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: Which presenting problem would you begin to assess first and which corresponding tool would you administer?
(A): suicidal thoughts; HDRS
(B): suicidal thoughts; C-SSRS
(C): panic attacks; PDSS
(D): panic attacks; BAI

Correct Answer: suicidal thoughts; C-SSRS
Explanation: Suicidal ideation must always be prioritized in the assessment phase of counseling as results may lead towards higher levels of care needed. The C-SSRS (Columbia-Suicide Severity Rating Scale) is the best evidence-supported tool to assess the client's needs most quickly and thoroughly. Once a client is cleared for continuing the session safely, especially while in a telehealth session, other areas like panic can then be addressed. If the client is rated high risk for suicidality, the content of the session might then shift towards making referrals either for in-person care or possibly inpatient psychiatric services. The HDRS (Hamilton Rating Scale for Depression), PDSS (Panic Disorder Severity Scale), and the BAI (Beck Anxiety Inventory) are all helpful tools that can be utilized in the assessment phase or as part of an ongoing treatment plan goal to further identify and define areas of need; they are however not considered the best options for crises interventions or specifically ruling out suicidality as the C-SSRS measures and informs history and present indicators of ideations, plans, intent and actual suicidal attempts. Therefore, the correct answer is (B)
Competency: intake, assessment, and diagnosis