Case Study
Patient Demographic:  Initial Intake: Age: 29  Gender: Female  Sexual Orientation: Heterosexual  Ethnicity: Caucasian  Relationship Status: Engaged  Counseling Setting: Agency - Telehealth  Type of Counseling: Individual
Mental Status Exam: Client presents as unkempt, hygiene unknown as it is unable to be assessed via telehealth. She is appropriately dressed. Motor movements are within normal limits. Her eye contact is intermittent as she appears to have difficulty focusing both eyes in the same direction (amblyopia or “lazy eye”). She is cooperative and engaged. She admits to having passive suicidal ideation when triggered with distressing emotions and has considered taking pills as a method that would be the most comfortable but declines having intent or plan to collect pills for this purpose. She states her anxiety increases when she takes her children to the grocery store and when she is around crowds, experiencing panic-like symptoms necessitating her to call a friend to calm her down. She reports experiencing flashbacks of sexual trauma and prefers to stay at home as often as possible. She is alert despite being distracted often by her children in the background and is oriented to person, place, time, and situation. She is fidgeting with her hands and speaking circumstantially, often changing topics and going on rants in different directions before returning to her main points. She reports low energy, sleeping too much and weight gain. She adds that she cries every night over losing her paternal grandfather over 10 years ago.
Presenting Problem: Diagnosis: Anxiety disorder, unspecified (F41.9), Reaction to severe stress, unspecified (F43.9) 
 

You are a new counseling intern in a community agency conducting virtual individual counseling sessions using Telemedicine technology. You were referred a 29-year-old female client by your agency’s Psychiatrist who felt she needed to return to weekly psychotherapy as she had previously been doing two years ago. During your initial assessment session, you learn she has three young children under age 8, lives with her fiancé who is the father of the two youngest children, and that due to medical reasons she is on disability through Medicaid and is unable to work. She tells you she has been depressed and contemplating suicide because she cannot find relief from her anxious thoughts. She wants to be a better mom to her children than her mother was to her and wants help overcoming grief and loss, traumatic memories, panic attacks and irritability.
Other Contexts: Family History:
Client has a strained relationship with her mother whom she reports is “always dating an alcoholic” and has been abusive to her growing up. She adds that her mother has “Bipolar depression and ADHD.” She complains often about both her mother and her fiance’s mother mistreating her, making her feel resentful and angry. Client has two sisters, one of which lives with her mother and is mentally challenged. Her other sister has little to no contact with her family. Her father, who has been divorced from her mother for over 20 years, was once accused of child sexual abuse which has alienated him from the rest of their family. The client is the only one who remains in contact with him.

Question: The client reports having several concerns about the antidepressants she has been prescribed by her psychiatrist and asks for your help in switching medications or modifying her dosage. Which of the following is the best choice for responding to the client's concerns?
(A): Before or after using techniques described in answer c, refer her back to her psychiatrist to discuss her medication changes.
(B): Offer alternative solutions for different medicinal regimens that are not known to have the same side effects.
(C): Validate the client's feelings and lead client into further discussion about symptoms through Socratic questioning.
(D): Confront deflection from addressing core issues and re-direct her to discussing negative core beliefs.

Correct Answer: Before or after using techniques described in answer c, refer her back to her psychiatrist to discuss her medication changes.
Explanation: Only psychiatrists, registered mental health nurse practitioners, and in some cases primary care physicians are qualified to make recommendations or adjustments to a client's mental health medications. While it is preferrable for a counselor to have knowledge of psychiatric medications and their effects, it is outside of the scope of practice and must be deferred to the appropriate professional. The approach in answer b) does not adequately validate the client's psychiatric or medical problem, which should be prioritized initially over cognitive behavioral therapy (CBT) approaches until a client has stabilized. Using these techniques will be optimally effective in conjunction with the correct medication and in later stages of treatment once the therapeutic relationship has been more established. It is most often the case that a client demonstrates the need for CBT to show improvement; but the approach in answer b) is also needlessly confrontational during an intake session, which may disrupt the trust-building and information gathering phase. In this case, the client has already been working with the agency's Psychiatrist, therefore it would be best practice to have her discuss with her doctor directly. Neglecting to address the client's reported issues with her psychiatric medications can also be deemed a liability and thus it is important to follow up with the client to ensure her needs are being addressed despite the counselor's opinion that the client has preoccupation with the psychiatric portion of her care. Therefore, the correct answer is (D)
Competency: counseling skills and interventions