Case Study
Patient Demographic: Client Age: 19 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual Presenting Problem: Suicidality related to body image Diagnosis: Body Dysmorphic Disorder 300.7 (F45.22), with absent insight/delusional beliefs
Mental Status Exam: Mental Status Exam: The client’s mood is sad and irritable. His speech is pressured when discussing his appearance but is otherwise normal. He is appropriately groomed and wears a beanie covering his ears. He admits to repetitively dissecting his face in the mirror several hours a day. The client offers that he cannot hide his ears with his hair because “it is too thin.” He denies audio/visual hallucinations. The client’s thought content is organized and coherent, but he shows poor insight and delusional thinking about how he and others regard his appearance. The client avoids social settings and reports that sometimes, an entire week goes by where he doesn’t leave the house. He denies suicidality and currently does not have a plan or intent to harm himself or others. Appetite and sleep are fair. The client denies drug use and states he consumes alcohol occasionally. You provide an in-depth suicide assessment, and you and the client work together to create a suicide safety
Presenting Problem: You are working in private practice and conducting an initial intake session with a 19-year-old male who presents today with his mother. The client was recently admitted to a psychiatric hospital for suicidality and was discharged four days ago. His mother reports that the client tried to commit suicide by overdosing. The client reports feeling increasingly hopeless following a “failed” cosmetic surgery procedure. He explains that he had an otoplasty performed to change the proportion and position of his ears. He states he has always hated his ears and is convinced people are staring and laughing at his “deformity.” His mother reports that she reluctantly consented to the surgery a year and a half ago, despite believing it was unnecessary. The client does not leave the house without wearing a beanie or hoodie. He has completed high school with no interest in attending college. He is unemployed due to shame and embarrassment over his “defective” appearance. Two weeks ago, the hospital psychiatrist changed his medication and placed him on a selective serotonin reuptake inhibitor (SSRI).
Other Contexts:     plan. Family History: The client’s parents are divorced and he lives with his mother and two younger siblings. There is a history of child protective services (CPS) involvement due to reports of domestic violence between his parents. The client witnessed these incidents between that ages of 10 and 12. His parents subsequently divorced and the client has had minimal contact with this father since. The client’s maternal aunt is diagnosed with obsessive-compulsive disorder. His mother previously attended therapy for anxiety and other trauma-related symptoms. The client began experiencing symptoms of body dysmorphic disorder at age 13, with symptoms worsening after starting high school

Question: Which of the following is NOT is an established evidence-based component of a client’s safety plan?
(A): Create an accessible list of emergency contacts and social supports to use when feeling suicidal.
(B): Establish a “no suicide” safety contract.
(C): Identify distractions to use when feeling suicidal (e.g., take a walk, call a friend).
(D): Identify early warning signs (e.g., body shaming, isolation).

Correct Answer: Establish a “no suicide” safety contract.
Explanation: There is no empirical evidence supporting no-suicide contracts for safety. Historically, clinicians have asked clients to sign no-suicide contracts indicating that they would not act on suicidal thoughts or reach out for support when experiencing suicidality. Not only do no-suicide contracts lack empirical evidence, but critics believe there can be an implication of coercion from the counselor due to concerns over professional protection and liability. Instead, a collaborative, strengths-based approach to safety planning is thought to empower the client and enhance the therapeutic alliance. There are various evidence-based components to treatment planning, including but not limited to: identifying early warning signs, using distractions when feeling suicidal, identifying social and emergency supports, identifying coping strategies, and making the environment safe. Therefore, the correct answer is (B)
Competency: treatment planning