Case Study
Patient Demographic: Client Age: 24 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Private practice counseling clinic Type of Counseling: Individual counseling Presenting Problem: The client comes to counseling for help in managing anxiety, workplace dissatisfaction, and a pornography addiction. Diagnosis: Generalized anxiety disorder (F41.1), other problem related to employment (Z56.9), religious or spiritual problems (Z65.8)
Mental Status Exam: Mental Status Exam: The client is oriented to person, place, time, and situation. The client appeared hesitant when talking about pornography
Presenting Problem: You are a professional counselor, and the client comes to counseling to work on anxiety, work dissatisfaction, and a pornography addiction. You and the client discuss his anxiety, and he identifies that he experiences anxiety at work, regarding daily tasks, and in social settings. The anxiety is characterized by restlessness, difficulty concentrating, muscle tension, and insomnia. The client states that at work he is often treated poorly by his supervisors, who often point out what he does wrong and do not acknowledge what he does right. He does not feel that he does as much wrong as they claim, and he often finds that their accusations do not accurately reflect his actions, which is frustrating. The client states that he has had many meetings with his supervisors and that they do not appear to try to understand his point of view. The client appears uncomfortable and begins to speak but stops for about a minute before saying that he also has a pornography addiction. The client says that he is a Christian and that he does not feel he should view any pornography, but also that he uses pornography a lot and does not feel like he has control over himself or the frequency at which he uses it. The client asks if you are a Christian, and you decide to disclose with him that you are, knowing this is an important part of the client’s life and perspective. The client states that his work problems and pornography use are his most pressing issues.
Other Contexts: use. Family History: The client has a close relationship with his parents and his older sister. The client has close friends.  The client inquires about his counseling records when you are explaining informed consent

Question: The client inquires about his counseling records when you are explaining informed consent. Which of the following statements is the most accurate with regard to the client’s records?
(A): The counselor must make reasonable precautions to ensure the privacy of client records in the event of termination, incapacity, or death.
(B): Client records must be kept for at least 5 years before being appropriately destroyed.
(C): You can share session notes with your counseling resident for educational purposes because they are practicing under your license.
(D): When the client requests his records, you must provide full access to the records and support their interpretation as needed.

Correct Answer: The counselor must make reasonable precautions to ensure the privacy of client records in the event of termination, incapacity, or death.
Explanation: The most factual statement regarding client records is with regard to making reasonable precautions in case you are suddenly unable to continue services. Even if a counseling resident is practicing under your license, you still need to obtain written consent for release of information to your resident. When a client requests records, if there is a risk of foreseeable harm, you can restrict access to some or all of the client’s chart. You should keep the client’s records within the bounds of the state’s laws within which you practice, which is typically a certain number of years, but the length of time varies based on the state in which you are licensed. Some clients have situations that might suggest that you keep records longer such as those having court involvement or abuse/neglect allegations. Therefore, the correct answer is (D)
Competency: professional practice and ethics