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  1. 1. CASE STUDY 1 Case Study Renee Jenkins Mount St. Mary’s College
  2. 2. CASE STUDY 2 VIGNETTE Karen Romanski, a 15-year-old Native American girl, was referred for treatment by her school after Karen went suddenly from getting all A’s to failing all her classes. The therapist spoke to Karen first alone. Karen said her parents were “overreacting” and that she did know the school material. Karen said that she had been sleeping fine and did not feel sad. She did say she had gained 10 lb in the past month and that she no longer was interested in normal activities like watching movies with friends and playing soccer. Karen said she did have lots of friends and that they liked to hang out at the mall, but she said that the last time she had done so was about two months ago. Karen denied drug or alcohol use, saying she had only ever tried beer once at a party. She said she was afraid of drinking as she had heard that Native Americans were at greater risk for becoming alcoholics. Karen said that she was adopted at birth by Caucasian parents—her biological parents were reportedly Native American but she had never known them. She said that she wished they had not given her up for adoption (when they were in high school) as she often felt out of place with White’s. The therapist then interviewed Mr. and Mrs. Romanski, both in their late fifties, blond, and blue-eyed. They had adopted Karen when she was three days old. They knew that the mother had not drunk alcohol when pregnant for which they were grateful, as the mother stated that “Indians are known to have trouble with alcohol”. The Romanski’s stated that Karen met all her developmental milestones on time, had always gotten A’s, and had been the star of the soccer team. Mrs. Romanski wondered aloud if Karen’s grades had dropped because Karen was angry at her mother for getting a job. Mrs. Romanski, after being a stay-at-home-mom, had gotten her first job in the fall as a receptionist at a doctor’s office. The Romanski’s reported that Karen slept well, although she had difficulty waking up in the mornings for school.
  3. 3. CASE STUDY 3 They said that she had recently gained weight but they were happy as they felt she was always too thin. Mrs. Romanski said that Karen had friends but that she had not been spending as much time with them lately, spending more time in her room and studying. She said Karen was spending less time with friends at the mall. The therapist asked about Karen’s identity as a Native American and if she had ever expressed concerns about not “fitting in”. The Romanski’s said that they had tried to help with this by giving Karen books about Native Americans. In addition, they said that they told the school to make sure Karen always played the role of the “Indian” in any school plays. They said they had never taken Karen to any Indian reservations because they did not want her to “see how lazy those people are”. The therapist obtained consent to speak with the school, who reported great concerns. The school counselor stated that Karen used to excel both academically and in soccer. In the past two months, however, Karen’s grades had dropped and she had missed half the soccer practices and had missed an important game. Before this she had never missed, even if sick. In addition, whereas Karen had always been a friendly and gracious girl, she now walked around “as if in a daze,” not even talking with her friends. The counselor said she recommended therapy to the family when Karen’s English teacher showed her a poem Karen had written describing a wintry place “without love or warmth”. At the end of the poem, the writer lies down awaiting death, and the counselor thought perhaps Karen was contemplating suicide. After this consultation, the therapist received a call from Karen’s mother saying that the night before Karen had taken a bottle of aspirin. They were now with her in the hospital. The hospital reported that she had not taken enough to kill herself.
  4. 4. CASE STUDY 4 IDENTIFYING INFORMATION AND PRESENTING PROBLEM Karen is a Native American female. She is 15 years old. According to her parents, even though she recently gained 10 lbs., she is “underweight”. Karen was adopted by a Caucasian couple when she was three days old. Her parents are currently married and in their late 50’s. Until recently, her mother, Mrs. Romanski was a stay-at-home mom. Client has had no known past psychological treatment or a psychiatric diagnosis or medication regimen. Client informed school counselor that she does not use substances and has only tried drinking one time at a party. Her parents initiated the therapeutic process at the request of the school counselor. The reasons for the school counselors referral are; sudden drop in grades (A’s to F’s), unusual non-participation in extra-curricular activity (missed half of soccer practices and an important game), significant change in affect (friendly and gracious to un-talkative and “daze”- like appearance), submitting schoolwork that contained wording which was perceived as suicidal ideation (poem that included the wording “awaiting death”). And while Karen’s parents list of concerns isn’t as long as the school counselors, they do find some of her behaviors distressing. The Romanski’s reported that Karen has difficulty getting up in the morning. Mrs. Romanski has also noticed that her daughter is spending less time with her peers in the social and sport arenas. And while she is happy about Karen’s recent weight gain, it is only because she has always perceived her as being underweight. The above-mentioned issues bring cause for further analysis and pinpointing of the possible causes related to Karen’s behavioral changes.
