Confidentiality in Counseling: Protecting Privacy and Ensuring Informed Consent

Confidentiality
I started by exchanging pleasantries, then I introduced myself, I cleared my position by
telling her that I am an intern at Liberty University. After it, I told the client about my
intentions to record a video. I told her that informed consent is necessary to protect her right
to privacy. I further told her about the ethics of the research where every subject has a right to
protect her identity and it is purely her choice and discretion to participate in the video
recording, her identity will be protected throughout and it will not be used commercially. She
agreed to the terms and conditions.
Demographic Information
Jane Doe is a 27-year-old African American female. She belongs to a disturbed and estranged
family. She is suffering from the pangs of separation; her intimate partner in the previous
relationship was abusive and violent in nature. In her present status, her life revolves around
her four-year-old son. She is a loner by nature this is why she doesn’t have a strong
social support system guarding her. Financially, she is passing through a rough patch because
her ex-husband is not supporting the upbringing of her son. The history of her mental illness
started with the attacks of mild depression. Her financial instability can be contributed as a
major reason behind regular attacks of depression and anxiety. The episodes of depression
and anxiety become severe when she is required to accompany her son to supervised visits
with his father.
Presenting Problem
During her first visit she told me that she is surprised that why she has been referred to
someone who offers psychological counseling, she mentioned about certain physiological
symptoms like chest congestion and headaches. She also suspected that she is suffering from
low Blood Pressure; however, she failed in presenting any corroborative statement in this

regard. After launching an ice-breaking session with her, I figured out certain symptoms of
post-traumatic disorders. Her past bad experiences were catching up with her all the time and
making her pessimistic. In the true spirit of a counselor when I said that she should stop
thinking negatively and focus more on the events that are under her locus of control then she
revealed about her constant worries related to the lack of a social support system because her
kid is very young. Financial worries were also troubling her.
Mental status exam
While having a friendly chat on an interpersonal level she also talked about her disturbed
state of mind during the four hours of supervised visit. This statement gave me a reason to
diagnose her with mild depressive disorder, with a single event causing episodes repetitively.
The pangs of the separation were also visible in her personality because she was suffering
from low self-esteem and she was not comfortable with her body. This low self-esteem
clubbed together with her isolation from the society gave me an idea that either she is on a
borderline or she has already become a victim of generalized anxiety disorder.
After reaching a level where I can say that I am familiarized with her, I started noticing her
more minutely. Psychotic thoughts were not present. Her cognitive features were sharp
enough to respond to the environment and social conditions. Her orientation with time place
and the person was right and her abstract reasoning was in place. Emotionally she was stable
and selection of the words was apt for the occasion.
The history associated with the presenting problem
Her childhood was normal, it was a fairy tale romance that she had with her ex-husband,
however, and her separation from her ex-husband was the darkest chapter of her life.
Biopsychosocial history