Case Study
Patient Demographic: Name: Marta Clinical Issues: Caregiving concerns Diagnostic Category: Trauma and Stressor Related Disorders Provisional Diagnosis: F43.23 Adjustment Disorder, with Mixed Anxiety and Depressed Mood Age: 55 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Colombian American Marital Status: Married Modality: Individual Therapy Location of Therapy : Agency  
Mental Status Exam: The client appears older than her stated age. She is disheveled, poorly groomed, and has a strong body odor. She is cooperative but demonstrates a high level of distress manifested as restlessness, being easily distracted, and consistently rubbing her hands. Her speech is initially slow and halted but later becomes elevated and loud. She is oriented X3. Her affect is characterized by anxiety and depression, as she is having difficulty answering your questions. The client indicates that she has thoughts about putting a pillow over her mother's face or taking an overdose of sleeping pills so that she does not have to deal with her family or her mother's demands anymore.
Presenting Problem: First session You are a counseling intern for a mental health agency. A 55-year-old Colombian American female presents to therapy with tears in her eyes. She appears distraught, anxious, and despondent. She describes feeling guilty about wanting to put her mother in an assisted living facility. Although the client knows that putting her mother in an assisted living facility is probably the best decision, she feels guilty because it goes against the values of her culture. She explains that in traditional Colombian culture, elders are revered, and it is the responsibility of the oldest child to take care of them. The client's siblings have been "critical of me even talking about moving her into an assisted living facility" and are pressuring her to keep their mother at home.    The client starts to cry and covers her face. Finally, she looks up and says, "I feel torn. There are these cultural expectations that I look after my mother, but she never even liked me and made my life miserable when I was growing up." The client does not have any nearby family who can help support her or assist in the care of her elderly mother. Her brothers live in different states, and her husband is an only child whose parents both passed away a few years ago. The client has expressed feeling overwhelmed by the responsibility of taking care of her mother and running her own household. She says, "I feel like I just can't keep up with everything. My kids need me, my husband needs me, and now I have to take care of my mother, too. And as for having any time to myself, that's a dream that's never going to happen." She further explains that her current circumstances remind her of what it felt like growing up in a chaotic household and feeling the pressure of having to take care of her younger siblings. She states, "It's like history is just repeating itself." She reports feeling "like a failure at being a wife, mother, sister, and daughter." As you listen to the client's story, you sense her feelings of guilt, frustration, and overwhelm about not being able to meet all the demands placed on her. You empathize with the client and validate her feelings. You compliment her on the strength it took for her to take on an additional responsibility despite the hardships that come with it.    When asked what she hopes to gain from therapy, the client tells you that she wants to figure out how to balance her responsibilities. She expresses wanting to find a way to care for her family members without "losing myself and my sanity in the process." You suggest meeting with the client for weekly sessions as a place to begin, and you walk the client through what she can expect from therapy.  Fourth session During a previous session, the client expressed an interest in bringing her husband to a therapy session to discuss her feelings and how to best manage their respective responsibilities. The client arrives to today's session with her husband, but he appears disengaged as you begin the session. You notice that the client is on edge, and she avoids looking at her husband. You start out by addressing both of them and asking how they are doing. The client responds first, saying that things have been difficult for her lately due to all the pressure she has been under from taking care of her mother in addition to managing her own household. She expresses feeling overwhelmed and anxious about not being able to meet everyone's needs perfectly.    The husband remains silent, so you ask him specifically what he thinks about his wife's concerns. He replies that he feels frustrated because he believes that she is being "too sensitive" and should focus on fulfilling her obligations as a wife and mother instead of worrying about how others think she should do things. Feeling defensive, the client interjects and tells her husband that he does not understand what it feels like to be in her position. He replies, "You're right. I don't get it. Look, I don't want to be the 'bad guy' here, but you're obsessed with what your brothers think. They don't have to live with your mother. We do. We should be thinking about what's best for our family, not your siblings." The client says, "I'm trying my best, but I feel like I'm alone in this. When you get home from work, instead of helping around the house, you just binge watch cartoons and ignore everything. It's like I don't have a husband - I have an extra child!" The husband appears angry and tenses up, and you notice that the client is equally upset. You acknowledge their feelings of frustration, disappointment, and overwhelm and reiterate that it is understandable to feel this way given the amount of pressure they are both under.    