  5. 5. CASE STUDY 5 CLINICAL EVALUATION Some or all of Karen’s current symptoms have been reported by the school counselor, her parents and via self-report to be present for at least eight weeks. They include, but are not limited to; sudden drop in grades (A’s to F’s), unusual non-participation in extra-curricular activity (soccer practices and a game has been missed over the past two months), significant change in affect (friendly and gracious to un-talkative and “daze”-like appearance), submitting schoolwork that contained wording which was perceived as suicidal ideation (poem that included the wording “awaiting death”). Furthermore, Mrs. Romanski believes that the onset of Karen’s symptomatic display was initiated by her recently attaining work outside of the home for the first time. The above-mentioned occurrences have adversely affected Karen’s usual level of functioning and give cause for a meeting with her and her parents to take place for further probing. Symptoms have impacted the client on an academic, emotional, and social level. Behavioral changes have caused Karen to exhibit poor performance in school. Additionally, she is no longer “the star of the soccer team” due to her recent lack of participation within the sport. According to her mother, she does not spend the same amount of time with her friends and at the mall. Moreover, the patient’s self-report of happenings brings to light other incidents and a varied perspective on the severity of outcomes as they relate to her actions.
  6. 6. CASE STUDY 6 Karen states that her parents are “overreacting”. Juxtapose to the reflection of her current grades, she states that she “knows the material”. She accounts for her lack of peer involvement via social and physical activity as simply due to her “no longer being interested”. Karen states that she has only tried beer once at a party because she is “afraid of drinking”. And while she seems to exude an elevated level of unconcern, she quickly conveys some deep-seated emotions. She goes on to convey that she wishes that her biological parents did not give her up for adoption. And while she knows they made the decision to place her up for adoption while they were in High School that is the extent of her knowledge about them. Karen also says that she “feels out of place with White’s”. When Mrs. Romanski explains how she incorporates Karen’s Native American culture into her life, it more clearly displays why Karen may feel the way she does. Mrs. Romanski proudly retorts that every time there is a Native American character in a school event, she makes sure Karen “plays the Indian”. Similarly she conveys her pride in Karen for meeting all of her developmental milestones, excelling within academia, having good study skills, and being a star soccer player. Within her response she describes Native Americans as “lazy” and goes on to state that “Indians have trouble with alcohol”. Based on these sentiments, and some adverse emotional expressions about White people made by Karen, it seems that this type of derogatory stereotypic observation about people identified as Native American may be a pattern within her environment. Furthermore a sense of perfection, assimilation and Eurocentric standards may be the bar in which she is always expected to operate under. If so, resentment towards the dominant culture may be a contributing factor to relational tension. Recently, Karen’s behavior became self-harming.
