Case Study
Patient Demographic: Client Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Community Mental Health Center Type of Counseling: Individual Presenting Problem: Depressive Symptoms Diagnosis: Persistent Depressive Disorder (PDD) (Dysthymia) Diagnostic Criteria 300.4 (F34.1)
Mental Status Exam: Mental Status Exam: The client is dressed in age-appropriate clothing and is well groomed. His affect is blunted and anxious at times. The client denies anxiety but discloses that he is nervous about the counseling process and doesn’t know what to expect. He is cooperative but hesitant to offer more information than is asked. The client is tearful when discussing his breakup and states that there are days when it is a struggle to get out of bed and go to work. He denies suicidal ideation, and he says that he has had no previous attempts. The client is oriented to person, place, time, and situation, and his thought content is organized. Fam
Presenting Problem: You are a counselor working in a community mental health center. Your initial intake appointment is with a 26-year-old African American male who presents with symptoms of depression. The client states that he has felt depressed since his teens, with symptoms increasing within the last couple of months. He reports feelings of worthlessness, fatigue, and occasional bouts of insomnia. In addition, the client indicates that his symptoms worsened after his girlfriend of 2 years broke things off with him. He explained that she grew tired of his low energy and pessimistic outlook on life. As a result, he has been hesitant to seek help, believing that he just needed to “man up” and handle his problems privately. The client is unsure of his insurance benefits but thinks his policy allows for a limited number of counseling sessions.
Other Contexts: You learn that the client withheld information during the intake interview because of a negative experience with psychiatric treatment. Two years previously, the client presented at the emergency room with symptoms of depression and suicidal ideation. The emergency department clinician recommended hospitalization, and the client complied. During his hospital stay, he was placed on an antipsychotic medication for paranoia and was diagnosed with schizoaffective disorder. Although the client admits to suicidal ideation, he denies ever experiencing paranoia. He reports having side effects from the medication and immediately discontinued it after discharge. The client states that he has been very depressed since the breakup with his girlfriend and was willing to give counseling another try before his depression “hit rock bottom.”  After disclosing his experience with hospitalization, the client asks questions about your credentials, counseling approach, and experience

Question: After disclosing his experience with hospitalization, the client asks questions about your credentials, counseling approach, and experience. What would be your first response?
(A): Understand and validate the client’s experience with hospitalization and consider contextualized factors.
(B): Shift the focus back to the client and emphasize the importance of honest communication regarding suicidality.
(C): Obtain a signed release of information to communicate with the hospital and request the client’s records.
(D): Provide a written copy of informed consent, which includes your credentials and related information.

Correct Answer: Understand and validate the client’s experience with hospitalization and consider contextualized factors.
Explanation: You would first seek to better understand and validate the client’s experiences with psychiatric care and consider contextualized factors (eg, race, gender, ethnicity). For example, researchers suggest that African Americans are more likely to be diagnosed with schizophrenia or psychosis than non-Hispanic whites presenting with the same symptoms. Your client’s misdiagnosis likely contributes to medical mistrust and influences his help-seeking behaviors. Establishing a therapeutic alliance at this juncture is critical. Empathetic listening and validation communicate warmth, positive regard, and affirmation. Emphasizing the importance of honest communication regarding suicidality is more likely to occur within the context of a trusting counselor-client relationship. Providing the client with a written copy of informed consent is appropriate but should not be the first consideration. Lastly, obtaining a signed release of information to communicate with the hospital may be helpful. However, using this as an initial response may communicate to the client that you doubt his experiences. Therefore, the correct answer is (C)
Competency: counseling skills and interventions