Case Study
Patient Demographic: Client Age: 19 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual Presenting Problem: Suicidality related to body image Diagnosis: Body Dysmorphic Disorder 300.7 (F45.22), with absent insight/delusional beliefs
Mental Status Exam: Mental Status Exam: The client’s mood is sad and irritable. His speech is pressured when discussing his appearance but is otherwise normal. He is appropriately groomed and wears a beanie covering his ears. He admits to repetitively dissecting his face in the mirror several hours a day. The client offers that he cannot hide his ears with his hair because “it is too thin.” He denies audio/visual hallucinations. The client’s thought content is organized and coherent, but he shows poor insight and delusional thinking about how he and others regard his appearance. The client avoids social settings and reports that sometimes, an entire week goes by where he doesn’t leave the house. He denies suicidality and currently does not have a plan or intent to harm himself or others. Appetite and sleep are fair. The client denies drug use and states he consumes alcohol occasionally. You provide an in-depth suicide assessment, and you and the client work together to create a suicide safety
Presenting Problem: You are working in private practice and conducting an initial intake session with a 19-year-old male who presents today with his mother. The client was recently admitted to a psychiatric hospital for suicidality and was discharged four days ago. His mother reports that the client tried to commit suicide by overdosing. The client reports feeling increasingly hopeless following a “failed” cosmetic surgery procedure. He explains that he had an otoplasty performed to change the proportion and position of his ears. He states he has always hated his ears and is convinced people are staring and laughing at his “deformity.” His mother reports that she reluctantly consented to the surgery a year and a half ago, despite believing it was unnecessary. The client does not leave the house without wearing a beanie or hoodie. He has completed high school with no interest in attending college. He is unemployed due to shame and embarrassment over his “defective” appearance. Two weeks ago, the hospital psychiatrist changed his medication and placed him on a selective serotonin reuptake inhibitor (SSRI).
Other Contexts: You and the client review his safety plan. The client believes the antidepressant has helped decrease his feelings of hopelessness and suicidality. Despite the hot and humid conditions, the client arrives at his counseling session in a hoodie. He explains that he has been getting out of the house “some” but continues to avoid social situations because of overwhelming thoughts of others staring at him and mocking his appearance. The client was a no-show for his appointment last week and has requested distance counseling to avoid anxiety experienced when leaving the house. You and the client work together to set appropriate treatment plan goals; however, this is difficult due to poor insight into his presenting problem. You provide psychoeducation about BDD and ask about his goals for the future.  You have discussed the client’s request for distance counseling with your supervisor, considered the potential risks and benefits, and have determined that honoring the client’s request is the best course of action

Question: You have discussed the client’s request for distance counseling with your supervisor, considered the potential risks and benefits, and have determined that honoring the client’s request is the best course of action. Before implementation, which of the following “test” questions would you ask yourself to help finalize this decision according to the American Counseling Association’s (ACA)Practitioner’s Guide to Ethical Decision-Making?
(A): Would I want my behavior reported in the press?
(B): Can I faithfully fulfill this obligation?
(C): Are there legal implications to this decision?
(D): Would this decision harm the client?

Correct Answer: Would I want my behavior reported in the press?
Explanation: Asking yourself if you want your behavior reported in the press (publicity) best helps finalize this decision. The American Counseling Association’s (ACA)Practitioner’s Guide to Ethical Decision-Makingprovides a framework emphasizing the following steps, “1. Identify the problem. 2. Apply the ACA Code of Ethics. 3. Determine the nature and dimensions of the dilemma. 4. Generate potential courses of action. 5. Consider the potential consequences of all options and determine a course of action. 6. Evaluate the selected course of action. 7. Implement the course of action (Forester-Miller & Davis, 2016)” When evaluating the selected course of action, there are three tests to help ensure the action is appropriate. The tests honor the principles of justice, publicity, and universality. According to the framework: “Justice: In applying the test of justice, assess your sense of fairness by determining whether you would treat others the same in this situation. Publicity: For the test of publicity, ask yourself whether you would want your behavior reported in the press. Universality: The test of universality asks you to assess whether you could recommend the same course of action to another counselor in the same situation (Forester-Miller & Davis, 2016)” Asking if there are legal implications to this decision is a consideration for step 1 of the decision-making model. The question regarding faithful fulfillment (fidelity) of this obligation is reviewed in step 3. According to the ACA’s decision-making framework, step 3 uses the core principles of autonomy, justice, beneficence, nonmaleficence, and fidelity to examine the dimensions of the dilemma. Asking if this decision would harm the client applies the principle of nonmaleficence. Therefore, the correct answer is (D)
Competency: professional practice and ethics