  7. 7. CASE STUDY 7 Client recently ingested a bottle of Aspirin and was hospitalized. Doctors reported that the amount of pills consumed by Karen was not enough to end a life. Aside from this occurrence no other significant medical or psychiatric treatment has occurred. Even though it seems as if Karen’s behavior may be taking a turn for the worse, fortunately she is not without support. Some identifiable assets she has are her high aptitude, athletic capability, and strong suit of being able to meet high expectations. Her parents seem to be concerned about her well-being and have taken the note-worthy step of seeking professional help. In addition, her school counselor has also been a person who keeps an eye out for her social, emotional, and academic success. For a more detailed clinical evaluation various assessments were implored. The first assessment utilized with Karen was the CHILD/ADOLESCENT FULL ASSESSMENT (MH533). Some noteworthy information was attained from that valuation. Firstly, Karen identifies herself as Native American. Questions regarding her family history recognize that currently all information related to her biological parents is unknown. Even though her adopted parents did not identify any cultural considerations, due to the varying viewpoints Karen has on not fitting in with White people and Mrs. Romanski has on Native Americans, I believe multicultural education needs to be explored. As far as clients past treatment goes, the only prior suicide attempt occurred two weeks ago. No lasting physical effects were identified by the treating physicians. When Karen was asked why she did this, she stated that she saw it as a “way to make the pain and confusion go away”. The parent substance use risk factor questionnaire detected that Mrs. Romanski believes that Karen’s Native American heritage puts her at a greater risk of using/abusing alcohol. Medical history place Karen at a normed level in all categories except for weight. In that classification her BMI (body mass index) is 10% lower in relation to gender and height. Detailed birth/delivery information is unknown.
  8. 8. CASE STUDY 8 That being said, an environmental stressor that can be connected to that occurrence is identified for age 0-3; resulting from the change in family composition that resulted in her being adopted. Within her current age range, she has experienced separation due to her mother now working outside of the home. Her independent functioning and peer/familial relationships have declined. Her ethnic self-identity seems to be conflicting with her maintaining positive viewpoints of the dominant culture she was reared in. Moreover she may be lacking authentic ethnic knowledge that is needed during adolescence to form a healthy sense of self and belonging. Client is currently in school but recent academic performance changes have resulted in her receiving multiple failing grades. Her current family composition is that of her immediate mother and father (no siblings or extended family). Socioeconomic status can be classified as upper middle-class. Religious identification is none or Atheist. Currently, the state of Karen’s relationship with her parents is conflictual. The Romanski’s parenting style is authoritative (with any problem solving having to result from client bending to the will of the parents). Client, parents, and assessor (myself) identified togetherness and care for each other’s well-being as being a strength. Family needs were then distinguished among the client, parents and assessor for a more in-depth examination. Client stated that her parents needed to be more understanding. The parents stated that Karen needed to get back on track. My initial belief is that they are in need of family counseling. In addition parenting class and multicultural education should be sought by the parents with more of a concerted effort being made to infuse knowledge and values of Native American culture to all parties involved. They client and her parents were then asked about what they hoped to gain from the involvement of mental health professionals.
  9. 9. CASE STUDY 9 Client and parents indicated that they are expecting assistance with a return to normalcy and betterment and will be open to adhering to therapy and other forms of assistance methodologies. Exploring Karen’s mental status provided even more information needed to make a diagnosis. When I met with Karen and her parents I facilitated a mental status exam, and observed many factors that would lead to a diagnosis of a mental disorder. The following is a summary of the observations. Client was dressed in tight fitting blue jeans, an oversized sweater, and enclosed flat shoes. Her hair was long and oily to the point that could result from not washing it for two or three days; with no other apparent grooming problems. When I spoke with Karen, she gave minimal eye contact, and answered most questions reluctantly. When interacting with her parents, her body language was standoffish (arms crossed leaning away), her tone was aggressive (loud) and retorts were defensive (denying any wrongdoing) in nature. That being said, the fluency, tone, and volume of her speech were within the range of normal. Thought process and cognition were also within the range common for someone in adolescence. Karen’s mood was depressed, anxious and irritable. When the topic of her taking a bottle of aspirin arose, client stated the occurrence “was the first time she acted out her thoughts”. When probed further about how often she thought about harming herself, she stated twice within the past two months. When Karen was asked for suggestions on how to get her life back to normal as she knew it and improve upon it, she stated that she did not know, and really believed her mom and the school counselor were overreacting until she woke up in the hospital. She went on to say that things have been different since her Mother started working last month and she just had a lot of things she needed to deal with that she does not believe her parents can help her with.
