Case Study
Patient Demographic: Name: Tabitha Clinical Issues: Family conflict and pregnancy Diagnostic Category: V-codes Provisional Diagnosis: Z71.9 Other Counseling or Consultation Age: 16 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Latina Marital Status: Not Married Modality: Individual Therapy Location of Therapy : School  
Mental Status Exam: The client appears healthy but tired and distracted. She is dressed in loose-fitting clothing and sits with her hands between her knees. Eye contact is minimal. Speech volume is low. She is reluctant to talk at first and denies having a problem. Thought processes are logical, and her thoughts are appropriate to the discussion. The client's estimated level of intelligence is within average range. She appears to have difficulty maintaining concentration and occasionally asks you to repeat your questions. The client denies suicidal ideation but states that she has been considering abortion. She has not acted on anything but is feeling very overwhelmed and desperate.
Presenting Problem: First session You are a school counselor in an urban school setting. The client is a 16-year-old student who is reluctant to see you. The session begins with a discussion of the teacher's concerns and your role as a school therapist. After some gentle probing and reassurance, the client is able to open up more and discuss her difficult relationship with her father. She identifies feeling overwhelmed and frustrated by his expectations, which leads to frequent arguments between them. She appears tired and has trouble sleeping at home because her parents constantly argue. She suggests that her parents "are the ones who need therapy, not me." She briefly describes the arguments that she claims her parents get into regularly. "They are always going at it, unless thay are at church. Then they act like everything is perfect."    When you ask about her friends and activities, she tells you she is involved in her church youth group and has an on-again/off-again boyfriend. You ask the client, "Can you tell me more about your relationship with your boyfriend? How long have you been together?" She says that they have been seeing each other for about a year, and she thought he was 'the one', but they had a "big fight" last week and have not talked since. You ask what she means by 'the one'. She looks down at the floor and starts to bite her fingernails. You see a tear fall down her cheek. She says, "I don't know what to do." You continue the session by providing a safe space for her to express and explore her feelings about her relationship with her boyfriend. She takes a deep breath and tells you that there is something she has not told anyone and she is scared that if she says it out loud that "it will make it too real." You tell her to take her time and that you are here to listen without judgment. She tells you that she missed her last menstrual period, and several "in-home" tests confirm that she is pregnant. She has not told her boyfriend and is scared to tell her parents because she is afraid they will disown her, so she has decided to keep the pregnancy a secret.    While you are tempted to try to talk the client into telling her parents and boyfriend about her pregnancy, you recognize that it is important to respect her autonomy and allow her to make the best decision for herself. You provide her with accurate information about the options available to her and encourage her to explore the pros and cons of each option. You share that having a support system and someone to talk to during this time can be helpful. She nods her head and tells you that she knows that her parents will find out about the baby eventually, whether she tells them or not, but she is anxious about how they will react to the news. You listen and provide empathetic reflections to help her gain insight into her feelings. You then focus on helping the client develop effective coping strategies for managing her stress and anxiety about the situation. You let the client know that she can come back to see you at any time if she feels overwhelmed or needs additional support. The session concludes with an understanding of what to expect in future sessions, including exploring possible solutions for dealing with her parents and boyfriend, as well as developing healthy coping skills for managing her emotions.
Other Contexts: The client has an older brother who is in college. The client lives at home with her parents. They are members of a Christian church and are all actively involved in their church group, and the client has a good relationship with her pastor. The client has never felt close with her father and says he has always had "high standards and expectations" for everyone in their family. The client says her parents "treat her like a child." She has not told her parents about her 16-year-old boyfriend as she knows they will disapprove. For the last year, she has been asserting her independence from her parents, which has caused conflict, friction, and discord within the family. The teacher who referred the client to you mentioned that the client has seemed distracted and anxious lately. She has not been completing homework assignments and failed a test last week. The client acknowledges these concerns and tells you she struggles to keep her grades up and has difficulty adjusting to hybrid learning. "One day, we're in school, and the next day we're virtual. It's just exhausting. I feel like giving up." 

Question: The client has shared a certain disaffection with her parents, and seemed reluctant to confide in the teacher who referred her to you. This could suggest a tendency in the client to have generational trust issues. How would you most effectively build a therapeutic alliance with this client?
(A): Explore resources that are available to her.
(B): Use self-disclosure of a difficult time in your past.
(C): Remain neutral and validate her experience.
(D): Examine why she is afraid to talk to her parents.

Correct Answer: Remain neutral and validate her experience.
Explanation: This client is in a particularly vulnerable state right now. She has just found out that she is pregnant. She is scared to tell her parents and unsure of what to do next. You must create a safe space for her to process her situation. Remain neutral, regardless of your values and opinions, and validate her experience. Therefore, the correct answer is (A)
Competency: counseling skills and interventions