Case Study
Patient Demographic:  Age: 27 Sex: Female Gender: Female Sexuality: Declined Ethnicity: Hispanic/African American Relationship Status: Single Counseling Setting: Community Agency Type of Counseling: Individual
Mental Status Exam: The client presents as her stated age with positive signs of self-care related to hygiene and dress. She appears overweight for height as noted in her intake. Her mood and affect are congruent and she appears to be cooperative and forthcoming in her responses. She demonstrates no retardation, spasticity, or hyperactivity of motor activity. She is oriented and demonstrates no unusual thought processes or patterns. Her insight is intact and she identifies goals for therapy. She reports no suicidal ideations, thoughts of harm to self or others, or difficulties with memory, judgement, or concentration. 
Presenting Problem: You are a counselor in a community agency that provides counseling.  Your client presents with a history of convictions for felony criminal offenses in her early 20s, of weight loss and gains since college, and currently rates herself as approximately 50 pounds overweight. She describes herself in years past as “fat,” “ugly,” and “grotesque.” She reports one long term relationship during high school and college, with a male she tells you was “manipulative, controlling, and emotionally abusive. She reports not “dating-dating” since their break up six years ago. She does report that recently she has engaged in self-destructive behaviors with different people in the context of online relationships. She states that in several cases, she has met men and women online and used elaborate methods, including using multiple telephone numbers and creating false names and life events to establish relationships with these individuals. Several relationships ended abruptly when the individuals, both male and female, made concerted efforts to meet the client, at which time she disclosed the truth to them. She tells you that she feels very badly about what she did, particularly because she had been helping each of the people with different problems in their lives, including one of the women with an abusive spouse, and she believes now these people will have no help.  She attended counseling for several months three years ago but reports she did not tell the counselor everything. Today she tells you that she is now in a professional graduate program for counseling and wants to be open about everything so she can “finally get her life in order.”
Other Contexts: Family History:
The client reports her support system as several male and female friends. She feels close to these people though she says they sometimes irritate her. She describes her father as distant and her mother as strict and controlling. She states she and her siblings were punished frequently for not following their mother’s strict expectations for “how young women and young men should act.” She states she and her siblings were required to engage in daily exercise; always dress in “their Sunday best” during childhood; and focus on dieting, food intake, and weight ideals. She tells you she daily engaged in binging and purging from age 13 to age 20, but never told anyone or saw a doctor for this. She tells you that she has not binge/purged for the past five years. She states that her sister did the same and still struggles with it, and two other siblings are in treatment for alcohol and methamphetamine addiction. Additionally, the client tells you that both of her maternal and paternal grandparents have histories of alcoholism, and she smiles when telling you that one of her grandparents was imprisoned for criminal behavior and “is connected.” She says that several other maternal and paternal relatives have criminal convictions.

Question: Which of the following would be the best intervention at this time?
(A): "It seemed like it was hard for you to connect what happened in your life to your feelings about yourself."
(B): "That's a big story, where do you want us to start?"
(C): "Can you tell me about your time in jail and how that changed you?"
(D): "You showed your parents that you weren't 'the good girl' anymore."

Correct Answer: "It seemed like it was hard for you to connect what happened in your life to your feelings about yourself."
Explanation: The client has provided lots of content but had difficulty connecting to herself in the story, as demonstrated by her pauses, when the counselor asked about feelings, and then moving back into content. Individuals with a fragile self-esteem or sense of identity (ie, such as narcissists) have difficulty with insight into their own emotions. Making an observation of what the counselor is observing opens up an opportunity to begin processing emotions with the content. Asking the client to determine where to start allows the client to direct the session, but if the client is struggling with connecting to emotions, the client will be more likely to stay content-focused rather than working therapeutically on process. Making a statement about the client not being "the good girl" anymore would likely be received as sarcasm or judgement about the client's actions, rather than listening for the emotions and thoughts underneath the content. Asking about how jail changed her is a good question but if it is asked right now, it changes focus away from the content and difficulty with emotional connection that the client has just demonstrated. It is best to work with the client where they are when there is a therapeutic opening, rather than redirecting to new content. Therefore, the correct answer is (D)
Competency: intake, assessment, and diagnosis