  10. 10. CASE STUDY 10 When her parents were asked what they believed would be something they could do to help Karen and their family function better together, Mrs. Romanski simply stated that she needed help because it seemed as if her way of parenting is not working any more. Mr. Romanski remained quiet and offered no response. Client and her mother expressed that they were willing to attend therapy and were open to constructive suggestions that would assist them. All of the above-mentioned information was analyzed for antecedents and diagnostic purposes. The results of the mental status exam and the psychosocial history led to an initial diagnosis of: 309.4 Adjustment Disorder with mixed disturbance of emotions and conduct. Karen’s symptoms meet the criteria for “the development of emotional and behavioral symptoms in response to an identifiable stressor occurring within 3 months of the onset of the stressor” (American Psychiatric Association, 2013). Moreover exhibiting marked distress that is out of proportion of the stressor (mother working outside of the home), and significant impairment in social (no longer associating with friends and non-participation in soccer), and other important functioning (academically went from A’s-F’s). In addition other conditions that need to be the focus of clinical attention warrant the application of: V61.20 Parent-Child Relational Problem. Karen’s family dynamics reveal an impairment of functioning in behavioral (father’s limited involvement with rearing), cognitive (Karen’s hostility toward her parents and their race) and affective (Karen’s apathy about her Mother’s concern) domains. Mrs. Romanski’s requirements of Karen meet the criteria for excessive parental pressure (Mrs. Romanski constant expectation of Karen to meet all of her academic, extracurricular, and study demands), avoidance without resolution of problem (father remaining silent and inactive throughout this ordeal), and unwarranted feelings of estrangement (negative/stereotypical attitude Mrs. Romanski attributes to Karen’s race contributing to Karen feeling as if she does not fit in with White’s).
  11. 11. CASE STUDY 11 CRISIS EVALUATION Moreover, initial crucial action in the area of client safety is to be addressed. Due to the presence of a recent attempt to self-harm and admitted suicidal ideation, the initial focus within the crisis evaluation will stem on the preservation of life and place other facets of treatment on ensuing levels of priority. Self-injurious action on the part of the client places the maintenance of her well-being at a point of crisis. In addition, Karen shows signs that are associated with suicide such as “pushing away friends, isolation, feelings of not belonging…and deterioration in psychological functioning” (Firestone, 2009). Thusly, the following steps must be taken to ensure welfare. A home safety plan has to be comprised in order to rid clients home of materials that can be used to harm. All medications and weapons should be removed from client’s place of residence. To aid in the diminishment of isolation and initiate the therapeutic process, a referral to a Day- Treatment facility that has peer support groups and conducts Dialectical Behavioral Therapy (DBT) is recommended. DBT “is designed to treat emotion regulation difficulty and suicidal behavior. One element, the skill-building component, addresses the issues of distress tolerance and the development of healthy affect regulation strategies, both of which are essential for suicidal clients” (Firestone, 2009). This facet of the evaluation is based on the continuum or cessation of suicidal attempts and/or ideation and is subject to include inpatient treatment/hospitalization if deemed necessary by any member of a clinical or collateral team. Following successful participation in suicide prevention efforts, the following determinations have been deemed as occurrences that will aid client in stopping or minimizing other symptomatic behaviors.
  12. 12. CASE STUDY 12 TREATMENT PLAN Karen’s individual treatment plan will encompass and attend to multiple issues. The matters of focus for remedy will be in line with concerns that arise from her current diagnosis in addition to internal and external disputes that arise from adoption, diversity concerns, and barriers unique to her family dynamic. One of the major underlying issues within her family make-up stems from differences in viewpoints that are caused by her adoption. According to Vernon (2009) dealing with children and adolescents who have been adopted means being aware that at critical periods in their growth and development, new issues and concerns may surface. Adopted children who have been adjusting well may find that at the onset of adolescence, they suddenly face major problems. As adopted children understand what makes them different, they realize they have had a loss in their life. Adopted children may have problems with trust, self-esteem, and a fear of being rejected. Parents need to be encouraged to discuss aspects of adoption openly. There is potential damage to children who are not involved in learning about their past and circumstances around their adoption (Vernon, 2009, p. 299). In addition to Karen being adopted the fact that she is a different ethnicity from her adoptive parents play a significant role in their interaction. Native American youth present with a variety of problems related to forced assimilation. Furthermore, they may have difficulties developing a strong cultural identity and positive self-concept and greatly benefit from interventions that reinforce values associated with the Native American community (Vernon, 2009, p.273). Aside from ethnicity, adolescence itself is a stage where parent/child interaction is tenuous.
