Case Study
Patient Demographic: 7   Initial Intake: Age: 18 Gender: Female Sexual Orientation: Bisexual Ethnicity: African American Relationship Status: Single Counseling Setting: Agency Type of Counseling: Individual
Mental Status Exam: Millie was well groomed and presented as anxious with constricted affect as evidenced by shaking her leg and tapping her pen frequently. Millie made good eye contact and speech was coherent and rational, however tangential with increasingly rapid rate at times. Speech content is somewhat guarded, demonstrating preoccupation with social influences and deflection from discussion about losing her mother. Millie was surprisingly graphic with detail about self-starvation and purging food and did not show concern; presented with incongruent affect and smiling while she talked about it. Millie denied SI.

Family History and Living Situation:
Millie lived alone with her mother in a different state until last year when her mother died, and she moved to a new state to live with her father and his girlfriend. Their relationship had already been strained therefore Millie opted to live with her paternal grandparents who also lived locally, which is where she lives now. Millie comes and goes as she pleases and does not regard house rules. She reports most often staying in her room with the door locked while on the computer or phone
Presenting Problem: Diagnosis: Major Depressive Disorder, single episode, recurrent (F33), Anxiety disorder (F41.9) provisional
 

You are a mental health counselor with a community agency and have been referred a new client named Millie, an 18-year-old African American girl, for problems adjusting to life without her mother who has passed away nearly one year ago from illness. Millie’s father brought her to your agency after convincing her to see a counselor. The referral form filled out by her father says she has never spoken about her mother’s death and does not talk about it with anyone he knows. Millie has had medical problems that have been best explained by disruptions in her eating and sleeping habits, which started after her mother died. You learn several reports were made during her senior year in high school of her fighting with other girls, which Millie tells you were erroneous and “not her fault”. Millie also demonstrates a highly active social life, but primarily online with strangers as she exhibits strong social phobic behavior in public and around others in person. You recommend in-person counseling rather than Telehealth virtual sessions to support her improvement.
Other Contexts: llie was well groomed and presented as anxious with constricted affect as evidenced by shaking her leg and tapping her pen frequently. Millie made good eye contact and speech was coherent and rational, however tangential with increasingly rapid rate at times. Speech content is somewhat guarded, demonstrating preoccupation with social influences and deflection from discussion about losing her mother. Millie was surprisingly graphic with detail about self-starvation and purging food and did not show concern; presented with incongruent affect and smiling while she talked about it. Millie denied SI.

Family History and Living Situation:
Millie lived alone with her mother in a different state until last year when her mother died, and she moved to a new state to live with her father and his girlfriend. Their relationship had already been strained therefore Millie opted to live with her paternal grandparents who also lived locally, which is where she lives now. Millie comes and goes as she pleases and does not regard house rules. She reports most often staying in her room with the door locked while on the computer or phone.

Question: Millie has still not addressed the death of her mother, and you feel the need to present her with this observation since it is obvious that she is distracting herself from her grief and all her subsequent anxiety and attachment issues are likely stemming from her loss. How should you approach this?
(A): Tell her you must conduct a Complicated Grief Assessment before end of session.
(B): Present this observation as soon as possible to make the most of the session.
(C): As it is only the second session, it is still appropriate for your client to lead the discussion.
(D): You should never bring it up first.

Correct Answer: As it is only the second session, it is still appropriate for your client to lead the discussion.
Explanation: In the first session of counseling with a client who is clearly engaging and sharing on their own without prompting, it is entirely appropriate that the conversation evolves as the client leads. It is often most appropriate for all client sessions to be led by the client in content; however, to ethically address underlying reasons for presented behavior problems that could be causing the client harm, it is important to present your clinical feedback at an appropriate time. Therefore, answer d is not the right choice, as your referral of this client was entirely based upon emotional disorders developed because of this tragedy. The counselor should not pressure the client to speak on this issue when they are not ready, but to effectively address treatment it will be necessary. A Complicated Grief Assessment is an appropriate intervention to use but does not have to be done at a certain time and would more likely follow a conversation in which Millie admits to experiencing her grief. Therefore, the correct answer is (B)
Competency: intake, assessment, and diagnosis