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 would be most appropriate to say to the client?
(A): It sounds like you have quite a lot more to deal with at home than you told me last time.
(B): It sounds like your family is worried about taking care of you, not your property
(C): I wonder what it is like for you to hear your DIL share her concerns about you.
(D): I wonder if we need to figure out a way to help you get all that stuff cleaned out.

Correct Answer: I wonder what it is like for you to hear your DIL share her concerns about you.
Explanation: Asking the client what it was like to hear her DIL express her concerns about the client and her living space allows the counselor to observe the client's insight, defensiveness, and assess symptoms of paranoid delusions while giving the client the opportunity to hear her family's perspective in a safe environment. This helps build trust in the counselor-client relationship. Statements shown in Options b and d are confrontational as they call attention to the discrepancy between what the client originally presented and what her DIL is now saying. Confrontations or suggestions that the client may not be truthful are not helpful in facilitating trust in the client-counselor relationship. While helping the client reduce and recover from hoarding may be an ultimate goal, suggesting this at this time is likely to cause the client to become anxious and suspicious of the counselor's motives as this has not been discussed between them. Therefore, the correct answer is (C)
Competency: intake, assessment, and diagnosis