Case Study
Patient Demographic: Name: Rick Clinical Issues: Referred for emotional and behavior issues Diagnostic Category: No Diagnosis Provisional Diagnosis: No Diagnosis Age: 18 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: Korean Marital Status: Single Modality: Group Therapy Location of Therapy : Community Center  
Mental Status Exam: The client is slouched over in his seat and appears withdrawn with a flat affect. He keeps his head down. The client plays with his shirt sleeve, twisting the material and pulling at it. You cannot see any cuts on his arms as reported by the mother. He does not appear to be angry at this time, which was also a symptom reported by his mother. He responds to your questions with one-word answers. He seems uninterested. The client denies any suicidal and homicidal ideation. The client mumbles, "I don't want to talk about anything here."
Presenting Problem: First session You work as both an individual and group therapist at a community center that primarily sees adolescents with emotional and behavioral issues. Rick is a senior in high school and lives with his mother and two sisters. Rick does not want to participate in individual or group therapy, but his mother insists that he get help. During the intake, you work to establish rapport with Rick. You also gather information to determine if he is an appropriate candidate for one of the groups you are preparing to start, along with a co-facilitator. You suspect he may have trouble trusting females as he expresses anger when talking about his mother, sister, and ex-girlfriend. Since his father left, Rick says that his mother has been "in his business" all the time, and he does not feel like he has any real privacy.    You remain patient with Rick, listening to his story and validating his feelings. You empathize with him, letting him know it is understandable to feel frustrated about not having much privacy. You explain that you are here to help him, not to control him and that you are interested in learning more about him.    You explain to Rick that you are planning to start a group therapy session with a co-facilitator and that you would like to see if it would be a good fit for him. You explain that the group will provide an opportunity for him to talk about his experiences in a safe space with others who may have gone through similar situations In addition, you share that it could be an excellent way for him to practice expressing himself and developing trust in others.    You also explain to Rick that individual therapy sessions could be beneficial in addition to group therapy. You discuss the possibility of one-on-one sessions that would give him a chance to talk more deeply about his experiences in a safe, private setting You emphasize that this could be an excellent way for him to explore his feelings and learn how to cope with them in a healthy way.  Sixth session Rick has been attending group therapy weekly. He continues to wear long sleeves to the session but appears engaged and involved in the group process. The group exhibits high cohesion, and all members participate in group activities. The focus is on continued productivity and problem-solving. You ask the members to reflect on the skills they have been practicing in the group and share an experience in which they have applied those skills outside the session.    Rick's experience in the group has further helped him to identify and understand his feelings. He has been able to recognize his anger and express it in a healthier way. He has also been able to recognize his need for connection. He says he recently called his ex-girlfriend to apologize for being angry about his parents and "taking it out on her" by withdrawing from her. This has enabled him to develop a more constructive approach to conflict.    The group members have provided Rick with a safe space to practice his new skills, giving him the confidence to try them in his real-life relationships. The other members have shown Rick support and encouraged him to take risks and to be open to opportunities for growth.    Rick's active engagement in the group has been instrumental in his progress. He has become more aware of his emotions, and he can express himself in a way that is respectful and appropriate. His newfound ability to communicate effectively has been a significant step towards strengthening his relationships both inside and outside of the group.  11th session The group as a whole has made progress, and members have found healthy outlets for expressing their thoughts and feelings. Rick has become more open with the women in the group and seems more receptive to what they have to say. Rick says that his grades have improved, his mother is proud, and he is encouraged by other group members who nod their heads and smile. The group has met its goals. The members have learned strategies to take with them as they prepare for termination. You remind the group that there are only a few more weeks left to meet. You begin to discuss the group members' feelings regarding the end of therapy. Rick starts to cry and says, "Why does every woman in my life cause problems for me?"    The other group members offer Rick reassurance and empathy, but he continues expressing his frustration and sadness. You encourage the group to reflect on each person's progress and to be mindful of the emotions that this ending brings out. You explain to the group that endings can be difficult and that giving them permission to feel the emotions that arise during this transition is important.    Rick is still struggling with the idea of ending the therapy and expresses his fear of being left alone. He continues to express his feeling that every woman in his life has caused him pain and suffering, and this group's ending has triggered his worst fears. You recognize his fear and attempt to validate his experience by emphasizing his progress in the group and the positive changes he has seen in himself. You explain that the group can support him through the transition and the other members offer encouraging words of encouragement.    Rick is still anxious and overwhelmed. He talks about the difficulty of coping with the loss of the group and how he worries that he won't be able to manage his feelings without the support of the group. You explain to the group that it is natural to feel sadness and loss as well as gratefulness and pride in the progress they have all made. You encourage the group to identify the strategies they have learned in the group that they can use to manage their emotions. Finally, you assure Rick that he can use the skills he has learned in the group to cope with the emotions associated with the end of therapy.
Other Contexts: The client is a first-generation American whose parents immigrated from Korea. He has an old sister who, based on Korean culture, is his superior whom he must obey and be subservient to. His parents have high expectations for him and are very controlling, expecting him to study every night and attend tutoring sessions on the weekend. They have arranged for him to marry a daughter of a prestigious family in Korea after he completes medical school eight years from now, with the intention that he and his wife will live with them and provide financial support. However, this plan has drastically changed.    Seven months ago, the client's father moved out after his mother had an affair. The client became sullen, angry, and withdrawn after this event. Four months ago, while doing laundry, the client's mother saw dried blood on his shirt sleeve. She also noticed that he was wearing long-sleeved shirts all the time. She waited until he was getting dressed, walked in on him, and found he had cuts up and down his arms. The client does not speak to his father much since his parents separated. The client expresses a lot of anger toward the women in his life, specifically his mother, sister and ex-girlfriend. The client is a senior in high school. His grades have been suffering lately, and he is currently failing his math and science classes. Personal/Social Relationships: The client had been concealing his romantic relationship with a girl from his Saturday tutoring class, but following his father's abrupt departure from the family, he chose to discontinue the relationship and cease attending the class. He has since refrained from any communication or contact with her. His mother's affair has caused him to feel overwhelmed with anger, leading him to develop a dislike of all women. 

Question: Although Rick has made significant progress in the group, you believe that he still has unresolved issues. What should you do to increase the likelihood of his success?
(A): Reinforce progress that has been made in treatment
(B): Offer to be available for individual therapy
(C): Practice mindfulness skills during the next group session
(D): Suggest that he join a new therapy group

Correct Answer: Offer to be available for individual therapy
Explanation: At this time, the group has met its goals and is ready to enter the termination stage. The client has made progress in the group but still has unresolved issues. It would help if you made yourself available to him for individual counseling to address these issues. Therefore, the correct answer is (C)
Competency: intake, assessment, and diagnosis