Case Study
Patient Demographic: Initial Intake:  Age: 32 Gender: Female Sexual Orientation: Bisexual Ethnicity: Caucasian Relationship Status: In a relationship Counseling Setting: Community mental health agency Type of Counseling: Individual via Telehealth
Mental Status Exam: Melanie is unkempt, looks tired and is casually dressed. Motor movements are within normal limits, eye contact is appropriate. Melanie reported passive suicidal ideation intermittently throughout her depressive episode as a means for escaping her feelings but has no plan or intent. Melanie reluctantly admits to several instances of past trauma which include losing her son’s father to a tragic car accident four years ago where her son witnessed him die, as well as having three other older children, all with separate fathers, with whom she has no contact. Her only support system is her boyfriend who takes great care of her and her son’s school, which provides help with his Individualized Education Plan.
Presenting Problem: Diagnosis: Dysthymic disorder (F34.1), provisional, Anxiety disorder, unspecified (F41.9), Post-traumatic stress disorder (PTSD) (F43.1)
 

Melanie has been in mental health counseling for several years through your agency and was referred to you by her last counselor who obtained a position with a local University and was leaving your company. Melanie is a 32-year-old Caucasian female who lives in a house with her boyfriend and her 9-year-old son, Gus, who suffers from ADHD, anxiety, and PTSD. Melanie is receiving psychiatric medication from your agency’s Psychiatrist, another Psychiatric practice by a Nurse Practitioner in a different city and is being treated medically by a Gastroenterologist who has also prescribed medications. Melanie is complaining of ongoing depression caused by her chronic nausea and a cyclic vomiting syndrome and does not want to leave her bed out of helplessness and hopelessness that nothing will ever change. She also reports experiencing anxiety and panic-like attacks when she is around others which causes her to socially isolate for sometimes days at a time. She is upset she cannot care for her son the way she desires and wants to continue counseling to help her feel better.
Other Contexts: Family History:
Melanie has what she states is a “complicated” relationship with her family, including her mother, whom she believes wants no involvement with her or her son, and has no contact with anyone else. Melanie states her falling out with her mother began when she was just a child. She comments that her father and her were “very close”, but his new wife makes it “challenging to communicate with him.” Melanie has lived on her own for much of her life and has not engaged in or sustained any relationship with her first three children. She adds that in each instance they were either unfairly taken away by the father or the state and that she has tried to initiate contact, but it has not been successful. Melanie continues to deflect from discussing family dynamics, causing gaps in your initial interviewing process.
 
Work History:
Melanie reports never having an “official” job but always being able to make money “somehow.” She has been on Medicaid for most of her life and continues to survive off government support and the charity of others. She tells you she has dreams of writing a book or even owning her own bakery but does not demonstrate willingness to take the steps at achieving those goals.
 
Legal History:
Melanie has incurred a criminal record for failing to pay child support several times over the past nine years and continues to receive notices and warnings to ensure she is making her payments on time.

Question: After the second session, what is the best intervention to conduct with her at this time?
(A): Prepare her for termination as she needs to be engaged with her program therapists
(B): Redirect her to focusing on what she must do each day to complete treatment
(C): Teach coping skills for managing anxiety
(D): Explain that now is the time to invest in EMDR to address those traumatic memories

Correct Answer: Teach coping skills for managing anxiety
Explanation: At this time, preparing Melanie for ending your therapeutic relationship is not appropriate and can exacerbate her emotional condition. Redirection would only be effective if Melanie had the ability to focus; however, it is her chief complaint that she does not have the skills to refocus and is beginning to convince herself she does not need to complete treatment. It is also advisable to directly address her trauma using the therapeutic modality you assessed would be useful from the initial intake, but this is not recommended for a client in early addiction treatment who has not yet demonstrated effective use of coping skills for stress. There are advanced technologies available in some treatment centers that provide Neurofeedback services which have been proven effective in addressing treatment of trauma on a neurochemical level concurrent with talk therapy services, but this is not the same as EMDR and either way it is safest for a client to have learned coping skills prior to any experimental or evidence-based treatments. Teaching or reviewing coping skills for managing Melanie's anxiety would best help her in the moment while addressing all her concerns. Therefore, the correct answer is (D)
Competency: counseling skills and interventions