Case Study
Patient Demographic: Client Age: 30 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Pacific Islander Relationship Status: Single Counseling Setting: Private practice counseling clinic Type of Counseling: Individual counseling Presenting Problem: The client and her boyfriend recently broke up, and she is “tired of being with the wrong guys.” She admits that she will often stay in relationships even if she knows they are wrong for her. Diagnosis: Provisional diagnosis: Dependent personality disorder (F60.7), personal history (past history) of spouse or partner violence, physical (Z69.11), and personal history (past history) of spouse or partner psychological abuse (Z91.411)
Mental Status Exam: Mental Status Exam: The client is oriented to person, place, time, and situation. No hallucinations, delusions, or paranoia are reported. The client was anxious at the start of the session, but she was able to calm herself down by easing into the counseling relation
Presenting Problem: You are a professional counselor working in a private practice clinic. The client comes in and sits quietly. The client appears nervous because she avoids eye contact and waits for you to initiate conversation. You ask why she is in counseling, and she responds that she is just tired. You ask more about this, and she says that she is not ready to talk about it yet. You decide to cover demographics and other less intimidating topics and then ask if she is comfortable talking yet. The client says that she feels a little more comfortable. She begins to state that she and her boyfriend broke up the previous week and that she was with him for 2 years. She explains that she has been “in this type of relationship before,” continually finds the “wrong guy,” and that she always goes “all in” with her relationships. Through processing, she identifies the following behaviors and beliefs: difficulty making daily decisions without the input of her partner, doing anything to gain support and affection even if she does not want to do the task or activity, quickly moving on to another relationship when a relationship ends, feeling that she cannot care for herself when she is not with someone else, and acknowledging that she needs others to take responsibility for major areas of her life. The client says that she has experienced physical and psychological abuse from partners, but that she is not ready to discuss this. The client identifies that her most important goal is to not end up in “the same relationship” again or rush into a relationship that is not right for her. Throughout the session, you provide empathetic and active listening. You suspect that the client has dependent personality disorder.
Other Contexts: The client comes in, sits down, and immediately says that she has been thinking and decided that she is now ready to talk about the physical abuse that she has experienced. She recounts that from age 18 until age 20 she was with a boyfriend who would smack her if she said something he did not like. She believes this is why she is so preoccupied with pleasing others. The client’s second relationship was when she was 25 with a man who would get drunk nightly and punch her in the stomach or in the back when he was upset. You empathize with the client and reflect her emotions regarding these events. The client states, “I didn’t deserve it when the drunk guy hit me, but I do feel I wasn’t the best girlfriend with the first guy. I often didn’t do enough for him and often said the wrong thing.” Throughout the session, the client was tearful and started shaking slightly when speaking several times. The client paused for long periods before sharing more difficult parts of the story. You decide to assess for PTSD during this session, but she does not meet the criteria. When closing the session, the client states that she is not able to pay for today’s session until the end of the week. The client has no history of nonpayment with you thus far.  Your informed consent includes fees for nonpayment and late cancellations of sessions

Question: Your informed consent includes fees for nonpayment and late cancellations of sessions. Which of the following is the most therapeutic response to the client’s inability to pay for the session until the end of the week?
(A): Allow the client until the end of the week to pay for the cost of the session with the added fee.
(B): Waive the session fee and nonpayment fee because the client is experiencing financial hardship.
(C): Allow the client until the end of the week to pay for the session and waive the nonpayment fee.
(D): Consistency with fees is important in the client–counselor relationship. The fee should still be applied, and payment is still expected on time

Correct Answer: Allow the client until the end of the week to pay for the session and waive the nonpayment fee.
Explanation: Because this client has no history of nonpayment, it would be the most therapeutic course of action to waive the nonpayment fee and allow the client extra time to pay for the session. Generally speaking, fees for the counseling sessions, for late cancellations, and for nonpayment are beneficial for the counselor and the client. The fees ensure that the counselor is paid, and they develop a level of buy-in and accountability for the client to have regular sessions. A blanket rule to apply the fee every time does not take into consideration special circumstances and can harm the counseling relationship. Waiving the fees for the session and nonpayment would not be a good course of action because you do not know at this point if the client will continue to have issues with payments and the client has already agreed to pay for your services. Therefore, the correct answer is (A)
Competency: professional practice and ethics