Case Study
Patient Demographic: Name: Dana Clinical Issues: Relationship distress with mother during divorce Diagnostic Category: Depressive Disorders;V-codes Provisional Diagnosis: F33.1 Major Depressive Disorder, Moderate, Recurrent Episodes; Z62.820 Parent-Child Relational Problem Age: 15 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Multiracial Marital Status: Never married Modality: Individual Therapy Location of Therapy : Under Supervision  
Mental Status Exam: The client is dressed in black attire. She sits with her hands folded and slumped over in the chair. She makes little eye contact and seems to distrust you. Her mood seems flat. During the intake, the mother complains about how her daughter "does not listen," "acts out all the time," and "picks fights with her sister." The client is reticent and shrugs her shoulders.    The client reported several other symptoms indicative of a depressive episode, including feelings of worthlessness, anhedonia, and lethargy. She also said having recurrent thoughts of self-harm that had become pervasive throughout her day-to-day life. On objective examination, the patient demonstrated psychomotor retardation, appearing to move and speak in a lethargic and sluggish manner. Cognitively, the patient's attention span was limited, and her concentration was impaired. She could not sustain her train of thought and had difficulty forming coherent sentences. Her mood was notably depressed, and her affect was constricted. This suggests a severe depressive episode, and these symptoms will likely require aggressive treatment.
Presenting Problem: First session You are a limited permit holder under direct supervision. The client is a 15-year-old multiracial female who presents to the first counseling session with her mother. The session begins with the client's mother monopolizing the conversation, and it is difficult for the client to get a word in edgewise. The client's mother continually brings up her husband as a source of her daughter's problems. The mother says, ""Our daughter is not doing well in school and has been talking back to her teacher. I think it comes from the relationship she's had with her father." The client interrupts and says, "It's not Dad's fault! You're the one who abuses me!" The mother is incredulous and begins to yell, saying that she would never hit her daughter and that the client is lying. The mother tells you that her daughter is a "liar, a thief, and creates problems." She reports that Child Protective Services (CPS) has been to their house several times, and she believes that these visits are her husband's fault.    The client is visibly upset, and her mother continues to berate her. You intervene and explain that the client's disclosure is serious and should be taken seriously. You explain that you must speak to the client alone before deciding the best course of action. While speaking alone with the client, you notice that she is shaking and close to tears. You encourage her to take deep breaths and explain that she can take some time to regroup before continuing. After a few minutes, she appears calmer and begins to describe her home situation. It becomes clear that the client's home life is chaotic and that she is being subjected to verbal and emotional abuse from her mother. She tells you that she wants to live with her father. The client also states that she has been bullied in school, and this has been going on for some time. You explain to the client that she has a right to feel safe and that you will do everything in your power to ensure her safety. You continue asking question to assess her level of distress, and you note the client's self-reported symptoms consistent with depression, including insomnia, fatigue, and a significant decrease in her appetite. She is also alienating herself from her peers and family.    After completing the initial session, you schedule an appointment to see the client and her mother next week to continue your assessment to determine the best course of action.  Third session During last week's session, the client's mother accompanied her to the session. Throughout that session, the mother continued to talk about her own personal issues, and you could not gather information from her daughter's point of view. The client's mother presents with her daughter again to today's session. After a few minutes, you realize that the mother is monopolizing the counseling session by talking about her personal life and making snide comments aimed at her daughter. You suggest that it might be better for the client's mother to wait outside while you talk alone with the client.    When the mother leaves, the client immediately relaxes and opens up about some of the struggles she has been going through. She shares that life at home has been difficult. She describes her mother as being "very mean" to her, and her grandmother makes fun of her. On the other hand, both adults are nice to her younger sister. The client states that she wishes she had never been adopted and that her life is "miserable." She expresses a desire to live with her father. Her behavior toward her parents has changed drastically since they started fighting in front of her, but she is not sure how to deal with their constant bickering. She has not told anyone at school about living in a "broken home" because she does not want any extra attention from her classmates. However, she has opened up more during therapy sessions, like today's meeting, telling you that music makes her feel better when upset. As homework, you ask the client to put together a playlist of music that is meaningful to her and bring it with her to the next session. Following today's session, the client's father calls you during off-hours to complain about his soon-to-be ex-wife.  