Case Study
Patient Demographic:  Initial Intake: Age: 20 Gender: Male Sexual Orientation: Homosexual Race/Ethnicity: African American Relationship Status: Single Counseling Setting: University counseling center Type of Counseling: Individual
Mental Status Exam: Jonathan presents as anxious with congruent affect, evidenced by client self-report and therapist observations of fidgeting, inability to sit still, tearfulness and shallow breathing with rapid paced speech. Jonathan occasionally closes his eyes and takes deep breaths when he begins to cry in attempt to slow himself down and prevent what he calls “another emotional breakdown.” He has prior inpatient treatment history of a one-week episode where he was involuntarily committed at 17 for making comments about planning to kill himself in response to his stress over finishing high school. He admits to passive suicidal ideations in the past few weeks while studying for exams but does not report considering a method or plan. He reports that he has been losing sleep because of long study hours and feeling too keyed up to calm down. You assess him as having distress primarily associated with anxiety, which at times of abundant stress turns to episodes of depression and hopelessness.
Presenting Problem: Diagnosis: Anxiety disorder, unspecified (F41.9), Major depressive disorder, single episode, unspecified (F32.9)
 

You are a brand-new counseling intern in the counseling resource center of a local university. Jonathan is a junior in college and comes to speak with you, as you are his newly assigned college university counselor. Jonathan is concerned about finals that he feels unprepared for, stating he is “overwhelmed” and “under too much pressure” from his family to “allow himself” to fail. He is making disparaging, negative remarks about himself and his abilities, often repeating himself and talking in circles using emotional reasoning. He asks you for help in getting his teachers to modify his deadlines so that he can have enough time to accomplish all his assignments, mentioning that his last counselor did that and called it “playing the mental health card”. There are no previous records on file for this student, but when you ask him who he met with he just changes the subject and continues to express his worry that he will “never amount to anything or graduate” if he fails these exams.
Other Contexts: Education and Work History:
Jonathan has a high academic performance history, despite short periods of time where he experiences heightened stress. Jonathan has never gotten in trouble in school or had any infractions at part-time jobs later as a teenager. He has worked after-school jobs at the grocery store, bowling alley, and local town library. Jonathan had only one work-related incident where he broke down emotionally when feeling overwhelmed and left work in the middle of his shift, but his supervisor was supportive and helped him.
 
Current Living Situation:
Jonathan lives in the college dormitory with a peer and is supported by his mother. His mother is a single mom who works full-time in Jonathan’s hometown, which is almost a full day’s worth of driving from where Jonathan goes to college. Jonathan mentions that his friends call him “Jonny.” He adds that the food available to him is not very healthy and he has poor eating habits due to prioritizing studying and his involvement in extra-curricular activities.

Question: You run into one of Jonny's teachers in the breakroom shortly after session and he says to you, "I hear you are meeting with Jonny, that's good. He really needs it." He sits down with you and asks, "Did he ask you to extend his deadlines? He's done that with all the counselors." How do you respond?
(A): "I remember being stressed in college. These kids have so much to worry about!"
(B): "Yes! He told me he has not done that before. I'll have a talk with him."
(C): "No, he has not said anything like that. Why do you think he really needs counseling?"
(D): "I cannot comment on things said in session, it is a violation of his trust."

Correct Answer: "I remember being stressed in college. These kids have so much to worry about!"
Explanation: This response gently redirects the subject away from speaking about Jonny while also building rapport with his teacher. As a fellow staff member of the university, you are a team of professionals working together to help the students and may often need input from teachers to support your counseling efforts. Declining to comment out of confidentiality while a co-worker is showing interest and engagement in a fellow student can be viewed defensively, and you may lose your ally in providing Jonny well-rounded care. Lying about what Jonny has said or not said is also unhelpful. Asking a teacher for their input or observations of Jonny may be useful to your needs, but in this case, attempting to obtain input when you did not directly ask for it, is somewhat opportunistic. Also, a public break room during may not be the best time or place to discuss student therapy issues. Breaking Jonny's confidentiality as in answer a) is also unethical towards your therapeutic relationship with him. Therefore, the correct answer is (D)
Competency: counseling skills and interventions