Case Study
Patient Demographic: Name: Aghama Clinical Issues: Cultural adjustments and sexual identity confusion Diagnostic Category: V-codes Provisional Diagnosis: Z60.3 Acculturation Difficulty Age: 18 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Bisexual Ethnicity: Nigerian Marital Status: Never married Modality: Individual Therapy Location of Therapy : University Counseling Center  
Mental Status Exam: The client comes to your office and sits rigidly and makes little eye contact. She is dressed neatly and appropriately for the weather with overall good hygiene. She appears cooperative and open to the therapeutic process. She expresses a willingness to discuss her experiences, thoughts, and feelings, but show some hesitation due to her unfamiliarity with therapy. The client's mood is depressed. Her affect is congruent with her mood, displaying a flat or subdued demeanor, but shows some variability when discussing her family or life in Nigeria. Her speech is clear, fluent, and coherent. She has no difficulty expressing herself in English and seems to have a good command of the language. Her speech is slightly slow. The client's thought process appears linear and goal-directed. She is able to articulate her concerns and goals; her thoughts seem to be dominated by her feelings of sadness, loneliness, and homesickness. The client demonstrates some insight into her situation and the impact of her homesickness on her overall well-being. She appears to be motivated to seek help and improve her situation. There is no evidence of suicidal ideation or intent. The client does not express any thoughts of self-harm or harm to others. However, her ongoing feelings of sadness and loneliness warrant close monitoring and support during the therapeutic process.
Presenting Problem: First session You are a licensed mental health counselor working at a university counseling center and take a humanistic approach in your work with clients. Today you are meeting with an 18-year-old student who recently moved to the United States from Nigeria. She tells you that she moved to the United States one month ago after missionaries in Nigeria granted her a scholarship. She feels lonely, misses her family, and is questioning her decision to come to the United States. She indicates she has never been to therapy before but was told by her academic advisor that it might be helpful to make an appointment with a counselor.    You continue the intake session by exploring the client's current psychological functioning. She expresses that she is homesick and is struggling to find her place in a new environment. She describes having difficulty making friends at college and feels isolated. She does not feel comfortable talking about her personal life with people she does not know well, which makes it even more difficult for her. Additionally, she is struggling with the pressure of living up to the expectations of the members of her church that gave her the scholarship to attend the university. She is currently pursuing a nursing degree at the university. You ask her to share some details about her family and cultural background in order to gain a better understanding of the context of her situation. She tells you that her parents are both teachers and she has two siblings. The family is very close-knit and they typically speak in their native language at home. You also ask about how she is managing her academic obligations, any specific challenges or barriers she might be facing, and how she is spending her free time. She says that her courses are challenging, but she is managing them well. In between classes, she spends most of her time in the library studying.    You discuss the therapeutic process and what she hopes to gain from counseling. She expresses that she would like to learn how to better cope with her homesickness and loneliness. She says, "I'm worried that I'll be a disappointment. It took a lot of money and effort to get me here, and I don't want to let them down. I was so excited when I first got the scholarship, but maybe it would have been better if it went to someone else." You validate her feelings and explain that it is natural to feel overwhelmed when faced with a new culture and environment. You further explain the importance of focusing on her strengths, as she has already accomplished so much by making the decision to attend college abroad. You describe therapy as an opportunity for her to explore her feelings, develop coping strategies, and adjust to her new environment. At the end of the session, she tells you she is on a "tight schedule" and needs to know when she can see you for therapy so she can plan accordingly. You provide her with your availability and suggest that an ideal therapy schedule would involve weekly sessions. You also explain the importance of consistency in order to allow her to make meaningful progress during therapy. You schedule an appointment for the following week.  Fifth session This is your fifth weekly session with the client, and she states that she likes the "structure" of seeing you on Wednesday afternoons. The client appears to be doing better since she last saw you. She begins today's session by telling you that she still feels isolated and is having difficulty making friends. You ask her to elaborate on the challenges she has been facing in connecting with students at the university. She tells you that most of the other international students are from countries closer to America like the Caribbean islands, and it is difficult for her to relate to them. She pauses for a moment and asks if she can tell you about something that happened a few days ago that she is feeling nervous about. You respond affirmatively, and she tells you that her roommate invited her to a party and she ended up drinking which is not something she would normally do. When she and her roommate got back to their dorm room later that night, they kissed. She goes on to say that she thinks she has developed romantic feelings for her female roommate. This experience made her feel confused and anxious, and her family's expectations weigh heavily on her mind. You ask her to elaborate on her feelings in order to gain a better understanding of the situation. The client shares that she is unsure what this could mean for her future and worries if her family will be disappointed in her if they find out. She says, "I am actually engaged to a man in Nigeria. We decided to postpone the wedding until I finished my degree, but now I don't know what to do. My parents were so excited when we announced our engagement, and the thought of breaking it off feels like a betrayal."    You explain that it is natural to feel confused when faced with new experiences and remind her that she is in control of the decisions she makes about her life. You suggest exploring what a relationship with her roommate might look like, as well as considering the consequences of breaking off her engagement. She says, "I know I need to stay true to myself. I just don't want anyone hurt in the process. I can't even imagine what it would mean if I told my parents or church family about my roommate. They are not as conservative as other people in the town where I grew up, but I don't think they know many, if any, people who are in same-sex relationships." You discuss with the client how her religious and cultural beliefs may affect her sexual identity and contribute to feelings of guilt and fear of disappointing her family.    During the next few weeks following today's session, the client cancels twice without proper notice and later tells you that she "had other stuff going on."  Seventh session During today's session, the client tells you that she read a few of the chapters in the book you recommended on human sexuality, and she is starting to feel more comfortable with herself. At your suggestion, she started keeping a journal to organize her thoughts and feelings about her sexuality. She says that she has "pretty much decided to end my engagement and take some time to explore who I am and what it means to be in a relationship with another woman." She relates that she still feels homesick at times, but her roommate has been supportive and understanding. She smiles and says, "My roommate surprised me the other day by cooking a traditional dish that I told her about that my mom used to cook for us growing up. It was so comforting to have a reminder of home like that." You continue to explore the client's thoughts on telling her parents about her newfound identity, and she says that although the idea of coming out to them and breaking off her engagement is frightening, she knows it is "the right thing to do." You provide guidance on how to approach this sensitive subject in a way that may be best received by her family. You also provide additional resources that may help her learn more about navigating conversations around sexuality and sexual orientation with family and friends. The client notes that if all goes well, she'd like to take her roommate back home with her for a visit during a school break so they can spend time together away from school.

Question: What is the best way to demonstrate empathic attunement in response to the client's fear of her family's disapproval?
(A): "What would you advise another person in your situation to do?"
(B): "It's understandable that you are worried about how your family will react. It can be very difficult to balance the expectations of your family with your own needs."
(C): "How would you feel about role playing a conversation with your family about your relationship? This might help alleviate some of the anxiety that you're feeling."
(D): "You're not alone in this experience and what you're feeling is valid."

Correct Answer: "It's understandable that you are worried about how your family will react. It can be very difficult to balance the expectations of your family with your own needs."
Explanation: This is an example of empathic understanding because it acknowledges the client's feelings and validates her concerns without passing judgment. It shows that the therapist understands the difficulty of navigating family expectations, while also affirming the client's autonomy to make decisions about her own life. This response allows the client to feel heard and understood in a non-judgmental environment. Therefore, the correct answer is (C)
Competency: core counseling attributes