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: Which approach should you try first to help Malik talk about her trauma with you?
(A): Use caring confrontation with her about how unaddressed trauma increases depression.
(B): Tell her the details about mistakes you have made in the past and that its normal.
(C): Use reflecting, paraphrasing, silence and empathic attunement.
(D): Remind her the purpose of her counseling is to get better by talking about it.

Correct Answer: Use reflecting, paraphrasing, silence and empathic attunement.
Explanation: These basic counseling skills are non-judgmental, evidence-based techniques that build rapport and trust, and most effectively help clients feel heard and understood without feeling pressured. The mentioned trauma is possibly sexual in nature so using techniques in answer d are the best way to be sensitive to Malik's comfort level, respect the establishment of her boundaries, and honor the timeline of her willingness to share. Using these techniques may also support her in sharing about all things that are contributing to her emotional distress, leading her to discuss what she is most willing to address first. Helping her to understand that unaddressed trauma may lead to increase of depression. Educating Malik about how trauma can increase symptoms of depression as well as reflecting together on your treatment plan goals are both valuable interventions, however, it may be better to address this earlier in the session. Alternatively, it may be more effective to discuss these issues after all other interventions have been exhausted. Using self-disclosure techniques such as in answer c are to be considered on a case-by-case basis, and while this approach can support a teenager in therapy, it is important not to blur the lines of the counselor-client relationship by any actions that might mimic the dynamics of a peer-to-peer relationship. Therefore, the correct answer is (D)
Competency: counseling skills and interventions