  13. 13. CASE STUDY 13 “All young people have the potential to become at risk and are influenced by pressures from family, school, peers, and society. As they attempt to deal with these pressures, adolescents often make choices that result in new problems” (Vernon, 2009, p.287). That being said “adolescents, despite their protests, need adults and want them to be a part of their lives, recognizing that they can nurture, teach, guide, and protect them on a journey into adulthood” (American Psychological Association, 2002). The aforementioned information now leads to the exploration of barriers distinctive to her family. Relational obstacles that must be tackled include but are not limited to; Mr. Romanski’s seeming limited-involvement in Karen’s life and addressing of problematic and harmful behavior. Compounding this difficulty is the negative perceptions and maladaptive manner Mrs. Romanski approaches multicultural elements with her adopted daughter. These behaviors can be pinpointed as a basis for some level of cognitive distortion, identity formation difficulty, and social withdrawal Karen is experiencing. Therefore, taking the clients referral, history, barriers, needed parental skill enhancement, current limitations and conceptions into account, Cognitive Behavioral Therapy (CBT) will be implemented as the main theoretical orientation and guise for interventions within her treatment plan. Specifically, CBT child group, plus parent involvement, will be the platform used to arrive at treatment goals. This Evidence-Based-Practice (EBP) model distinctively focuses on ways cognition, behavior, and emotion are connected and influential on one another. The application of this therapeutic model is a good fit for a host of reasons.
  14. 14. CASE STUDY 14 Within this type of therapy, goals can be arrived at together. In this critical stage of adolescence, it is important for Karen to have an active role in her healing process. The parents will also be involved in the formulation of treatment objectives. The mutual understanding between the therapist and Karen will further ensure her cognitive growth and independence. This process will also give Karen the tools necessary to discover what she is capable of and use that as fuel to positively affect her thoughts and behaviors. Short and long term goals will be established in order to give her a step-by-step method to attain desired outcomes. Karen’s short term goal will be to participate in treatment via group and remain actively engaged in all other therapeutic assignments such as but not limited to homework, in and outside of the counseling environment. In addition, a desire to learn and implement taught skills must be established by the client and her parents. Karen’s long-term goal is not so clear-cut. Karen’s long-term goal will be practicing taught skill, completing homework and other assignments to the point in which awareness can be generated that result in cognitive and behavioral change. Said changes will enhance her quality of life by implementation of transformative efforts that have the consequence of reducing her distress, problems and symptoms via cessation of suicide attempts and/or ideation, academic improvement, social interaction with peers, cultural and self-identity, and healthy communication and perception of her parents. Moreover maximizing her developmental functioning to the point in which this type of marked distress that is out of proportion to stressors does not occur at this level again. With goals established, further detail regarding how the treatment will be implemented is outlined.
  15. 15. CASE STUDY 15 COURSE OF TREATMENT The course of treatment will take place over a maximum of 20 sessions. To initiate the beginning phase of progression, the first session will be held with the client’s parents. During this meeting, Karen’s assessments and diagnosis will be discussed, goals will be contemplated, and her treatment plan and issues regarding consent will be covered. The second session will be held with Karen. In brief, this meeting will be the starting point of negotiating goals, and the formulation of a separate treatment contract will take place. The next six sessions will be held within a peer group counseling setting. “Group counseling allows children who have common experiences to feel normal, to share their stories with others who can understand them, and to gain support in knowing they are not the only one” (Vernon, 2009, p.300). Journaling will be introduced in order for Karen to keep tabs on her concerns, feelings and questions. “CBT journaling, writing down thoughts and feelings, reinforces…problem-solving skills” (Clabby, 2006). Mr. and Mrs. Romanski will also journal during this period. Their daily entries will be responses to worksheets that will be given to them in order to aid communication and enhance understanding of Karen’s current state and aid them with know-how to create a home environment where change is more likely to occur. The middle phase of Karen’s treatment will involve the integration of Bibliotherapy. In a recent clinical trial, Cognitive Behavioral (CB) Bibliotherapy participants showed significantly greater reduction in symptoms when compared to those who only utilized a journal in addition to CBT. Additionally CB and Bibliotherapy produced intervention effects that persisted into follow-up post treatment (Stice, Rhode, Seeley & Gau, 2008). Both Karen and her parents will participate in this sect of treatment with book materials aimed at diminishment of distress in both parties. The end phase of treatment will include more collateral support.
