Case Study
Patient Demographic: Client Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Community Mental Health Agency Type of Counseling: Individual Presenting Problem: Hallucinations and Delusions Diagnosis: Schizophrenia 295.90 (F20.9)
Mental Status Exam: Mental Status Exam: The client displays an angry affect, and his mood is irritable. His speech is disorganized and pressured. He is oriented to person, place, time, and situation. He reports audiovisual hallucinations, which include seeing “the shadow man” and hearing voices others cannot hear. The client exhibits tangential and disconnected thinking. He is firm in his conviction that he is being poisoned and says he is exhausted from constantly trying to maintain vigilance. The client’s insight and judgment are poor. He denies suicidal ideation, homicidal ideation, and command hallucinations. The client first experienced symptoms of schizophrenia in his late teens but was misdiagnosed with bipolar disorder until rece
Presenting Problem: You are a counselor working in an outpatient community mental health center serving clients with severe psychiatric disorders. A 26-year-old male, accompanied by his caseworker, presents for counseling due to symptoms of schizophrenia. The caseworker reports that the client was doing well until he stopped taking his prescription medication. He resides in assisted living, where he was placed after being discharged from the hospital last month. The client claims someone he calls “the shadow man” is following him and putting poison in his food. The caseworker reports that the client has been more agitated recently and has engaged in verbal altercations with other residents. The client is refusing to take his medication because of the side effects. He had an initial therapeutic response to Haldol, an antipsychotic, but stopped taking it because it made him restless and nervous. He explains, “I felt like I constantly had to keep moving.” The client is adamant about his desire to stay off medication and becomes angry when his caseworker mentions the possibility of going back into the hospital.
Other Contexts: ntly. Family History: The client has an older brother who transports the client to appointments and periodically checks in with the client. Hospital records indicate that the client becomes increasingly agitated during visits with his parents. The hospital social worker noted that his father was critical and dismissive toward the client during family therapy. The client’s mother is diagnosed with generalized anxiety disorder and had to quit her job due to the overwhelming burden of the client’s care. The father blames the client for the excessive toll his illness has placed on the family

Question: How should you respond to the client’s desire to stay off medication and out of the hospital?
(A): Tell him you will work with him to avoid rehospitalization if he agrees to be evaluated for a different medication.
(B): Tell him you will grant an extended trial period off medication and re-assess at his next visit.
(C): Tell him you will work with him to avoid rehospitalization if he agrees to take his medication.
(D): Tell him you will work with him to avoid rehospitalization, and he is not obligated to take medication.

Correct Answer: Tell him you will work with him to avoid rehospitalization, and he is not obligated to take medication.
Explanation: The most ethically sound response is to tell him you will work with him to avoid rehospitalization, and he is not obligated to take medication. Counselors have the ethical obligation to abide by the principles outlined in the American Counseling Association Code of Ethics (2014). Answer C honors the principles of autonomy and justice. Autonomy involves allowing individuals to control the direction of their lives. Justice necessitates fair and equitable treatment. At this juncture, the client is oriented and is not a harm to himself or others. Trust is the cornerstone of counseling, and it is the counselor’s responsibility to ensure the counseling environment is safe. All other answer options reflect the notion of a transactional relationship between taking medication and avoiding hospitalization, which creates a power imbalance between the client and counselor and can impede the client’s growth and autonomy. Therefore, the correct answer is (C)
Competency: counseling skills and interventions