Case Study
Patient Demographic: Initial Intake: Age: 20 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Community Mental Health Agency Type of Counseling: Individual
Mental Status Exam: The client presents looking appropriate to stated age and with positive signs of self-care related to hygiene and dress.  Mood and affect are congruent, and motor activity is within normal limits. His interpersonal communication is cooperative, open, and forthcoming. His speech is within normal limits with respect to volume, tone, or rate. His thought processes appear within normal limits with insight into his thoughts and behaviors, including concerns others express about his situation. He demonstrates the ability to connect ideas with circumstances and choices. He reports no thoughts of suicide or self-harm.
Presenting Problem: You are a counselor in a community mental health agency setting.  Your client presents as a 20 year old man with feelings of sadness, discouragement, being overwhelmed, and anxious. These feelings have been present for the past 4 to 5 years. He reports that while in high school, he had planned to commit suicide but did not follow through with it as he did not want to hurt his family and friends. The client tells you that he has moved frequently with his family; living overseas during his last two years of high school then beginning college in the United States. He states that he moved here 8 months ago because he wanted to be independent of his family and start “a new life without so many ups and downs.”   He lives in a house that his paternal aunt left to his family when she died. His mother and father recently separated and his father provides him with financial support. Until recently, he reports having been employed as a server in a restaurant but was fired after being accused of disrespect to a coworker. Your client states that the coworker had never liked him and he had not been disrespectful of her; however, their manager chose to let him go. He is currently attending classes at the community college and is in a mechanical engineering program. He chose this program because he thought he would really like it but he has been struggling with his courses due to his work schedule and now his major concern is making a living so that he can stay in school. He says he’s beginning to doubt whether this is the right path for him. He reports having no friends or anyone to spend time with on his days off.
Other Contexts: Family History:
The client is an only child. His parents have moved frequently with his father’s job and have lived in different areas of the world. His mother currently lives across the country and his father lives in the Middle East due to his work. They formally separated three months ago. Prior to moving here, the client lived with his mother but was concerned that she was “spending all our money.” His mother is retired and is supported by his father. He states he doesn’t want to be like her and live off of his father’s wealth.

Question: As you begin the intake, the client appears anxious and states that he has many things he wants to share with you and says he "needs to get all these things off his chest." What discussion should you have with him before you begin?
(A): Discuss the non-judgmental nature of the counseling process
(B): Review limits of confidentiality
(C): Remind him that he will set the pace for what he needs to share with you
(D): Give permission for him to share slowly so he doesn't later regret his vulnerability

Correct Answer: Review limits of confidentiality
Explanation: Counselors are required to discuss the limits of confidentiality with all clients prior to counseling. This client has a history of suicidal ideation and intent so the counselor must review the circumstances that would require breaking confidentiality to protect the client from self-harm. Discussing the nature of counseling is important as is allowing the client to set the pace for self-disclosure based on the growing therapeutic relationship. Research has shown that clients who overshare too early in the counseling relationship often regret their vulnerability and may discontinue counseling due to embarrassment or shame. Therefore, the correct answer is (C)
Competency: professional practice and ethics