Case Study
Patient Demographic:  Initial Intake: Age: 14 Gender: Female Sexual Orientation: Heterosexual Ethnicity: Hawaiian American Relationship Status: Single Counseling Setting: School-based mental health counseling Type of Counseling: Individual
Mental Status Exam: Malik presents as well groomed, good hygiene and behavior within normal limits. She is highly anxious, evidenced by limited eye contact, tense expressions and fidgeting with her hands. Malik admits to having suicidal thoughts and has self-harmed by cutting herself in the past. She reluctantly shares that she had a traumatic event in Hawaii right before leaving but is unwilling to discuss it and begins crying. She then changes the subject and tells you moving out of Hawaii has been painful because “everything is different here, including how they do school and how people talk about each other.” She adds that she experiences at least one nightmare a week since moving.
Presenting Problem: Diagnosis: Major depressive disorder, single episode, unspecified (F32.9), Anxiety disorder, unspecified (F41.9)
 

Malik, a 14-year-old girl entering High School is referred to you for mental health counseling by her school counselor for reports of her leaving the classroom in tears and because of calls received by her mother stating that she has crying spells at home. After speaking with Malik’s mother, you learn her mother, stepfather and sisters have recently moved with her to the mainland states from the Hawaiian Islands and that she has been missing her father, friends, school, and other family members left behind. Malik spends most of her time in her room, appears depressed often, gets upset easily and is constantly on her phone. Her mother asks that you meet with her during school hours and help her understand what is going on. She says Malik has been crying since just before leaving Hawaii.
Other Contexts: Family History:
Malik’s parents divorced while she was young but had always lived in Hawaii, making it easy for her to see both sides of her family at will. Malik has several siblings, cousins, and all her grandparents are still alive. Malik has a strained relationship with her father and stepmother and feels heavily influenced by her father’s opinion of her, stating “he just wants what is best for me, but he’s really harsh about it and it sometimes hurts my feelings and stresses me out.” She is struggling to connect with her mother now because she is working full-time, and she feels “doesn’t have time for her anymore.” Malik is also forced to do most of the household chores and care for her younger siblings on top of managing her schoolwork. All of this has made her feel overwhelmed.

Question: When would be the most appropriate time to conduct your follow-up suicide assessment?
(A): Right in this moment with her crying, as you will get the most accurate results.
(B): Consider a reasonable moment in the next five or ten minutes as you discuss her feelings.
(C): Do not bring up her suicidal thoughts unless she does, it might only trigger her more.
(D): At the end of the session before she leaves, so you don't interrupt her thought process.

Correct Answer: Consider a reasonable moment in the next five or ten minutes as you discuss her feelings.
Explanation: Because suicidal thoughts were present, it is your ethical responsibility and clinical best practice to readdress her mental status by conducting a follow-up suicidal assessment. This information is significant for assessing her safety, developing a pattern of data to further justify interventions and future care, and ensuring her evaluations are improving and not degrading. Confronting Malik with questions of her suicidal thoughts right as she begins crying and is sharing her trauma for the first time may not be the optimal time as you are still working to develop rapport, help her feel safe, and receive accurate information when she is thinking more clearly and not responding out of heightened emotion. It is important to understand if she has suicidal thoughts while emotional, but this can still be discussed moments later when you can help her feel more comfortable and elaborate on her feelings. Saving the suicidal assessment for the end of her session is unwise at it may bring about further discussion that you no longer have time for and neglecting to discuss it altogether is in poor judgment and not the safest option. Therefore, the correct answer is (D)
Competency: intake, assessment, and diagnosis