Case Study
Patient Demographic: Name: Christopher Clinical Issues: Gender identity development Diagnostic Category: Gender Dysphoria Provisional Diagnosis: F64.1 Gender Dysphoria Age: 13 Sex Assigned at Birth: Male Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : Agency  
Mental Status Exam: The client presents partially as her preferred gender, wearing makeup and a semi-long hairstyle while still dressed as a cis-gendered 12-year-old male. She reports feelings of depression, anger, and suicidal ideation without a plan or intent. She appears to be her stated age, cooperates during the interview, and maintains good eye contact. Speech is normal in rate, rhythm, and volume. The client's thought processes are organized and goal-directed. She is alert and oriented X2. Insight and judgment are fair.
Presenting Problem: First session A 13-year-old, assigned male at birth and identifying as female, arrives at your office in a community mental health agency where you work as a mental health therapist. Both parents are also in attendance. The client introduces herself to you as "Christine," although the father says "Christopher" each time he addresses the client. The client appears dejected every time her father misgenders her. The client reports experiencing bullying from male peers at school and is upset that her father refuses to use her chosen pronouns or name.    The client reports that she has been feeling increasingly isolated and hopeless since the start of her transition, leading to intrusive thoughts associated with suicide. She is trying to express her identity through clothing, hair, and physical appearance but is not allowed to do so by her father. The client's mother is somewhat more supportive of her transition and has been trying to advocate for her, but her father remains resistant to the idea and is often dismissive of her identity. The client expressed feeling frustrated and helpless in her home life, as she cannot express her gender identity freely.    Once the client's parents leave the room, the client reports wanting to kill herself and tells you about the depression that sets in after being bullied at school or after arguments with her father. She also holds a lot of anger toward her father. Toward the end of the initial counseling session, the client says she feels safe with you and "would like to work together."  Fourth session The client has been "looking forward to working with you" and appears more comfortable today than in previous sessions. You recommended meeting with her once a week for therapy. You have built a positive rapport, and she no longer considers suicide a coping mechanism for dealing with her problems and stressors. However, when assessing her family relationships, the client states that her dad is "hard on her."    She asks if you would mediate between her and her father in your next session, and you agree. She is relieved at the idea of having a mediator present during the conversation with her father and shares her father's expectations of her and how she is being treated differently at home than her siblings. You role-play the future encounter to help the client to be able to verbalize her needs and feelings in a way that will be heard and understood by her father.  Ninth session The client has reported increased dysphoria due to persistent bullying and lack of support at school. As a result, she has noted an increase in negative self-talk and feelings of worthlessness. She has also reported increased feelings of isolation, as she does not have any friends she can confide in or turn to for support. The client has also expressed that her home environment is still difficult, as her father has not entirely accepted her gender identity, leaving her feeling unsupported. The client has further said that she does not feel safe or secure at school and feels uncomfortable seeking help from her peers.    The client has further reported that her emotional regulation has been difficult. She finds herself becoming overwhelmed and frustrated more quickly than before. She has also noted difficulty concentrating on tasks and completing schoolwork. Her mood has become increasingly labile, and she has experienced more frequent thoughts of self-harm and has expressed that she doesn't know how to cope with her emotions.    The client's mental health has also been deteriorating. She has reported increased symptoms of depression and anxiety. She has difficulty sleeping, often unable to fall asleep or only sleeping for short intervals. She has been experiencing intrusive thoughts, racing thoughts, and difficulty focusing on tasks. She has also been avoiding social situations and expressed that she feels uncomfortable around people due to her negative self-image.    She does like the school psychologist but needs help setting up a meeting. You intend to reach out to the school psychologist to expand the continuum of care.
Other Contexts: The client loves her mother but has difficulties with her father. Her parents differ in child-rearing styles, with her father not understanding her gender presentation. The client has a deep-seated fear of rejection and abandonment from her father due to the ongoing disagreement about her gender presentation. She feels that her father does not accept her for who she is and does not understand her identity. The client has a strong need for her father's acceptance and approval, but her attempts to bridge the gap between them have been unsuccessful. This has caused her to feel disconnected from her father and has created a sense of sadness and insecurity in the client. Neither parent supports her gender choice, but her father actively confronts her daily. Her mother is confused and worried for the client but does not know what to do. The client is high achieving academically and is well-liked by her teachers. In addition, she is involved in a community dance team where she excels. However, she is socially isolated and has few friends. Her classmates mock her for "acting like a girl" and bully her on the playground. She is especially bullied by her male peers in school.    The client is displaying symptoms of social anxiety as she has difficulty developing and maintaining relationships with her peers. Her fear of being ridiculed and judged by her peers has resulted in her feeling socially isolated, impacting her self-esteem. The client is anxious in social situations, particularly when interacting with her male peers, and displays a pattern of avoiding social interactions due to the fear of being judged. 

Question: How often should you assess for suicidal ideation for this client?
(A): Daily, through the school psychologist
(B): When the client mentions suicidal ideation
(C): Every session
(D): Monthly

Correct Answer: Every session
Explanation: Knowing this client has a history of suicidal ideation suggests that this should be assessed during each session. Therefore, the correct answer is (B)
Competency: intake, assessment, and diagnosis