Case Study
Patient Demographic: Client Age: 30 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Agency Type of Counseling: Outpatient Presenting Problem: Recent Hospital Discharge Diagnosis: Borderline Personality Disorder (BPD) 301.83 (F60.3)
Mental Status Exam: Mental Status Exam: The client is wearing a low-cut blouse and short shorts. Her affect and mood are labile, and her speech is pressured. She is fidgety at times and sits with her arms crossed. The client states that she has had three previous suicide attempts and has been cutting since her late twenties. Her last suicide attempt was an overdose, which resulted in her recent hospitalization. She stated that this was the result of her last boyfriend “ghosting” her. The client denies audiovisual hallucinations but states that she often feels that others are conspiring against her. She says that she continues to have suicidal thoughts but denies having a current plan. Fam
Presenting Problem: You are a mental health counselor in an outpatient setting. Your client is a 30-year-old white female who was released from the hospital 48 hours ago. The client presents today for a postdischarge follow-up appointment. The hospital clinician diagnosed the client with borderline personality disorder(BPD) and substance use disorder. The client has a history of suicidality, impulsivity, and relational instability. She explains that she has a “quick temper,” which occurs when she is feeling rejected. She explains that she has a long history of being treated poorly by others, including her last boyfriend, former employers, and family members. During these times, the client admits to substance misuse and self-mutilation (i.e., cutting). She states that there are times when she drinks to black out and that she is more inclined to do so when her feelings become intolerable. The client has had multiple hospital admissions and has been in the care of several counselors. She questions your credentials and your ability to “work with someone like (her).”
Other Contexts: You and the client develop a clear and explicit treatment contract to provide a foundation for informed consent. Through this collaborative process, you establish an agreement outlining treatment roles, responsibilities, and expectations for you and the client. The client agrees with your suggested goals but does not want to include safety issues as part of her treatment plan. You provide psychoeducation on BPD, and she relates to experiences of abandonment. She would like to learn how to navigate romantic relationships and requests interventions targeting this area

Question: What is the primary purpose for engaging the client in the process of contract setting?
(A): To eliminate client “splitting” and manipulation
(B): To provide legal protection in the event of a boundary violation
(C): To establish trust and build a working alliance
(D): To give grounds for termination if the client does not uphold her portion of the agreement

Correct Answer: To establish trust and build a working alliance
Explanation: You engage in contract setting to help establish trust and build a working alliance. When you work with the client to establish trust and a collaborative working alliance, there is an increased likelihood of the client engaging in and benefiting from therapy. Although contract setting is helpful for addressing other issues, answer A is the best response. Eliminating client splitting and eliminating manipulation are not collaborative goals, making answer option B incorrect. Client contracts do not provide legal protection in the event of a boundary violation. It is the counselor’s responsibility rather than the client’s to ensure that boundaries are clearly defined and kept intact. Lastly, using contracts to give grounds for termination is not the primary purpose of contract setting. Therefore, the correct answer is (A)
Competency: counseling skills and interventions