Case Study
Patient Demographic: Name: Jeff Clinical Issues: Referral following hospitalization for suicidal ideation Diagnostic Category: Bipolar and Related Disorders Provisional Diagnosis: F31.32 Bipolar I Disorder, Moderate, Most Recent Episode Depressed Age: 33 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Never married Modality: Individual Therapy Location of Therapy : Private Practice  
Mental Status Exam: The client's overall presentation during the examination is disheveled. He is thin, taller than average, and hunches over in his chair. He appears tired and exhibits low energy. Several times during the examination, he massages his neck and shoulders. He has inconsistent eye contact and often looks down at the floor. Speech is quiet and slow. You have to wait several seconds for him to answer questions. Thought content reveals negative themes. At various times he appears numb and indifferent but then shifts to tearfulness. Memory is slightly impaired, and he has difficulty staying focused. He denies homicidal ideations but states having past suicidal ideations.
Presenting Problem: First session You are a clinical mental health therapist working in a private practice setting. The client is a 33-year-old male referred to you by an ER physician as a follow-up after being hospitalized due to suicidal ideation. This is not the first time the client has been hospitalized. During the initial counseling session, the client discloses, "I don't know why I'm here. No one can help me. My sister made this appointment for me because I got this referral when I left the hospital. She drove me here and is sitting out in the waiting room." He continues with a tearful eye, "I'm a total failure. No one cares about. My sister looks after me, but I think it's because she feels sorry for me."    You continue with your assessment to gain a more thorough understanding of his current situation. He tells you that there are times when he feels "really low" and his mind tells him that he would be better off dead. Other times, he feels "pretty good" with a lot of energy, a positive self-image, and motivation to complete various projects. You ask about his relationships with friends and family, and the client reveals that he has lost contact with most of his close friends due to a "series of negative events" in his life. He further discloses that he has difficulty maintaining relationships. He expresses feelings of loneliness and disconnection from the world. He is worried that his sister will eventually "give up" on him. When asked about his parents, he softly laughs and says, "They took the easy way out and died. Mom in a car crash and Dad from cancer. They are the ones who deserve to suffer and instead, they've got it easy."    You discuss your role as a therapist and what the client can expect from the counseling process. You also review the parameters of confidentiality involved in therapy. He tells you that he would like to "give counseling a try" and see you for another session. You schedule an appointment to see him the following week.  Fourth session The client appears energetic during this session. He presents as much more carefully groomed and in an elevated mood. He states, "It sure has been a journey these past few days." He reports that he met a woman at a local bar, and after spending the night together at a local hotel, they ended up taking a spontaneous road trip to Florida. He talks about the weekend as "mind-blowing", and states that this adventure has helped him design his new goal, which will be "life-changing."    He goes on to say that his boss "didn't appreciate my free spirit because I had a bunch of voicemails from her waiting for me when I got home." He laughs when he relates that he had turned his phone off, so he didn't have to be "brought down." He recognizes that he had made commitments to work over the weekend, but he states, "If you met this girl, you'd know why I did it." Then laughs.    You listen to the client's story intently and encourage him to talk more about his experience. Then you explore his feelings around the situation and his decision to leave work without making prior arrangements to cover his absence. You also discuss with the client the potential consequences of his actions and help him consider how to move forward in a way that is not harmful or dangerous. You ask him to think about his goals and create an action plan to help him reach those goals. Together, you and the client come up with strategies for the client to move forward in a healthy way.
Other Contexts: The client's parents divorced when he was ten years old. He has an older sister who he currently lives with. He recalls his childhood memories as traumatic and reports experiencing verbal and physical abuse by both parents. The client states that he lived with his dad after his mom died when he was 14 years old. He explains that living with his dad was difficult, saying, "Being around my dad was like being around a ticking time bomb. There were times when he was calm and seemed interested in what I was doing, but there were other times when he would become very angry and I was never sure what might set him off." The client works in a local pizza shop. He says he is written up weekly for being late to work. He reports verbal altercations with his coworkers because they will not listen to him. In his teen years, the client used alcohol to cope with his family situation. Since that time, he only drinks socially.

Question: Your private practice needs to shift to telehealth due to safety-based concerns in the community. What would you not implement with your client at this time?
(A): Contact the client prior to the first online session to set up appropriate protocols within your virtual therapy environment
(B): Contact the client and work out which online communication platform would be most convenient and comfortable for him.
(C): Contact the client and identify telehealth-based releases the client needs to sign, even though there were already several communication-related forms already signed.
(D): Contact the client directly to make him aware of the need for this change in modality and to deal with any immediate issues.

Correct Answer: Contact the client and work out which online communication platform would be most convenient and comfortable for him.
Explanation: The therapist must identify to clients the limitations and boundaries associated with using any social media. The use of FaceTime would lead to ethical violations with the release of Personal Health Information (PHI) as it is not a HIPPA-encrypted compliant platform. Therefore, the correct answer is (B)
Competency: professional practice and ethics