing symptoms of grief each year, and becomes inconsolable on the anniversaries of her late husband’s passing. She tells you only country music calms her down.
 
Work History:
Mary was a stay-at-home mother and wife for both of her marriages, working several jobs in-between marriages as a children’s dental receptionist and an antiques shopkeeper. She opened her own shoppe after meeting her late husband where she sold and displayed southern home décor. She had to close her store down when her husband moved for work. She spent much of her free time making greeting cards and crafts at home, until her hands developed arthritis and she lost enjoyment of her hobbies. She now lives off social security and her late husband’s estate that he left for her.

Question: Unfortunately Mary is a no-show for your next virtual session and is unavailable for contact for over 30 days thereafter. You have three missed calls from Evelyn. What should you do?
(A): Discharge Mary from care and ignore the missed call.
(B): Call back and ask if Mary is okay because you are very worried.
(C): Return the call without confirming any information and ask what it is regarding.
(D): Do not return the phone call and continue to wait for Mary to re-contact.

Correct Answer: Return the call without confirming any information and ask what it is regarding.
Explanation: In this case, it is reasonable to assume Mary may be avoiding therapy as is consistent with her mental health diagnoses, but it is also a possibility that Mary is unwell or has befallen harm as she is a lonely senior with unresolved complex grief and has suddenly disappeared. Either way, the phone calls from Evelyn can be returned out of concern for Mary's safety, without breaking confidentiality. For instance, "Hello Ms Evelyn, I see you called me, and I was returning your call to ask what it was regarding". Evelyn may tell you directly if there is news involving Mary's status that may change the terms of confidentiality. If she does not, you are within your legal right to maintain your confidential position by replying "I'm sorry, Ms Evelyn, I am still unable to comment on the status of any clientele I may or may not have, I just wanted to follow up the reason for your call". Depending on your agency or practice's rules, you may be within your right to discharge Mary from care or wait for her to re-contact. However, the best practice decision would be to follow up if there is any doubt about her safety. Answer b) breaks confidentiality, even if you end up discovering that Mary is not okay. Therefore, the correct answer is (D)
Competency: professional practice and ethics