Case Study
Patient Demographic:  Initial Intake: Age: 16 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Community Health Type of Counseling: Individual
Mental Status Exam: The client presents as a thin young woman, whose weight is appropriate for her age. Her clothing is appropriate for her age and to the situation. She identifies her mood as happy and her affect is congruent. The client shows some retardation in movement but no spasticity or physical or abnormal movements. The client appears open and honest in her responses, though responses are short. She responds to closed questions without pause but appears to struggle to answer open-ended questions as evidenced by staring and smiling without speaking or saying “I don’t know.” On examination, the client shows little insight into her mother’s concerns and uses childlike judgement when responding to hypothetical questions. The client denies suicidal or homicidal ideations or intent, delusions, or hallucinations, but does admit to playing a game with children at her maternal grandmother’s house where they attempt to see ghosts in the bathroom mirror.
Presenting Problem: You are a counselor in a community health setting which includes in-office sessions as well as home visits. Your client is a 16 year-old female who presents with a history of academic difficulties, problems following rules at home, and fighting with her sister, which recently included threatening to cut her sister with a kitchen knife. Her mother tells you that the client has always had some problems in school but they are getting worse. Her teachers say that she doesn’t pay attention and struggles with simple concepts, but is always polite and friendly to others. When asked to tell you how she thinks things are going, she answers “good” and smiles. You notice that she often smiles while her mother is talking but when her mother talks about the problems at home, the client looks away from both of you and stares out the window. The client’s mother reports that the client does not clean her room, has to be told to attend to her hygiene, and does not complete chores when they are assigned, such as cleaning out the refrigerator or vacuuming the living room. Mother reports that the client stays at home alone or with her two younger sisters when her mother or mother’s boyfriend are at work or away from home during the day.
Other Contexts: Family History:
The client is the oldest of three children born to her mother. Her siblings have different fathers and her youngest sister’s father currently lives in the home and is identified as “mom’s boyfriend” or “Robert.” Client’s mother reports no family history of mental health disorder or substance abuse. The client reports that she often spends several nights a week with her grandmother “to give Mom a break” and plays games and spends time with the neighborhood children. The client states that her grandmother “makes me sit and she reads the Bible to me” for several hours each day. She reports that she likes spending time at her grandmother’s house because she and her sister watch “scary movies” including movies about monsters, murders, and witchcraft.

Question: Which of the following would be the counselor's next step in working with this client?
(A): Explain to the client's school that she is experiencing hallucinations and delusions
(B): Express your concerns to client's mother and have her choose the next step
(C): Enroll the client in a social skills group for adolescents to build social skills
(D): Refer to psychiatry for medication evaluation

Correct Answer: Refer to psychiatry for medication evaluation
Explanation: The client should be referred to psychiatry for medication evaluation to treat her schizophrenia and depressive symptoms. Schizophrenia does not resolve on its own and the client will likely require medication throughout her lifetime. Once she has been evaluated and medication is prescribed, the counselor and parent will notify the school of any concerns regarding the client. Enrolling the client in a social skills group may be helpful after medication has been instituted as she will need to learn skills in communicating appropriately with others while feeling limited by her medication. Medications for schizophrenia have side effects that make it difficult for individuals to engage with others. It is appropriate for the counselor to express concerns to the client's mother, but this should be done while providing the treatment options rather than asking the mother how to handle the situation as she does not have the expertise about the disorder and treatment that the counselor possesses. Therefore, the correct answer is (A)
Competency: intake, assessment, and diagnosis