Case Study
Patient Demographic: Name: Sierra Clinical Issues: Adjustment related to physical loss/injury/medical condition Diagnostic Category: Trauma and Stressor Related Disorders Provisional Diagnosis: F43.23 Adjustment Disorder with Mixed Anxiety and Depressed Mood Age: 16 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Native American (Cherokee) Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : Private Practice  
Mental Status Exam: The client's appearance is slightly disheveled. Her behavior is withdrawn. She has her arms crossed throughout the session. The client's affect is congruent. Her mood is depressed during the initial intake. She reports that she sometimes "doesn't feel like existing" when thinking about her injury. She shares that the thought of not being able to dance ever again is "too much to bear." Exploration of thought content reveals that she has considered how she might harm herself. She reports that her father has guns locked in a safe, but she knows the passcode. The client denies she would ever act on this impulse and identifies three friends she could contact for support.
Presenting Problem: First session You are a mental health therapist in a rural private practice setting. A 16-year-old female is referred to you by her pediatrician for concerns about her mood, behavior, and low appetite. She is accompanied by her mother and father. You begin by speaking with all three family members, reviewing the informed consent process and how confidentiality will be handled with the daughter. They all acknowledge and sign the appropriate paperwork.    Next you meet one-on-one with the parents to understand their concerns. They are extremely concerned about their daughter's mental health and wellbeing. They share that their daughter has been crying more often lately and she has become incredibly sensitive to criticism. She is often irritable and "snaps" at them over minor issues. She withdraws from social interaction with friends, which is out of character for her. She appears increasingly withdrawn from activities she used to enjoy like drawing and playing the piano. She is also sleeping more and eating less than usual, resulting in weight loss. The parents confirm that they have limited insight into their daughter's actual feelings, as she often refuses to discuss them. The mother tells you, "She had a ballet injury a couple of months ago, and she seems to be struggling with it. We've been trying to stay positive and supportive, but she's just not getting better. Her physical therapist said that keeping up a positive attitude is really important in the recovery process, but our daughter doesn't seem to care."    After you feel you have obtained a thorough understanding of the parents' concerns, you ask the parents to wait in your waiting room and invite the daughter back into your office. You begin by expressing your understanding of the situation that lead her parents to bring her in for therapy. You state, “From what your parents have told me, I understand you have been going through a difficult time lately with your physical injury and the changes that it has caused in your life.” After establishing this understanding, you ask her to tell you about her experience with the injury, how it has impacted her life, and how she has been feeling since it occurred. She tells you she has a hard time concentrating at school because she is unable to dance. She becomes tearful when you attempt to find out about how her ballet injury is affecting her. She says her "life is ruined now" and "I will likely never dance again. I'll never be able to fulfill my dream of being a ballet dancer. I hate it. All of my dreams are crushed." She begins sobbing uncontrollably. You take a moment to de-escalate her intense emotional reaction. You explain that it is common to feel overwhelmed in the aftermath of a major injury, and there are strategies she can use to cope with her feelings. You discuss the importance of staying connected to friends, family, and supportive people during this difficult time. After completing your mental status examination of the client, you note suicidal ideation as an issue to discuss with her parents.  Second session The client presents to her second counseling session in a defensive state. She is upset that you reported her suicidal ideation to her parents because she thought that everything she told you would remain confidential. She says, "Why should I tell you anything else? You'll just tell my parents." You tell the client that you understand her frustrations and empathize with her. You explain to her why confidentiality is not always absolute and that as a clinician, it is your responsibility to keep clients safe, even when they don't want you to. You further explain that in this case, you felt it was important for her parents to know about the suicidal ideation she has been experiencing. You emphasize that her parents care deeply about her, and they need to know what is going on with her in order for them to help. She responds by saying, "Okay, I get what you're saying, but telling them about it has only made things worse." She reports that her parents now treat her "differently" and do not allow her access to any "dangerous items like kitchen knives" without supervision. She feels restricted and watched. You nod your head in understanding and reflect that it can be difficult to feel like your parents don't trust you and have put restrictions on things they normally wouldn't. You also encourage her to try and see the situation from their perspective and agree that although the restrictions can be inconvenient, her safety is their top priority. She takes a deep breath and says, "I guess I can understand why they did it, but it still doesn't feel fair." You acknowledge her feelings of unfairness and validate that feeling. After your discussion, the client appears to have a better understanding of her parents' motivation for the restrictions and feels less resentful towards them.    