Case Study
Patient Demographic: Client Age: 19 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual Presenting Problem: Suicidality related to body image Diagnosis: Body Dysmorphic Disorder 300.7 (F45.22), with absent insight/delusional beliefs
Mental Status Exam: Mental Status Exam: The client’s mood is sad and irritable. His speech is pressured when discussing his appearance but is otherwise normal. He is appropriately groomed and wears a beanie covering his ears. He admits to repetitively dissecting his face in the mirror several hours a day. The client offers that he cannot hide his ears with his hair because “it is too thin.” He denies audio/visual hallucinations. The client’s thought content is organized and coherent, but he shows poor insight and delusional thinking about how he and others regard his appearance. The client avoids social settings and reports that sometimes, an entire week goes by where he doesn’t leave the house. He denies suicidality and currently does not have a plan or intent to harm himself or others. Appetite and sleep are fair. The client denies drug use and states he consumes alcohol occasionally. You provide an in-depth suicide assessment, and you and the client work together to create a suicide safety
Presenting Problem: You are working in private practice and conducting an initial intake session with a 19-year-old male who presents today with his mother. The client was recently admitted to a psychiatric hospital for suicidality and was discharged four days ago. His mother reports that the client tried to commit suicide by overdosing. The client reports feeling increasingly hopeless following a “failed” cosmetic surgery procedure. He explains that he had an otoplasty performed to change the proportion and position of his ears. He states he has always hated his ears and is convinced people are staring and laughing at his “deformity.” His mother reports that she reluctantly consented to the surgery a year and a half ago, despite believing it was unnecessary. The client does not leave the house without wearing a beanie or hoodie. He has completed high school with no interest in attending college. He is unemployed due to shame and embarrassment over his “defective” appearance. Two weeks ago, the hospital psychiatrist changed his medication and placed him on a selective serotonin reuptake inhibitor (SSRI).
Other Contexts: You and the client review his safety plan. The client believes the antidepressant has helped decrease his feelings of hopelessness and suicidality. Despite the hot and humid conditions, the client arrives at his counseling session in a hoodie. He explains that he has been getting out of the house “some” but continues to avoid social situations because of overwhelming thoughts of others staring at him and mocking his appearance. The client was a no-show for his appointment last week and has requested distance counseling to avoid anxiety experienced when leaving the house. You and the client work together to set appropriate treatment plan goals; however, this is difficult due to poor insight into his presenting problem. You provide psychoeducation about BDD and ask about his goals for the future

Question: Which is of the following is an ethical expectation for certified counselors providing distance counseling and maintaining a social media presence?
(A): Refrain from viewing a client’s personal or public social media profile without permission; however, counselors must discuss professional limitations with maintaining confidential electronic communication.
(B): Ensure that professional social media accounts are merged with personal accounts to avoid ambiguity and confusion.
(C): Refrain from entering personal virtual relationships with clients for a period of 5 years following the last professional contact.
(D): Develop informed consent procedures covering issues such as the possibility of technology failure, emergencies, and the increased risk for harmful boundary violations.

Correct Answer: Refrain from viewing a client’s personal or public social media profile without permission; however, counselors must discuss professional limitations with maintaining confidential electronic communication.
Explanation: Distance counseling, technology, and social media use is covered in section H of the ACA Code of Ethics (2014). Concerning social media, counselors must refrain from viewing a client’s personal or public social media profile without permission. Confidentiality and its limitations must be addressed in terms of potential unauthorized and authorized electronic records and their transmissions. Answer B is incorrect because counselors are encouraged to keep their personal and professional accounts separate. For answer C, developing informed consent procedures covering issues such as the possibility of technology failure and emergency policies is correct, but addressing the increased risk for harmful boundary violations (eg, sexual relationships, exploitation) is incorrect because counselors are solely responsible for protecting clients from harm and eliminating risks. Boundary violations are not only unethical but may also have legal implications. Lastly, according to the ACA Code of Ethics, “counselors are prohibited from engaging in a personal virtual relationship with individuals with whom they have a current counseling relationship (eg, through social and other media) (ACA, 2014)” The 5-year timeframe refers to sexual relationships. Specifically, “client interactions or relationships with former clients, their romantic partners, or their family members are prohibited for a period of 5 years following the last professional contact (ACA, 2014)”. Therefore, the correct answer is (A)
Competency: professional practice and ethics