Case Study
Patient Demographic: Name: Jill Clinical Issues: Depression and recent death of a close friend Diagnostic Category: Depressive Disorders;Substance Use Disorders Provisional Diagnosis: F34.1 Persistent Depressive Disorder, with Anxious Distress, and F10.99 Unspecified Alcohol-Related Disorder Age: 26 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Eastern European Marital Status: Never married Modality: Individual Therapy Location of Therapy : Agency  
Mental Status Exam: The client is a 26-year-old female who appears slightly disheveled and unkempt with bags under her eyes, suggesting recent lack of sleep. Her affect is flat and her behavior is withdrawn. She speaks in a quiet monotone and is tearful at times. Her speech is coherent, though her thoughts are sometimes diffuse. She exhibits difficulty in focusing on topics and has some difficulty in supplying relevant details. The client reports that she has difficulty concentrating and recalling information, as well as making decisions. No perceptual distortions are reported. The client has limited insight into the cause of her distress, but appears to understand that her drinking is a problem. Her judgment appears impaired due to her drinking, as evidenced by her blackout episodes. The client expresses feeling overwhelmed and states that if counseling does not help, she is not sure she wants to go on living. She has also had thoughts of death and dying.
Presenting Problem: First session You practice as a mental health therapist at an agency. A 26-year-old female presents for therapy following a recent incident involving the death of her close friend. The client elaborates on her friend's death by saying, "He was beaten to death because he was transgender." The attack occurred a week ago, but the client states she has felt depressed for as long as she can remember. She says, "He was the only person who could actually put up with me. Now that he's gone, I feel like I have no one." She tells you that during the past few years, she has been drinking as a way to cope with her feelings. She states that she is usually able to control her drinking, but admits that lately it has "gotten out of hand." After her friend was killed, she went to a party and blacked out after drinking. She states that she cannot seem to find joy in anything and cannot stop thinking about her friend. You continue your assessment by exploring the client's history and current symptoms. After gathering more information, you determine that the client is experiencing a major depressive episode which has been compounded by her friend's death.    When asked what she is hoping to gain from therapy, she responds, "I just want to stop feeling so awful all the time." You validate her feelings and applaud her willingness to seek help. You share information about the counseling process and treatment options, including potential risks and benefits. You tell her that it is important to be open and honest during therapy and that she may need to talk about some difficult topics to make progress. After explaining the importance of developing a trusting relationship, you encourage her to ask questions and ask if she has any concerns. She asks if she can contact you outside of your counseling sessions. You review your agency's policies with her, including information about therapist availability.  Third session You and the client have agreed to meet for biweekly therapy sessions as she feels she needs extra support right now. This is your third session with the client, and she presents looking exhausted and can barely speak. You consider alcohol use, but there is no smell of alcohol, and the client's eyes do not seem dilated. She is neither slurring her words nor stumbling. You can sense that she is exhausted, both mentally and physically. She shares that she has not slept in 48 hours and is struggling with nightmares about her deceased friend.    She says, "Why did he have to die? I feel like it's my fault." Next, you ask her, "What do you think caused your friend's death?" but she looks away and shakes her head, unwilling to answer. You then try to explore the nightmares she has been experiencing, but she becomes irritable and angry. Finally, she breaks down and begins to cry. You allow her time to cry, knowing that it is a way for her to release some of the pain she is feeling. After a few minutes, you ask the client if she would like to talk about what is going on in her life. She agrees and starts talking about how overwhelmed she feels. She hates her job, her past, and her present. The client feels like everything is too much for her to handle. You listen patiently as she talks about her feelings.
Other Contexts: The client grew up in a very chaotic household with five siblings. The client is a first-generation Eastern European whose family immigrated to the United States before her birth. Her parents never adapted to the culture. Her father committed suicide when she was in high school. She says, "It was like my dad leaving us just made everything worse." The client says she has no patience with her siblings when they call and has little desire to keep in touch with them. After completing her associate's degree, the client immediately started her job as a paralegal. She is a paralegal at a law firm where she has worked for two years. She describes her work as "okay, but not something I'm passionate about." She says that she has been feeling increasingly overwhelmed and stressed out. At work, she becomes easily annoyed, has trouble concentrating, and feels tense. She has difficulty getting along with her colleagues and tries to avoid them when she can. 

Question: Given the client's presentation during today's session, what would you prioritize as a short-term goal in her treatment plan?
(A): Eliminate depression
(B): Increase exercise
(C): Extinguish anxiety
(D): Decrease insomnia

Correct Answer: Decrease insomnia
Explanation: Increasing sleep is a short-term goal. She can be referred for medication such as Trazadone. You can create a sleep regime with her by using a tool such as a sleep diary to help with consistency. Therefore, the correct answer is (D)
Competency: treatment planning