Case Study
Patient Demographic: Name: Marta Clinical Issues: Caregiving concerns Diagnostic Category: Trauma and Stressor Related Disorders Provisional Diagnosis: F43.23 Adjustment Disorder, with Mixed Anxiety and Depressed Mood Age: 55 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Colombian American Marital Status: Married Modality: Individual Therapy Location of Therapy : Agency  
Mental Status Exam: The client appears older than her stated age. She is disheveled, poorly groomed, and has a strong body odor. She is cooperative but demonstrates a high level of distress manifested as restlessness, being easily distracted, and consistently rubbing her hands. Her speech is initially slow and halted but later becomes elevated and loud. She is oriented X3. Her affect is characterized by anxiety and depression, as she is having difficulty answering your questions. The client indicates that she has thoughts about putting a pillow over her mother's face or taking an overdose of sleeping pills so that she does not have to deal with her family or her mother's demands anymore.
Presenting Problem: First session You are a counseling intern for a mental health agency. A 55-year-old Colombian American female presents to therapy with tears in her eyes. She appears distraught, anxious, and despondent. She describes feeling guilty about wanting to put her mother in an assisted living facility. Although the client knows that putting her mother in an assisted living facility is probably the best decision, she feels guilty because it goes against the values of her culture. She explains that in traditional Colombian culture, elders are revered, and it is the responsibility of the oldest child to take care of them. The client's siblings have been "critical of me even talking about moving her into an assisted living facility" and are pressuring her to keep their mother at home.    The client starts to cry and covers her face. Finally, she looks up and says, "I feel torn. There are these cultural expectations that I look after my mother, but she never even liked me and made my life miserable when I was growing up." The client does not have any nearby family who can help support her or assist in the care of her elderly mother. Her brothers live in different states, and her husband is an only child whose parents both passed away a few years ago. The client has expressed feeling overwhelmed by the responsibility of taking care of her mother and running her own household. She says, "I feel like I just can't keep up with everything. My kids need me, my husband needs me, and now I have to take care of my mother, too. And as for having any time to myself, that's a dream that's never going to happen." She further explains that her current circumstances remind her of what it felt like growing up in a chaotic household and feeling the pressure of having to take care of her younger siblings. She states, "It's like history is just repeating itself." She reports feeling "like a failure at being a wife, mother, sister, and daughter." As you listen to the client's story, you sense her feelings of guilt, frustration, and overwhelm about not being able to meet all the demands placed on her. You empathize with the client and validate her feelings. You compliment her on the strength it took for her to take on an additional responsibility despite the hardships that come with it.    When asked what she hopes to gain from therapy, the client tells you that she wants to figure out how to balance her responsibilities. She expresses wanting to find a way to care for her family members without "losing myself and my sanity in the process." You suggest meeting with the client for weekly sessions as a place to begin, and you walk the client through what she can expect from therapy.
Other Contexts: The client is the oldest child in her family. She has 3 younger brothers, all of whom are separated in age by one year. She was born and raised in Colombia. When she was in middle school, her family immigrated to the United States in search of better opportunities. Her father worked long hours as a taxi driver while her mother worked as a nanny taking care of other people's children. The client stated that she often felt like she had no parents because they were always working. The client stated that when they moved, her mother asked her to help out more at home with the cooking, cleaning, and taking care of her siblings. She often felt overwhelmed and guilty because she wanted to spend time with friends or focus on her studies rather than watching her brothers. The client revealed that she often feel a deep sense of resentment knowing that while other girls were able to go outside and play, she had responsibilities to take care of. Personal/Social Relationships: The client's father passed away four months ago and her 76-year-old mother has been living with the client since then. The mother does not speak English and requires assistance with medical appointments, financial dealings, and daily care. She constantly "nags" the client about how she is raising her children and often complains about her cooking. The client's husband, who is second-generation Irish American and grew up in Boston, is becoming increasingly irritated with his mother-in-law. He complains to his wife about her mother, which puts a "massive strain" on the couple's relationship.  

Question: Given the client's presenting issues, what would you focus on assessing first?
(A): Family dynamics
(B): Colombian culture
(C): Possibly severe depression
(D): Suicidal/homicidal ideation

Correct Answer: Suicidal/homicidal ideation
Explanation: During the MSE, you noted that the client made homicidal and suicidal statements. In addition, her appearance, affect speech and thought process indicates that she is experiencing significant distress. You must assess this further to determine her risk of homicide and/or suicide. Therefore, the correct answer is (D)
Competency: intake, assessment, and diagnosis