Case Study
Patient Demographic: Client Age: 9 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private practice clinic Type of Counseling: Individual counseling with family involvement Presenting Problem: Behavioral problems and social skills issues Diagnosis: Autism spectrum disorder, without accompanying intellectual impairment (F84.0)
Mental Status Exam: Mental Status Exam: The client is oriented to person, place, situation, and time. The client appears clean and is wearing season-appropriate clothing; however, his parents report that he often wears the same outfit for several days because he gets frustrated with having to change his clothes and showering. The client was minimally involved in the intake session and was instead focused on reading a video game walk-through
Presenting Problem: You are a private practice, licensed counselor. The client is 9 years old and comes to the first session with his parents. The client has been previously diagnosed with autism via use of the Autism Diagnostic Observation Schedule-Second Edition by a psychologist, and you receive supporting documentation for this diagnosis. The client demonstrates difficulties with normal back-and-forth communication with peers, difficulty maintaining eye contact during the session, and difficulty with imaginative play with peers as reported by his parents. The client and his parents also report what they call “OCD behavior”—for example, he often lines up toys and insists that they “have to be this way”—and that he has trouble with changes in schedule, often becoming aggressive toward the parents if changes occur. The parents report that he is very rigid and that certain activities and play have to be done a certain way or he becomes upset, which affect the home, social, and school settings. The client’s intellectual quotient is above average for his age per the supportive testing provided. The parents report that the client’s difficulty with changing plans or daily changes causes him to become angry and confrontational.
Other Contexts: This session is occurring in the client’s home in order to observe behaviors in his natural environment. The client’s parents and 8-year-old brother are present. You are observing during this session in order to gather information and then to provide psychoeducation at the end of the session to the parents. The client and his brother are sitting on the floor playing with a building toy, which the client’s parents report is often a toy that causes him frustration because he plays very specifically with it and his brother does not want to play how he does. After about 5 minutes, the client becomes visibly frustrated as he is telling his brother to put a brick in a certain place because it is the same color and his brother says he is not going to and goes to build on his own. The client continues to build and asks for the piece repeatedly over a few minutes. The client then picks up what he is building and throws it against the wall and leaves the room.  During the session, the parents leave to answer a phone call, and the client’s uncle comes into the room

Question: During the session, the parents leave to answer a phone call, and the client’s uncle comes into the room. When the client’s uncle asks who you are and why you are in the home, which one of the following would be the most ethical response?
(A): “I’m a friend of the family; my name is (state your name).”
(B): “I’m (state your name), your nephew’s counselor.”
(C): “I’m (state your name); it’s nice to meet you. I can’t answer that question, but you’re welcome to ask your brother.”
(D): “I’m a counselor, but I can’t say who I’m here to work with.”

Correct Answer: “I’m (state your name); it’s nice to meet you. I can’t answer that question, but you’re welcome to ask your brother.”
Explanation: Working in the community provides opportunities for situations like this. You are not able to tell anyone other than the client (or who you have a release of information to talk to) why you are present and who you are working with. It is most appropriate to redirect the uncle to the client’s parents because the client is a minor and he may not be able to appropriately choose whether to reveal who you are. Telling the uncle that you are there as a friend of the family is not true and would not assist in developing trust with the client’s uncle if you end up having to coordinate services with him also. Telling the uncle that you are the nephew’s counselor would breach confidentiality, as would telling him that you are a counselor but cannot say who you are working with. Therefore, the correct answer is (D)
Competency: professional practice and ethics