Case Study
Patient Demographic:  Initial Intake: Age: 42 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Hispanic Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual
Mental Status Exam: The client appears her stated age and is dressed appropriately for the circumstances. She identifies her mood as “somewhat anxious” and her affect is labile and congruent. She is noted to rub her hands together at times and she appears uncomfortable at times as she talks about herself. She demonstrates good insight, appropriate judgment, memory, and orientation. She reports no history of trauma, suicidal thoughts, or harm towards others.
Presenting Problem: You are a non-Hispanic counselor in a private practice setting.  Your client is a 42 year old female who reports that she has been working for the same accounting firm for 10 years and was recently laid off due to a downturn in the economy. She tells you that prior to this firm, she worked in a company doing managerial accounting that she joined right after college. She says that she has liked the people that she has worked with but over the past several years she has enjoyed her work less and less. She reports that she is upset to have lost her job but, in some ways, she sees it as an opportunity to find something else she is more passionate about, but she has no idea where to start. She does say that she wants a job and work environment that is a better fit for her personality. She also tells you that she is afraid that she is too old to begin again or that she doesn’t have “what it takes” to begin a new career.
Other Contexts: Family History:
The client reports no significant family history related to mental health issues or relationship problems. The client tells you that she chose accounting in college because she grew up in a small town and her parents told her that she needed a skill that would help her support herself. Additionally, she states that she has been married for 19 years and has a good relationship with her spouse. She tells you that he is supportive of her exploring new careers but that her income is helpful for the family and it is important that she works.

Question: Using the information you have learned, which of the following should be the first focus of this session?
(A): Ask the client why receiving the books made her panic.
(B): Have the client describe what it feels like to be stressed and overwhelmed.
(C): Ask how did the client manage her concerns with sending her parents money.
(D): Assess the client's past history of panic attacks.

Correct Answer: Assess the client's past history of panic attacks.
Explanation: The client has not mentioned panic attacks previously, so the counselor will need to understand the client's history of panic attacks, including any triggers, symptoms, and how the client has managed her attacks in the past. This will help the counselor and client form a treatment plan to manage the client's stress and any future panic attacks. The counselor should not ask about the client's parents and how she managed that issue. Since the client has not brought it up, the counselor may likely be indulging the counselor's own curiosity, rather than asking for therapeutic reasons. Having the client describe how it feels to be stressed and overwhelmed will be addressed in the session as the counselor and client develop treatment strategies for maintaining the client's well-being. Stress and feeling overwhelmed in the moment when embarking on a new venture, such as graduate school, is not abnormal and should not be pathologized. However, because the client states she had a panic attack and has a history of panic attacks, it will be important to address the panic attacks first and then work backwards to feelings of stress. Asking the client why her books triggered a panic attack will not be a helpful question. Panic attacks are triggered by content that may or may not have connection to the actual panic. Asking why the books were a trigger is not important to understanding the panic attack. Therefore, the correct answer is (C)
Competency: counseling skills and interventions