Case Study
Patient Demographic:  Initial Intake: Age: 14 Gender: Female Sexual Orientation: Heterosexual Ethnicity: Hawaiian American Relationship Status: Single Counseling Setting: School-based mental health counseling Type of Counseling: Individual
Mental Status Exam: Malik presents as well groomed, good hygiene and behavior within normal limits. She is highly anxious, evidenced by limited eye contact, tense expressions and fidgeting with her hands. Malik admits to having suicidal thoughts and has self-harmed by cutting herself in the past. She reluctantly shares that she had a traumatic event in Hawaii right before leaving but is unwilling to discuss it and begins crying. She then changes the subject and tells you moving out of Hawaii has been painful because “everything is different here, including how they do school and how people talk about each other.” She adds that she experiences at least one nightmare a week since moving.
Presenting Problem: Diagnosis: Major depressive disorder, single episode, unspecified (F32.9), Anxiety disorder, unspecified (F41.9)
 

Malik, a 14-year-old girl entering High School is referred to you for mental health counseling by her school counselor for reports of her leaving the classroom in tears and because of calls received by her mother stating that she has crying spells at home. After speaking with Malik’s mother, you learn her mother, stepfather and sisters have recently moved with her to the mainland states from the Hawaiian Islands and that she has been missing her father, friends, school, and other family members left behind. Malik spends most of her time in her room, appears depressed often, gets upset easily and is constantly on her phone. Her mother asks that you meet with her during school hours and help her understand what is going on. She says Malik has been crying since just before leaving Hawaii.
Other Contexts: Family History:
Malik’s parents divorced while she was young but had always lived in Hawaii, making it easy for her to see both sides of her family at will. Malik has several siblings, cousins, and all her grandparents are still alive. Malik has a strained relationship with her father and stepmother and feels heavily influenced by her father’s opinion of her, stating “he just wants what is best for me, but he’s really harsh about it and it sometimes hurts my feelings and stresses me out.” She is struggling to connect with her mother now because she is working full-time, and she feels “doesn’t have time for her anymore.” Malik is also forced to do most of the household chores and care for her younger siblings on top of managing her schoolwork. All of this has made her feel overwhelmed.

Question: It is clear to you that Malik has returned to engaging with the boy that was involved in her traumatic experience. Which is the most direct and ethical approach for responding to this presentation?
(A): Present your observations of her changes in behavior and ask for her perspective on what has contributed to these changes.
(B): Gather the data mentally and inquire more information from her mother next time you speak.
(C): Lovingly confront her obvious behaviors and gently question the wisdom of her choices.
(D): Have Malik write down a timeline of events from before leaving Hawaii until now.

Correct Answer: Present your observations of her changes in behavior and ask for her perspective on what has contributed to these changes.
Explanation: Giving your client feedback and soliciting their perspective on contributing factors is the most ethical way to guide discussion of their own development of insight. Although d is clearly the most direct approach, it is not the most ethical choice as you are pointing out observations that might be assumptions or involve content that has not yet reached her level of understanding. Answer d could also damage your rapport as you may come across as judgmental and cause her to become defensive. Answer a is indirect because you would be deriving information from a parent, and unethical if Malik did not give expressed permission for you to discuss the content of your sessions with a parent. Minors under age 18 have HIPAA rights and should be afforded the same confidentiality provisions as adults. Answer b is a great intervention to conduct with Malik but is not the most direct form of therapy as timeline therapy can involve numerous areas and goals outside of the target discussion. Therefore, the correct answer is (C)
Competency: counseling skills and interventions