  16. 16. CASE STUDY 16 Evidence based therapy has expanded, “these different foci also draw on different modes of intervention (e.g., with child, parent, school and neighborhood resources) to accommodate the problems that adolescents experience” (Weisz & Kazdin, 2010). The last phase of the therapeutic process will call on the assistance of the school counselor to join in a minimum of one group session and back up the skill building and behavioral changes made by the client and her parents post-treatment; with an emphasis on monitoring academic and social interaction improvement. School counselors can “engage adopted children in the therapeutic process using a variety of developmental techniques including drawing, journaling, storytelling, incomplete sentences and role plays” (Vernon, 2009). Positive identity formation with an emphasis on ethnically diverse groups will be explored in depth via multicultural talks with emphasis on positive values and practices from the Native American culture. According to the findings of a recent research study conducted by The University of Oregon, “minority group adolescents often develop in an ecological context that presents a number of challenges that distinguish their experience from those of the majority group adolescents” (Yasui, Dorham & Dishion, 2004). The final sessions will bring focus back on the child-parent relationship. As we all know, parents are influential role models in their child’s life. “A parent modeling adaptive beliefs and cognitive processing of day-to-day events and rewarding a child for approaching situations in an optimistic manner can be especially helpful for anxiety reduction” (Weisz & Kazdin, 2010). Also referrals will be made to ensure continuance of positive parenting and involvement by them and the client in diversity workshops to strengthen their relationship and understanding and acceptance of differences. The last three counseling sessions will be utilized for follow-up.
  17. 17. CASE STUDY 17 DIVERSITY Within this case study, the issue of diversity plays a crucial role in the formation and maintenance of a healthy mental state for the client. In order to initiate assisting Karen in this area, the current impact of her Native American culture, level of acculturation, social structure and environment have to be examined. According to a recent treatment implication write-up by the Council of National Psychological Associations for the Advancement of Ethnic Minority Interests, introducing this aspect in “group work may be the most effective treatment …for Native children; with emphasis being placed on analyzing client’s level of acculturation” (American Psychological Association, 2003). Also: The native clients level of acculturation must be assessed prior to treatment planning. Treatment plans for a traditional Native client may need to differ significantly from those of an acculturated Native person. Treatment strategies need to strengthen client’s connectedness to the community. Due to the fact that Karen’s environment has constructed a high level of acculturation founded in Eurocentric American beliefs, the viewpoints of her parents and school community and willingness to make transformative efforts within client’s change process will impact treatment. Presenting ethnic self-identity problems with Native American “adolescents …tend to revolve around acculturation issues and being misunderstood by non-Native American school personnel” (Vernon, 2009, p.273). That being said, their positive assistance is needed and will help her thrive. Further boosting of the client and her support system accomplishing this is their upper middle class socioeconomic status that will make treatment attainable on a continual basis. This and all other factors of her treatment will have to be tackled in an ethically sound manner.
