Case Study
Patient Demographic: 7   Initial Intake: Age: 18 Gender: Female Sexual Orientation: Bisexual Ethnicity: African American Relationship Status: Single Counseling Setting: Agency Type of Counseling: Individual
Mental Status Exam: Millie was well groomed and presented as anxious with constricted affect as evidenced by shaking her leg and tapping her pen frequently. Millie made good eye contact and speech was coherent and rational, however tangential with increasingly rapid rate at times. Speech content is somewhat guarded, demonstrating preoccupation with social influences and deflection from discussion about losing her mother. Millie was surprisingly graphic with detail about self-starvation and purging food and did not show concern; presented with incongruent affect and smiling while she talked about it. Millie denied SI.

Family History and Living Situation:
Millie lived alone with her mother in a different state until last year when her mother died, and she moved to a new state to live with her father and his girlfriend. Their relationship had already been strained therefore Millie opted to live with her paternal grandparents who also lived locally, which is where she lives now. Millie comes and goes as she pleases and does not regard house rules. She reports most often staying in her room with the door locked while on the computer or phone
Presenting Problem: Diagnosis: Major Depressive Disorder, single episode, recurrent (F33), Anxiety disorder (F41.9) provisional
 

You are a mental health counselor with a community agency and have been referred a new client named Millie, an 18-year-old African American girl, for problems adjusting to life without her mother who has passed away nearly one year ago from illness. Millie’s father brought her to your agency after convincing her to see a counselor. The referral form filled out by her father says she has never spoken about her mother’s death and does not talk about it with anyone he knows. Millie has had medical problems that have been best explained by disruptions in her eating and sleeping habits, which started after her mother died. You learn several reports were made during her senior year in high school of her fighting with other girls, which Millie tells you were erroneous and “not her fault”. Millie also demonstrates a highly active social life, but primarily online with strangers as she exhibits strong social phobic behavior in public and around others in person. You recommend in-person counseling rather than Telehealth virtual sessions to support her improvement.
Other Contexts: llie was well groomed and presented as anxious with constricted affect as evidenced by shaking her leg and tapping her pen frequently. Millie made good eye contact and speech was coherent and rational, however tangential with increasingly rapid rate at times. Speech content is somewhat guarded, demonstrating preoccupation with social influences and deflection from discussion about losing her mother. Millie was surprisingly graphic with detail about self-starvation and purging food and did not show concern; presented with incongruent affect and smiling while she talked about it. Millie denied SI.

Family History and Living Situation:
Millie lived alone with her mother in a different state until last year when her mother died, and she moved to a new state to live with her father and his girlfriend. Their relationship had already been strained therefore Millie opted to live with her paternal grandparents who also lived locally, which is where she lives now. Millie comes and goes as she pleases and does not regard house rules. She reports most often staying in her room with the door locked while on the computer or phone.

Question: Millie admits to abusing pain medication prescribed by her doctor for treating medical issues, as well as getting high on inhalants in her room at her grandparents' house. What is your next step?
(A): Educate Millie on the harmful effects of substance abuse.
(B): Inform her father and grandparents for her own safety.
(C): Prepare Millie for a referral to a higher level of care.
(D): Call 911 to have Millie expedited to detox.

Correct Answer: Prepare Millie for a referral to a higher level of care.
Explanation: Unless Millie is experiencing an overdose, incapacitated, or in danger of harming herself or others, calling 911 is not necessary and you can work with Millie on understanding what the next steps would be for entering into a higher level of care should she choose to comply with your recommendations. Education, as in answer b, would present itself as an intervention used during this referral conversation, as well as throughout substance use treatment, but is not enough at this time to ethically address Millie's use. Millie would also be responsible for informing her parents of her plans, as HIPAA does not permit the counselor to report this to an adult's family on their behalf with special exceptions, such as if an individual has a previously indicated mental handicap and is under special guardianship as an adult for such purposes. Therefore, the correct answer is (D)
Competency: treatment planning