Case Study
Patient Demographic:  Initial Intake: Age: 15 Gender: Female Sexual Orientation: Unknown Ethnicity: Hispanic Relationship Status: Unknown Counseling Setting: School-based through a counseling agency Type of Counseling: Individual
Mental Status Exam: Maria is slightly unkempt with a flat expression and normal rate and tone of voice. Maria is highly tense, hypervigilant, and anxious, flinching in response to loud noises and intermittently darting eye contact. She appears to “veer off” mentally while you are speaking with her, then realizes she is doing so and returns her attention to you by nodding her head and reconnecting with her gaze. She denies history of trauma, prior to this event, has no prior experience in counseling, and denies SI/HI. Maria maintains the position that she does not need counseling for herself but is willing to talk to someone about how she can better help her siblings.
Presenting Problem: Diagnosis: Acute Stress Reaction (F43.0), Provisional
 

You are a mental health counseling intern providing sessions for students inside of a high school. Maria enters the conference room that you use to meet with students and sits down to tell you that she needs help for her siblings. You have no referral for Maria and were not scheduled to meet with anyone during this hour of the day. Maria shares that two days ago, her and her two younger elementary school siblings witnessed their father take a gun to their mother, shoot and kill her, and then use the gun on himself. She tells you she is fine and does not need counseling, but she wants her brother, age 7, and sister, age 4, to receive counseling because it was likely “very traumatic for them.” Identifying that Maria is clearly in shock, you offer your sincere condolences, followed by recommending Maria have counseling as well. She declines at first, insisting she is doing okay and has nothing to talk about. After inviting the school counselor and assistant principal to the discussion, with Maria’s permission, they help convince her that it would be healthy for her and her siblings if she was also being seen by a counselor. The principal adds that some of the school staff, including herself, responded to the incident the following day by going to the neighbor’s house to assess for the children’s safety and let them know they had permission to take a leave of absence from school. Maria insisted on coming to school the next day, saying she was “fine” and “needed the distraction.” Maria consents to meeting with you, but only because she believes it will help her family stick together. Due to the nature of the trauma and obvious client need, you receive permission from your supervisor to provide services pro bono until insurance or payment can be established.
Other Contexts: Family History:
Maria is the oldest child of three children, and to her knowledge her siblings were born of the same two parents as herself; but she was unable to confirm this with absolute certainty during the initial assessment. She has difficulty providing historical information on her parents but can tell you in her own words she knows her dad was “sick” with “mental problems” and that her parents fought often. She tells you after the incident occurred her neighbors rushed to their aid and were able to take them in until they can establish a more permanent living situation with their grandmother, who lives across town and is preparing to have them move in soon. You ask if she can have her grandmother sign your company’s consent paperwork, but she replies that she has no transportation and does not speak English. She adds that her mother always told her she would want her to “go to her grandmother” if something ever happened to her and her father.

Question: Assuming you can obtain consent from Maria's grandmother to continue counseling, you discuss with Maria the goals of counseling sessions while her family is in crisis. What should you tell her?
(A): "I am going to teach you how to cope with this tragedy step by step."
(B): "We will be discussing your traumatic recall and emotional processing to avoid dissociation."
(C): "We will work together on helping you and your siblings feel safe and supported."
(D): "We can talk about anything you want, and I won't tell anyone because it's private."

Correct Answer: "We will work together on helping you and your siblings feel safe and supported."
Explanation: The goals of crisis therapy are to promote a sense of safety after a trauma, help keep a client calm, promote a sense of self-efficacy, encourage community or victim connectedness, and instill a sense of hope. In the first few hours or days following a significant trauma, a client may not be ready to address their grief and loss, as they are still in shock and likely unable to process the event as well as they could weeks later through cognitive therapy. A teenager is unlikely to be motivated for counseling if they feel they will be forced to discuss a pre-written agenda, and in Maria's case it is clear she is unwilling to share her own thoughts or feelings about what happened. Using clinical language is also challenging for a teenager to connect when using simpler language would be more helpful. Telling them they can talk about whatever they want is mostly true, however you want to inform her that the purpose of the sessions is to help her through this trauma - and neglecting to share that may also come off as insensitive. Furthermore, telling a minor you will not share anything they tell you is misleading as you are required by law to break confidentiality if she reports being abused, plans to hurt herself, or is going to harm someone else. Therefore, the correct answer is (D)
Competency: treatment planning