  18. 18. CASE STUDY 18 ETHICS Haman & Holloman’s (2008) study on the topic of ethical considerations for CBT mentioned the following: Research is distinguished from clinical practice by the intention to advance knowledge and draw conclusion about a treatments impact. In order to gain knowledge, some degree of extra constraint or demand is often placed on the patient and therapist. The benefits of the knowledge to be gathered are expected to balance the cost of study participation. In reality maintaining such a balance between costs associated with gathering knowledge and offering benefits to make participation worthwhile for clients can offer some ethical challenges. In the practice setting, issues such as confidentiality, duty to warn and protect, duty to report and the responsibility to abstain from dual relationships creates boundaries that may affect the effectiveness of implementation and receptiveness to the intervention. The California Association of Marriage and Family Therapists (CAMFT) have comprised a code of ethics that have to be adhered to when practicing as a licensed Marriage and Family Therapist (MFT). The standards outlined by the CAMFT not only dictate ethics within the client-therapist relationship, but furthermore add ethical duties in relation to; peers, operating within a particular realm of professional competence, the profession, financial agreements and the legal system. “Ethical behavior must satisfy not only the judgment of the individual marriage and family therapist, but also the judgment of his/her peers, based on a set of recognized norms” (CAMFT, 2014). Moreover therapists also have to adhere to dictates constructed outside of governing bodies within the counseling profession.
  19. 19. CASE STUDY 19 LAWS Laws at the state and federal level, consist of a system of rules that have to be followed. If said laws are not obeyed, penalties including but not limited to; fines, halting one’s ability to continue practicing, and imprisonment can be implemented. State and legislative codes guide and restrict how services are rendered. The governing bodies within federal and state entities, as they relate to the counseling profession, make legal standards that situate how and when the counselor must act. The guidelines include obligations such as; continuing counseling requirements, confidentiality constraints, duty to warn when one has knowledge regarding impending harm to others, consent and hospitalization. The necessity to abide by the aforementioned set of rules is the root of much debate. “Governmental monopsony ensures that competing local agencies acquiescence to the details of federal intentions” (Attewell & Gerstein, 1979). This conditioning of how practice can occur coupled with internal agency dilemmas at times results in a systematic approach to the handling of client care that can at times fail to deliver the full benefits of the therapeutic process to the client. However, the continued desire by those in the mental health profession to provide expert assistance that aims to meet the client where they are and form a relationship that is fueled with understanding, empathy, and curtailing an intervention in a manner that best suites the client allows many clients to have successful outcomes.
  20. 20. CASE STUDY 20 References American Psychiatric Association. (2002). Developing adolescents: A reference for professionals. Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Attewell, P., & Gerstein, D. (1979). Government policy and local practice. American Sociological Review, 44, 311-327. California Association of Marriage and Family Therapists. (2014). Code of ethics. Retrieved from Clabby, J. (2006). Helping depressed adolescents-a menu of cognitive-behavioral procedures for primary care. The Primary Care Companion to the Journal of Clinical Psychiatry, 8 (3), 131-141. Counsel of National Psychological Associations for the Advancement of Ethnic Minority Interests. (2003). Psychological treatment of ethnic minority populations. Retrieved from Firestone, F. (2014). Suicide: What therapists need to know. Continuing Education in Psychology. Retrieved from Harman, K.L., & Hollon, S.D. (2009). Ethical considerations for cognitive-behavioral therapists in psychotherapy research trials. Cognitive and Behavioral Practice, 16 (2), 153-163. doi: 10.106/j.cbpra.2008.08.005
  21. 21. CASE STUDY 21 Stice, E., Rhods, P., Seeley, J., & Gau, J. (2008). Brief cognitive behavioral depression prevention program for high-risk adolescents outperforms to alternative interventions: A randomized efficacy trial. Journal of Consulting and Clinical Psychology, 76 (4) 595- 606. doi: 10.1037/90012645 Vernon, A. (2009).Counseling children and adolescents. (4th ed.). Denver: Love Publishing. Weisz, J., & Kazdin, A. (2010). Evidence-based psychotherapies for children and adolescents (2nd ed.). New Yory, NY: The Gilford Press. Yasui, M., LaRue-Dorham, C., & Dishion, T.J. (2004). Ethnic identity and psychological adjustment: A validity analysis for European American and African American adolescents. Journal of Adolescent Research, 19, 807-825. doi: 10.1177/0743558403260098