Case Study
Patient Demographic: Client Age: 20 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: College Campus Counseling Clinic Type of Counseling: Individual Counseling Presenting Problem: Depression and “Odd Behavior” Diagnosis: Bipolar 1 Disorder, Current Episode Manic Without Psychotic Features, Moderate (F31.12)
Mental Status Exam: Mental Status Exam: The client states that she slept for 4 hours the night before, which was the most she has slept in one night in the past week and that she now feels tired for the first time. The client had dark circles around her eyes and was wearing sweatpants and a t-shirt with stains on it. The client is oriented to person, place, time, and situation. The client’s affect and speech are
Presenting Problem: You are a licensed therapist working on a college campus in the counseling center. A 20-year-old female client comes to counseling following 8 days of experiencing the following symptoms: little to no sleep most nights with the longest stretch of sleep being 2 hours, several middle-of-the-night shopping sprees, and distractibility. She reports that some of her college professors have called on her to stop talking during class and that she has not been doing very well in school this semester. The client identifies that she has felt this way before over the past 2 years and that this last time scared her because she was more aware of the negative impact it is having on her schooling. The client continues to relate that she also experiences depression at times and that she does not understand where it comes from but that it happens for a few weeks at a time every few months. When in a depressive episode, the client experiences a depressed mood more often than not, decreased enjoyment of activities, hypersomnia, fatigue, and a significant decrease in appetite.
Other Contexts: The client comes to the counseling center during walk-in hours. The client is continuing to experience a manic episode. She reports that she went out to dance with friends the previous evening and ended up buying a gram of cocaine for $100 and reported doing several lines throughout the night. The client says that she has never used any drugs before and that it scared her that she would spend that much money on drugs and that she used drugs at all. You empathize with the client’s frustration with her behavior and provide psychoeducation on impulse control to support her. The client appears tired as evidenced by her affect and slow movements, and she also appears to have poor hygiene because her clothes have visible stains and she has a slight body odor.  The client has not followed up with psychiatry referrals that you provided and is continuing to struggle with managing her manic symptoms

Question: The client has not followed up with psychiatry referrals that you provided and is continuing to struggle with managing her manic symptoms. Which would be the most appropriate next step?
(A): Respect the client’s personal decision not to follow up.
(B): Provide psychoeducation on the benefits of a combination of medicine and therapy for bipolar disorders.
(C): Encourage or remind the client to follow up with the referrals.
(D): Evaluate cognitive barriers or reservations about medication.

Correct Answer: Evaluate cognitive barriers or reservations about medication.
Explanation: The most appropriate answer is to evaluate the client’s cognitive barriers and reservations about medication. This opens up a conversation about what makes it hard for the client to follow up and to address the anxiety or other barriers caused by manic behavior. The client’s personal decision to not take medication is very important and should be respected; however, this is the second session and you have not fully processed the client’s feelings about medication. It might help to provide psychoeducation about the benefits of medication and therapy, but this should have been done when you provided the referral, and it may feel like nagging to the client. You can encourage or remind the client to follow up, but this may not address what kept her from following up and therefore may not provide any practical solutions or support. Therefore, the correct answer is (A)
Competency: professional practice and ethics