Sixth session You have seen the client every week since the initial intake. During today's session, the client tells you she has written a suicide note and left it in her room. Her mother is waiting in the lobby for the session to end. You tell the client you must bring her mother into the session and discuss the suicide note. You explain to the client that her mother's presence is necessary to explore and understand why the suicide note was written. The client expresses frustration and says, “You can’t bring my mom in here! She won’t understand why I wrote the note!” You empathize with her feelings, but also explain that it is important to discuss the reasons for writing the suicide note with her mother present. You reassure the client that you will guide the conversation to explore why she wrote the note and support her in addressing any underlying issues. You explain that understanding these reasons is an essential step toward moving forward and developing healthier coping strategies. The client reluctantly agrees, but insists on speaking with you alone first before bringing her mother into the session. You emphasize that it is important for her to be honest about her emotions and to talk about her experiences in order to identify the root cause of her distress. Throughout the conversation, you provide validation and affirmation in order to create a safe space for her to express her feelings. You remind her that she does not have to face the situation alone, and that you can work together to find a way forward.    Once the client has had an opportunity to share her thoughts and feelings, you ask if she is ready for you to invite her mother in. She agrees, and the mother joins you in session. You explain to the mother that her daughter wrote a suicide note and that the two of you have been discussing the suicide note and why it was written. You emphasize that your goal is to better understand the circumstances leading up to this situation, so that you can work together to find a way forward. You state that your primary focus is on finding solutions, rather than assigning blame or judgment. The mother looks at you in disbelief and says, "What do you mean, she wrote a note saying she was going to kill herself? What are we doing here? I'm paying you to help my daughter, not make things worse!" She grabs her daughter's hand and storms out, after expressing her anger loudly the whole way to her car.    You are unsure of how to proceed, so you discuss the case with your supervisor. Your supervisor listens and notes your concerns, offering advice and guidance on better handling the situation. He then suggests that you reach out to the client's primary care physician to discuss the possibility of hospitalization and other forms of support that might be available to the client. After further discussion, you call the client's physician and discuss the options.
Other Contexts: The client has experienced a great deal of distress due to the chaotic environment of her home life. Her adoptive parents are in the middle of a "messy divorce," and it has been difficult for her to process, as she has had to witness her parents' arguments and the shifting dynamics of her family. This strain has been further compounded by her mother and grandmother's favoritism towards her younger sister, leading to the client feeling neglected and overlooked. In addition, her attempts to connect with her mother and sister have often been met with hostility, leading to frequent arguments and further exacerbating her feelings of alienation and loneliness.    The client has also expressed feelings of anxiety and depression due to her current living situation. She has expressed a strong desire to live with her father and escape the hostile environment of her mother's home, yet her mother has continuously denied this request. This has resulted in the client feeling trapped and powerless to alter her current situation, leading to a sense of hopelessness.    The client's relationship with her mother is strained, and she has difficulty trusting her. As a result, she is often guarded around her mother and expresses her distrust and resentment, resulting in further conflict and tension between them. The client's school environment has affected her mental health. She is constantly subjected to verbal and physical bullying from her peers, leading to feelings of worthlessness and insecurity. Her academic performance is suffering, and she cannot concentrate in class, leading to further isolation from her classmates. Previous Counseling: The client has been in and out of therapy with many different professionals. She has been diagnosed with Major Depressive Disorder. Her mother is also in therapy and believes her daughter needs "help." The client states that her mother has abused her before, and Child Protective Service (CPS) has been to the house numerous times but has not found any evidence of abuse. 

Question: What is the best strategy to de-escalate the mother's anger in session?
(A): Explain that suicidal gestures are common with depression and that this is not a reflection of the client's progress or lack thereof in therapy
(B): Explain that understanding the circumstances leading up to this situation is an essential step toward moving forward
(C): Validate her feelings and emphasize that her daughter’s wellbeing is your primary focus
(D): Employ therapeutic silence, to help the mother explore her own feelings.

Correct Answer: Validate her feelings and emphasize that her daughter’s wellbeing is your primary focus
Explanation: An effective strategy would involve validating her feelings, listening to her perspective, and reassuring her that you are actively seeking solutions for her daughter's wellbeing. Therefore, the correct answer is (D)
Competency: counseling skills and interventions