Case Study
Patient Demographic: Initial Intake: Age: 70 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/Non-Hispanic Relationship Status: Widowed Counseling Setting: Private Practice Telemedicine Type of Counseling: Virtual Individual
Mental Status Exam: Mary presents with anxious mood and congruent affect. Speech is normal rate and tone, motor movements within normal limits. Denies hallucinations, delusions, suicidal or homicidal ideation. Mary is well-dressed, adorned with makeup, jewelry, and stylish hairstyle. Mary frequently resists the urge to cry as evidenced by smiling and deflecting when becoming tearful. She tells you she wants to work on herself but appears mildly offended whenever given feedback or asked a personal question and then changes the subject.
Presenting Problem: Diagnosis: Anxiety disorder, unspecified (F41.9), Adjustment disorder, unspecified (F43.20)
 

You are an associate counselor and receive a new referral for a virtual client through your company’s telehealth practice. Mary is a 70-year-old widow who lives alone with her dog in a 55+ active living community. Mary moved to her town to live closer to her daughter and son-in-law when she lost her husband suddenly to cancer four years ago. Mary is struggling with feeling comfortable leaving the house or engaging in any social gatherings outside of being with her children. She wants to make friends her age and take local activity classes, but her anxiety prevents her from committing to plans. Mary has been widowed for four years but has not yet committed to counseling or attendance in grief support groups. She has felt insecure socially since her husband died, but reports being a “social butterfly” before his passing. She admitted to only visiting her husband’s grave on his birthday but is unable to do so any other time. Also, since the COVID-19 outbreak, Mary’s fears and concerns have increased as she is immunocompromised. She asks you for counseling but cannot define what she wants to get out of it.
Other Contexts:  
Family History:
Mary was married to her children’s father for 25 years until he had an affair and left her for the other woman. After a few years, Mary met her late husband and was married another 20 years until he became diagnosed with lymphoma and died within three months of being diagnosed. Mary has three older sisters, all of whom live in different states but come to visit seasonally. She celebrates her late mother’s birthday annually, expressing symptoms of grief each year, and becomes inconsolable on the anniversaries of her late husband’s passing. She tells you only country music calms her down.
 
Work History:
Mary was a stay-at-home mother and wife for both of her marriages, working several jobs in-between marriages as a children’s dental receptionist and an antiques shopkeeper. She opened her own shoppe after meeting her late husband where she sold and displayed southern home décor. She had to close her store down when her husband moved for work. She spent much of her free time making greeting cards and crafts at home, until her hands developed arthritis and she lost enjoyment of her hobbies. She now lives off social security and her late husband’s estate that he left for her.

Question: Considering the first session notes, which of Mary's issues would you attempt to discuss with her next?
(A): shopping addiction
(B): stress from dog's health
(C): redirect back towards social phobia
(D): complex grief

Correct Answer: stress from dog's health
Explanation: Mary has just told you her here-and-now functioning is being negatively affected due to stress that her only live-in companion is not doing well. Address this with Mary right away as it demonstrates compassion and concern, helps you better understand her feelings and fears, and focuses in on another stressor that could be driving maladaptive behavior. Mary presents as in denial over her shopping patterns which may be driven more by perfectionism, compulsion out of boredom, and lack of life satisfaction more so than addiction. This would require further processing, but Mary does not have insight into this considering her response to your question during session. Changing the topic entirely to a different treatment plan goal or projecting her fears about her dog onto other known issues such as grief are both not the most compassionate and empathic choices. Therefore, the correct answer is (B)
Competency: counseling skills and interventions