You ask her to tell you more about how she has been feeling lately and invite her to share any other issues she is having trouble managing. She tells you that her ballet teacher has invited her to help teach the younger ballet classes, but she is ambivalent about pursuing this opportunity. Though she still loves ballet, she thinks it will be painful to watch other children fulfill the dreams that she can no longer pursue. She says, "I'm afraid that if I agree to teach, I'll never get over my injury. It will just keep reminding me of what I could have been." You explain to her that it is natural for her to have these feelings and that it is okay to take time to make a decision. You ask her if she can see any benefits to teaching. She pauses and says, "I don't know...I've never really thought of myself as a teacher. I've always been the student." You acknowledge the difficulty of this transition and understand that it can feel risky to try something new. You suggest that teaching could be an opportunity for her to gain a sense of purpose, as well as an activity to help her stay connected to something she loves. You encourage her to try and explore her capacity for teaching and imagine what impact she could have on her students.  Seventh session Almost two months have passed since you first met with the client. She has been meeting you for weekly therapy sessions. During previous sessions, you continued to work on developing a sense of trust with the client which has allowed her to open up to you about the myriad of feelings that she has regarding her injury. You explored and processed feelings of grief and sadness, as well as feelings of anger and resentment. Several sessions have been dedicated to identifying automatic thoughts that have been contributing to the client's negative attitude and replacing negative self-talk like "I'm broken" with more positive and realistic statements. You have also been using solution-focused techniques to help her to focus on what is within her power to change and take active steps toward making those changes.    During today's session, the client agrees with you when you state that you believe she has achieved many of her goals in therapy. The client has worked through her ambivalence towards teaching the younger ballet classes and is now actively pursuing this opportunity. She reports that she finds a sense of purpose in helping the students learn and appreciate dance, as well as feel accomplished for their achievements. She says, "It's still strange not being the student anymore, but I'm glad that I decided to try it. The kids had a performance last week, and one of the girls gave me this really sweet clay ballet shoe that she made in her art class. She told me that I'm the reason she felt 'brave enough' to keep dancing even though she was scared. That meant a lot to me."    You then ask her about her relationship with her parents. She reports that it has improved since they had the discussion about trust. They are now more willing to listen to her opinions and have loosened some of the restrictions, though there are still some limits in place. Although they still have expectations of her and restrict certain activities, they now talk to her more openly and engage with her in a positive manner. She tells you that she would like to get all A's this semester to make her parents proud. She is getting better grades in history but states that her other classes are "boring." She also mentions wanting to put some limits on the amount of time she spends with her friends and "get away from smoking as much." She says that she is trying to be a better role model for her ballet students. You acknowledge how hard she has worked to reach this point and congratulate her on taking initiative in improving her academic performance and setting new boundaries with her friends.
Other Contexts:  The client reports that she is doing "okay" in school. Her parents report that she used to make straight A's but is now making C's and D's. She is failing history because she did not complete a project. They share that her teachers have tried to reach out to her, but she has not responded to any of them. The client reports that she smokes cigarettes. She used to smoke once every couple of months while out with friends. Her use has become more frequent, and she is now smoking several times a week. She has tried alcohol (three beers) and smoked a joint at a friend's party, but she reports that she did not like how they made her feel. Pre-existing Conditions: The client fell in dance class two months ago and broke her ankle. There were complications during surgery to repair the break. The client is currently in intense rehabilitation planned for at least one year, but it may take longer. Doctors are unsure if she will ever regain full mobility of her ankle.

Question: What do you identify as a significant barrier to the client achieving her stated goal of getting A's in all classes?
(A): The client's level of engagement in classes
(B): The client's relationship with her parents
(C): The client's medical history
(D): The client's substance use history

Correct Answer: The client's level of engagement in classes
Explanation: The client describes the classes as boring, indicating that her level of engagement in the assignments may be a barrier to achieving her stated goal. Therefore, the correct answer is (C)
Competency: counseling skills and interventions