You take this moment to help both the client and her husband understand each other's perspectives in a supportive way. As you discuss their different points of view, it becomes clear that both the client and her husband are feeling overwhelmed by having to balance the demands of caring for an elderly family member. You explain the importance of being able to express their feelings and work together when making decisions about how to manage the family's needs. Next, you suggest that the client and her husband take some time to reflect on their feelings and experiences. You educate them about strategies they can use at home to express their feelings in a supportive way.  10th session During the last few counseling sessions, you and the client explored ways that she and her husband could better collaborate and communicate in order to manage their respective responsibilities. You worked with the client to develop coping skills to manage her anxiety, including deep breathing exercises and visualization techniques. You also engaged the client in a discussion about how her beliefs and values were influencing her reactions to her family's needs and strategized how to set boundaries and make decisions that honor her values without feeling guilty or overwhelmed. She has been actively using these coping strategies to better manage her emotions and has been more successful in communicating her needs to her husband.    When you meet for today's session, the client appears to be in a positive mood. After a long discussion with her husband and her brothers, everyone finally agreed it would be best to move her mother into an assisted living facility. She says, "I had the most trouble convincing my youngest brother that assisted living was the best option. I think my sister-in-law was the one who finally helped him to understand why making the switch would give my mother the best chance for a better quality of life." She goes on to describe it as "one of the most difficult decisions I've ever made." You ask her how she is feeling now that the decision has been made, and she tells you, "a little bit guilty, but mostly relieved." You affirm her courage and ability to handle such a challenging situation. She tells you that she "can finally breathe again." She also believes that she might be able to have a better relationship with her mother with her being in an assisted living facility. The client does not want to resent her mother every day and expresses a desire to try to make the most of the time they have left together. She tells you that she has been going through some old family photo albums and came across a picture of her mother when she was newly married. She says, "She and my dad looked so happy together. There was a time when she wasn't so critical and demanding." The client tells you that she has been reflecting on her own experiences as a mother lately and thinking about "the courage my mother must have had to leave everything that was familiar to her and move to a new country with four kids in tow." She remarks that this newfound awareness has helped her understand why her mother was so demanding and strong-willed; she now sees that all of these qualities stem from a desire to provide for their family and give them the best possible life.    Toward the end of the session, the client says, “I’m so grateful for everything you have done. You have been a great listener and given me the tools to cope with everything in a healthier way." You acknowledge her progress and remind her that she has come a long way since the beginning of your counseling sessions.
Other Contexts: The client is the oldest child in her family. She has 3 younger brothers, all of whom are separated in age by one year. She was born and raised in Colombia. When she was in middle school, her family immigrated to the United States in search of better opportunities. Her father worked long hours as a taxi driver while her mother worked as a nanny taking care of other people's children. The client stated that she often felt like she had no parents because they were always working. The client stated that when they moved, her mother asked her to help out more at home with the cooking, cleaning, and taking care of her siblings. She often felt overwhelmed and guilty because she wanted to spend time with friends or focus on her studies rather than watching her brothers. The client revealed that she often feel a deep sense of resentment knowing that while other girls were able to go outside and play, she had responsibilities to take care of. Personal/Social Relationships: The client's father passed away four months ago and her 76-year-old mother has been living with the client since then. The mother does not speak English and requires assistance with medical appointments, financial dealings, and daily care. She constantly "nags" the client about how she is raising her children and often complains about her cooking. The client's husband, who is second-generation Irish American and grew up in Boston, is becoming increasingly irritated with his mother-in-law. He complains to his wife about her mother, which puts a "massive strain" on the couple's relationship.  

Question: How would you affirm the client's ability to handle the decision for her mother's long-term care?
(A): "It takes a lot of strength and courage to make difficult decisions, especially those that involve the wellbeing of your loved ones. I'm proud of you for taking this big step."
(B): "It must have been tough having to make such a difficult decision."
(C): "You should feel proud at showing the strength and courage to make a hard decision in the face of opposition from your family. That was a big step."
(D): "You've made a lot of progress since we started counseling and I'm impressed with how far you've come."

Correct Answer: "It takes a lot of strength and courage to make difficult decisions, especially those that involve the wellbeing of your loved ones. I'm proud of you for taking this big step."
Explanation: This response is validating and affirming, acknowledging the client's courage in making a difficult decision while still honoring their autonomy. It also reinforces the idea that the client has made progress since they started counseling. Therefore, the correct answer is (A)
Competency: counseling skills and interventions