Case Study
Patient Demographic: Client Age: 13 Sex Assigned at Birth: Male Gender: Transgender; Gender Nonconforming (TGNC) Ethnicity: Caucasian Counseling Setting: Child and Family Agency, School-Based Services Type of Counseling: Individual and Family Presenting Problem: Truancy; Gender Dysphoria Diagnosis: Gender Dysphoria, Provisional (F64.1); Social Exclusion or Rejection V62.4 (Z60.4)
Mental Status Exam: Mental Status Exam: The client is dressed in age-appropriate clothing. They wear eye makeup and chipped black fingernail polish, and they have bitten most fingernails down to the quick. The client’s mood is irritable, and they are quick to show anger toward their mother when misgendered. Their thoughts are coherent, and they deny audio/visual hallucinations. The client acknowledges feeling sad and hopeless but denies suicidal ideation. They attribute increased levels of anxiety at school to bullying, particularly with select peers. They explain that a select group of students threaten the client and call them offensive and derogatory names. Family History and History of th
Presenting Problem: You are a school-based mental health counselor in a public middle school. Your client is a 13-year-old Caucasian 7th grader who presents for the initial intake with their mother. The mother says that the client has had several unexcused absences from school because “he is confused about his gender.” The client adamantly denies being confused and explains that they self-identify as transgender. The client’s preferred pronouns are “they/them.” The client further states that they have had a strong desire to be a different gender since early childhood, and this desire and their distress have recently intensified. The mother reports that the client is chronically irritable, spends a lot of time alone, and has “basically shut everyone out.”The client reports experiencingbullying—both verbal and physical—in school “nearly every day.” In addition to the bullying, the client says that certain teachers refuse to allow them to use the bathroom aligned with their identified gender. To prevent this conflict, the client does not eat breakfast or lunch at school.
Other Contexts: The client arrives for the session without her husband. Her affect is flat, and she presents as more subdued. The client explains that she has been in bed for the last 4 days, which has caused escalated conflict and tension with her husband. She says that her husband believes that they are at an impasse and threatened to leave during their fight last night. When processing the details of their altercation, the client states that her fear of being alone has become unbearable. She denies any suicidal plans but says she feels hopeless and void of purpose and is in significant levels of physical pain due to intractable migraines. You conduct a suicide risk assessment to determine the client’s level of safety

Question: You ask the client “What are your reasons for living?” What are you are trying to determine with this question?
(A): The level of marital distress
(B): Protective factors
(C): The appropriate level of care
(D): Religious or spiritual support

Correct Answer: Protective factors
Explanation: You are trying to determine the client’s protective factors. Protective factors mitigate suicide risk and include coping skills, social support, religious beliefs, and restricted access to lethal means. The client’s level of marital distress is a risk factor that has already been determined. Religious or spiritual support is one example of a protective factor; however, the question is posed to help determine all protective factors. This question is one of a series of questions posed as part of a suicide risk assessment, which helps guide recommendations for an appropriate level of care (eg, outpatient, inpatient, residential). Therefore, the correct answer is (B)
Competency: intake, assessment, and diagnosis