Case Study
Patient Demographic: Client Age: 30 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Pacific Islander Relationship Status: Single Counseling Setting: Private practice counseling clinic Type of Counseling: Individual counseling Presenting Problem: The client and her boyfriend recently broke up, and she is “tired of being with the wrong guys.” She admits that she will often stay in relationships even if she knows they are wrong for her. Diagnosis: Provisional diagnosis: Dependent personality disorder (F60.7), personal history (past history) of spouse or partner violence, physical (Z69.11), and personal history (past history) of spouse or partner psychological abuse (Z91.411)
Mental Status Exam: Mental Status Exam: The client is oriented to person, place, time, and situation. No hallucinations, delusions, or paranoia are reported. The client was anxious at the start of the session, but she was able to calm herself down by easing into the counseling relation
Presenting Problem: You are a professional counselor working in a private practice clinic. The client comes in and sits quietly. The client appears nervous because she avoids eye contact and waits for you to initiate conversation. You ask why she is in counseling, and she responds that she is just tired. You ask more about this, and she says that she is not ready to talk about it yet. You decide to cover demographics and other less intimidating topics and then ask if she is comfortable talking yet. The client says that she feels a little more comfortable. She begins to state that she and her boyfriend broke up the previous week and that she was with him for 2 years. She explains that she has been “in this type of relationship before,” continually finds the “wrong guy,” and that she always goes “all in” with her relationships. Through processing, she identifies the following behaviors and beliefs: difficulty making daily decisions without the input of her partner, doing anything to gain support and affection even if she does not want to do the task or activity, quickly moving on to another relationship when a relationship ends, feeling that she cannot care for herself when she is not with someone else, and acknowledging that she needs others to take responsibility for major areas of her life. The client says that she has experienced physical and psychological abuse from partners, but that she is not ready to discuss this. The client identifies that her most important goal is to not end up in “the same relationship” again or rush into a relationship that is not right for her. Throughout the session, you provide empathetic and active listening. You suspect that the client has dependent personality disorder.
Other Contexts: The client comes in, sits down, and immediately says that she has been thinking and decided that she is now ready to talk about the physical abuse that she has experienced. She recounts that from age 18 until age 20 she was with a boyfriend who would smack her if she said something he did not like. She believes this is why she is so preoccupied with pleasing others. The client’s second relationship was when she was 25 with a man who would get drunk nightly and punch her in the stomach or in the back when he was upset. You empathize with the client and reflect her emotions regarding these events. The client states, “I didn’t deserve it when the drunk guy hit me, but I do feel I wasn’t the best girlfriend with the first guy. I often didn’t do enough for him and often said the wrong thing.” Throughout the session, the client was tearful and started shaking slightly when speaking several times. The client paused for long periods before sharing more difficult parts of the story. You decide to assess for PTSD during this session, but she does not meet the criteria. When closing the session, the client states that she is not able to pay for today’s session until the end of the week. The client has no history of nonpayment with you thus far.  At the end of this session, the client gives you a gift card to a restaurant because it is the last time you will see this client before Christmas

Question: At the end of this session, the client gives you a gift card to a restaurant because it is the last time you will see this client before Christmas. Which one of the following is the most appropriate clinical response considering ethics and your client’s needs?
(A): Based on the presenting problems, you decline the gift.
(B): Accepting gifts with a value of greater than $50 is inappropriate, so you decline the gift.
(C): Accepting gifts is never appropriate, and you decline the gift.
(D): You accept the gift because it is not high in value and because the client’s culture would view this rejection as offensive.

Correct Answer: Based on the presenting problems, you decline the gift.
Explanation: It would be inappropriate to accept the gift because the client’s diagnosis of dependent personality disorder makes boundaries more complicated and could possibly allow for manipulation. The ACA Code of Ethics does not specify a dollar amount or a clear point of view about when to accept gifts; rather, it focuses on the motivation of accepting the gift or the client’s intent for giving the gift. Cultural considerations for accepting or declining gifts are an important consideration; however, the client’s diagnosis takes priority in the consideration of accepting gifts. Therefore, the correct answer is (D)
Competency: professional practice and ethics