Case Study
Patient Demographic: Initial Intake: Age: 68 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Widow Counseling Setting: Community Agency Type of Counseling: Individual
Mental Status Exam: The client presents appearing thin for height and older than her stated age. She is dressed in jeans and a shirt, no make-up and appropriate hygiene.  Her mood is identified as euthymic and her affect is congruent. She is talkative and tells stories about herself and others, although she appears very distractible and changes subjects easily. She demonstrates appropriate insight, judgment, memory, and orientation using mental status exam questions. She reports never having considered suicide and never consider harming herself or anyone else.
Presenting Problem: You are a counselor in a community agency and your client presents voluntarily, though at the request of her family members. She tells you that her stepson and daughter-in-law told her they are concerned about her because she lives alone and they don’t believe that she can take care of herself at her home. She tells you that she is very happy living alone and is never lonely because she has over 20 indoor and outdoor cats that she feeds and they keep her company. During the intake, the client tells you that her husband of 33 years died five years ago from lung cancer. When asked why her family wanted her to come to counseling, your client says that she gets along well on her own; however, she believes that her stepson is looking for ways to take over her property. She tells you she owns a large section of land that includes two trailer homes, one of which is in better shape than the other so that is where she lives; ten or eleven vehicles, some that run and some that do not; and five large carports that hold the items that she and her husband used to sell at the daily flea market before it closed 15 years ago. She tells you that she sometimes finds uses for some of these items around her house but keeps all of them because they may “come in handy” at some point. She currently has no help on her property for mowing or upkeep, unless a neighbor or her son-in-law volunteers to help.
Other Contexts: Family History:
The client reports that her parents divorced when she was a young teenager and she did not see her father again after that time. She reports he was an alcoholic as was her mother and they often argued. She relates that her mother did not work and she grew up with government assistance for food and shelter. She tells you that several years after the divorce, her mother’s mobile home was destroyed in a fire and the two of them lived in a friend’s trailer until they were able to buy another one to put on their property. She reports that she quit high school in 10th grade after having trouble reading for many years, married at age 16, had one daughter, and then divorced at 19 due to her husband’s continuing drug use. She tells you that her daughter has not been around for the “past few years” because she lives in another state and has some “mental problems, like bipolar something.” She tells you that she married again at age 20 and remained married to her husband until his death. She tells you her husband was a “good man” though he had many problems related to his military service in Vietnam and health problems due to smoking. She reports he had lung cancer and lived for 20 years although the doctors did not expect him to live so long. This was a second marriage for both of them and she tells you that her husband had one son. The client tells you she has not been close with her stepson because he has never helped them out and it has been worse since she stopped letting him keep his hunting dogs on her property. She tells you that he never took care of them and she had to feed them every day because he did not. The client tells you that she is close to her stepdaughter-in-law and that she trusts her much more than she does her stepson. The client tells you that she and her husband worked at the local flea market for many years selling things they had collected, but since the flea market closed 15 years ago, they lived on Social Security and the money her husband made doing “odd jobs” around town.

Question: Which of the following referrals will be most helpful in treating the client's hoarding disorder?
(A): Refer client to psychiatry for medication evaluation
(B): Refer client to local government services for evaluation of adequate housing
(C): Refer client to behavioral health to determine client's competency to make decisions
(D): Refer client to a professional organizer who can help organize the client's home

Correct Answer: Refer client to psychiatry for medication evaluation
Explanation: Referring the client to psychiatry will be most helpful for treating the client's hoarding disorder due to the components of depression, OCD, and ADHD that are often co-occurring with hoarding disorder. Treatment with SSRIs is helpful in treating those with hoarding disorder. Referring to a professional organizer will not be adequate, although once the client has made gains through therapy, teaming a counselor with a professional organizer who is trained to work with hoarding disorders may be helpful. While hoarding disorders may include difficulty with decision-making, the client does not demonstrate incompetence and referral for evaluation or declaration of incompetence would be inappropriate. Counselors may provide information on local resources for housing but although the client's housing may not be adequate at this time, referring her to resources that may condemn and/or remove her from her home threatens the therapeutic relationship and dishonors the autonomy of the client to choose where she lives. Therefore, the correct answer is (B)
Competency: counseling skills and interventions