Case Study
Patient Demographic: Client Age: 8 Sex: Female Gender: Female Grade: 3rd Ethnicity: African American Counseling Setting: School-based Type of Counseling: Individual and Family Presenting Problem: Defiance Diagnosis: Oppositional Defiant Disorder 313.81 (F91.3)
Mental Status Exam: Mental Status Exam: The client displays an angry affect and sits with her arms crossed. She is well dressed and well groomed. The client’s PGM repeatedly prompts her to say, “yes ma’am” and “no ma’am” when answering questions. The client sits slumped in her chair. She agrees to color in a feelings thermometer that reflects increased anger, sadness, and fear. Her insight is poor. The client often refuses to eat school lunch, and the PGM reports that the client is a picky ea
Presenting Problem: You are a school-based mental health counselor conducting an initial intake with an 8-year-old African American female in the 3rd grade. The client presents today with her paternal grandmother (PGM), the client’s legal guardian. The PGM states that the client is argumentative, refuses to take responsibility for her actions, and has a tantrum when she receives a consequence for her behavior. She reports that the client is restricted from “every single privilege indefinitely.” The client has been told she can regain privileges once she “learns to act her age.” The client states she is treated unfairly and “blamed for everything” at home and school. The client’s teacher reports that she has difficulty following directions, is easily annoyed by her classmates, and frequently loses her temper. The client’s grades are poor, and she is below grade level in reading. However, she enjoys art and proudly reports that one of her pictures came in 1st place and is hanging in the library.
Other Contexts: The client’s formal assessment, along with informal observations, warrants a psychiatric evaluation to assess for ADHD, and the PGM has agreed to this. The client has done well in therapy and has met her short-term counseling goals. She has processed grief and loss concerning separation from her parents and shows improvement with emotional regulation. The use of brief strategic family therapy (BSFT) has helped address patterns of interaction between the client and her PGM, and the client is having fewer tantrums. The PGM reports that the client continues to talk back, and she is not completing her chores. You plan to conduct a series of home visits to assist the PGM with parent management skills but receive word from your agency’s office indicating the client has lost insurance coverage

Question: Which is the best course of action upon discovering the client has lost insurance coverage?
(A): Suspend services indefinitely and resume when the client’s insurance is reinstated.
(B): Initiate bartering with the client in exchange for the continuation of services.
(C): Terminate the counseling relationship and offer appropriate referrals.
(D): Provide the remaining services pro bono to avoid client abandonment.

Correct Answer: Terminate the counseling relationship and offer appropriate referrals.
Explanation: The best course of action is to terminate the counseling relationship and offer appropriate referrals. The client has met her short-term goals and her treatment is nearing completion. Policies related to termination, payment, and insurance coverage are all part of informed consent. Informed consent is reviewed during the initial intake and continues throughout treatment. According to the American Mental Health Counselor Association (AMHCA) Code of Ethics (2020), “CMHCs may terminate a counseling relationship when clients do not pay fees charged or when insurance denies treatment. In such cases, appropriate referrals are offered to the clients” Bartering is unethical in this situation because it is initiated by the counselor. According to the American Counseling Association (ACA) code of ethics (2014), “Counselors may barter only if the bartering does not result in exploitation or harm, if the client requests it, and if such arrangements are an accepted practice among professionals in the community. Counselors consider the cultural implications of bartering and discuss relevant concerns with clients and document such agreements in a clear written contract” There is not a need to avoid client abandonment due to the conditions outlined in the informed consent. While providing pro bono services is encouraged, there are potential downfalls with providing services free or at a reduced cost. If you are not applying the same rate to all of your clients, this may be perceived as discrimination. Suspending services indefinitely is problematic simply because you may not know if or when the client’s insurance will be reinstated. Additionally, medical necessity may be questioned because of the requirement to provide medically justifiable treatment (ie, the right intensity, duration, and frequency) matching the client’s current needs. Therefore, the correct answer is (A)
Competency: professional practice and ethics