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: Using the information provided, which of the following steps should be taken first?
(A): Setting up initial boundaries for client and her behavior at home.
(B): Working with mother to determine if client should stay with grandmother.
(C): Asking client and mother if they are willing to work together to help client.
(D): Discussing mother's thoughts and feelings about services and home visits.

Correct Answer: Discussing mother's thoughts and feelings about services and home visits.
Explanation: Addressing the parent's thoughts and feelings about needing or choosing to access services, which includes home visits, is critical to building a therapeutic relationship with both client and her parent. Depending on the mother's cultural history and beliefs, having a stranger in the home, who is acting as an authority figure, may feel demeaning, intrusive, or frightening. Building the therapeutic relationship with the client's mother is equally as important as building it with the client. Asking the client and mother if they are willing to work together may be received as a judgment that mother has not been working for her child up to this point and may be perceived as insulting. Setting up initial boundaries for the client and determining whether the client should stay with her maternal grandmother are choices made by the client's mother and the relationship may be too fragile at this first meeting for the counselor to begin making suggestions for changes for parenting. Therefore, the correct answer is (B)
Competency: counseling skills and interventions