Counselling Case Study: Assessment, Referral, and Reporting for Mena

This case study focuses on the assessment, treatment, and ethical considerations surrounding Mena, a 32-year-old married woman from Egypt, now residing in Australia. Mena is experiencing trauma, depression, and difficulties caring for her four-year-old daughter following her husband's accident. The assessment involves a comprehensive psychosocial and mental health evaluation, including mental health and trauma assessments, to determine appropriate interventions. The case study details the assessment tools, processes, and potential services like Cognitive Behavioral Therapy (CBT), Headspace, and the Black Dog Institute. Ethical responsibilities, including privacy, confidentiality, duty of care, and informed consent, are thoroughly addressed, along with the importance of working within the limits of one's role. The case study also outlines potential risks and the roles and responsibilities of various parties, including Mena, her family, and healthcare professionals. The goal is to develop a comprehensive plan to support Mena's recovery and well-being, considering the complexities of her situation and the need for collaboration and ethical practice.

Running head: COUNSELLING CASE STUDY
COUNSELLING CASE STUDY
Name of the University:
Name of the Student:
Authors Note:

2COUNSELLING CASE STUDY
1. You are preparing to assess Mena, in order to decide on what treatment and services will
be most useful for her. (When answering the following questions, you will need to bear in
mind the role that your organisation’s policies and procedures will play in assessing
clients.)
a) Identify which type of assessment you think will be most helpful for Mena, and
explain the benefits of using this method.
An assessment in the psychosocial and mental health domain needs to be carried out in which
Mena’s history of mental health, behavioural and emotional developments, social competence
and identity developments need to be assessed. To be precise, mental health assessment and
trauma assessment need to carried out. A psychiatrist will need to make a mental health plan
where Mena’s requirement for medication or psychological support will be chalked out. A
psychologist trained to assess trauma will help Mena in understanding and managing her
responses to the traumatic event by developing effective coping techniques and strategies.
b) Briefly outline which assessment tools and processes you will need to prepare prior
to assessing her.
The assessment tools and processes required to prepare prior to assessment would include Mini-
Mental State Examination (MMSE), Geriatric Depression Scale (GDS), DMI-10 Self-Report
Questionnaire, Edinburgh Depression Scale, Indigenous risk impact screen (IRIS), Mental
Health Transcultural Assessment Checklist .
c) Mena’s issues are complex and interrelated. Summarise in dot points the existing
information that you have regarding Mena’s case, and explain what you believe
her main issues and needs might be.

3COUNSELLING CASE STUDY
The existing information that is available regarding Mena’s case are-
 She is 32 years old, is married and has a four-year-old daughter Ahlia.
 She is from Egypt.
 She has lived in Australia for the past five years after getting married.
 She cannot speak English well.
 She suffers from trauma because of her husband’s accident 6 months ago which has
rendered him unlikely to regain his capacities.
 She has been taking anti depressants.
 She has been unable to take care of Ahlia or follow up with her routine.
 There are signs that she has physically abused Ahlia.
Her main issues are that she has been suffering from trauma, depression and has been unable to
cope with her daughter’s mental condition..
d) Who might you speak to in order to obtain more information regarding the
potential issues that may be affecting Mena?
First, it is essential to ask Mena for a self-report as that information would be compared to the
ones from other sources, This would give a fuller picture about her situation and will be helpful
for us to check the reliability. Information from other sources like Mena’s previous case notes,
Health and specialist reports, her neighbors and family will give us a valuable insight to
Mena’s present mental condition. Observation is also an effective way to pickup essential
information from Mena’s appearance, speech, relatibility to others, ways of completing tasks and
many more.

4COUNSELLING CASE STUDY
2. You are conducting your initial assessment of Mena. Compose a dialogue between you
and Mena in which you explain the assessment process to her and obtain her consent, as
well as organise and establish the practical aspects of the assessment that is about to occur.
(Note: a translator would likely be present in this situation. Assume that the dialogue
between you and Mena is being translated, and write your response in English.)
Hello Mena, How are you?
How have you been doing today?
Are you comfortable?
I am going to conduct certain assessments on you so that I can get a clearer view of the issues
that you have been having. The assessment results will help us understand the intensity of how
you have been feeling. You have the right to have a copy of all the assessments you take.
I will need you to fill up a consent form stating that you are willing to take the assessments.
There will be a translator available in case you need any help. You can also bring in someone
you are comfortable with, if you want, during the time of your assessment.
Please let me know in case of any discomfort or if you have any questions at any point.
3. List and describe three strengths-based tools or services that you might incorporate into
this assessment, or consider when referring Mena to other services.
The strengths based tools that can be incorporated in th assessment include-
 Strengths Finder 2.0 by Gallup- This tool helps individuals finf theor intrinsic strengths
and proved ideas about how to incorporate them
 VIA survey by VIA Institute of character – This is a personality test that focuses on the
strengths of an individual and helps them find their core capacities.

5COUNSELLING CASE STUDY
 Strengths profile ex-R2- This strengths based tool measures about 60 key strengths of an
individual across three dimensions of performance, usage and energy of those strengths.
4. Outline the roles and responsibilities of each of the following in Mena’s assessment:
a) The community worker-
A community worker will need to provide Mena with all the results of assessments that she took.
He/she should be able to help Mena in having an insight into her issues, give her various ideas
and information, suggest her services and ways so that she can move forward, but most
importantly must be able to help the client in identifying and prioritizing her own needs and
requirements.
b) Mena-
Mena will have to cooperate while being assessed, try to have an insight about her situation and
be willing to listen to the therapist about making the necessary changes in her life. She needs to
understand the outcomes of the assessments and the steps that are required to be taken further.
c) Mena’s family-
Mena’s family needs to be supportive during the period of her assessment and be considerate
about her situation. They need to understand the results of her assessment too and help her
understand the steps that are required to be taken further.
d) Mena’s GP-
Mena’s GP needs to provide all the previous health history reports and give an elaborate
information about her past behaviors. The GP and her therapist need to collaborate in order to
make a proper mental health plan for Mena.

6COUNSELLING CASE STUDY
e) Ahlia’s therapist and any other health practitioners-
Ahlia’s therapist needs to provide all the health histories of Ahlia and past relationship reports
between Ahlia and her mother. He/she also needs to help chalk out a schedule for Ahlia so that
Mena’s family can get a vivid idea of how to deal with Ahlia’s autism and how to give her
proper training.
5. List at least three indications that Mena’s situation is or has become urgent.
Three indications suggesting Mena’s urgent situation are-
 Depressive state and intake of anti-depressant pills without any consultation with the
therapist.
 Signs of physically abusing her daughter.
 Inability to cope with a traumatic incident and failing to deal with Ahlia’s situation or go
through with her training sessions.
6. Based on the information you have about Mena, what services do you believe she may be
eligible for? Research and describe three to five services or networks (internal and/or
external) that might be appropriate for Mena.
Few services that might be eligible for Mena that she could benefit for includes-
Cognitive Behavior therapy- either from a psychotherapist or online. CBT therapy helps
individual cope with anxiety, depression and trauma.
Headspace- this is a government-funded organization which gives out information about how to
deal with trauma and depression.
Black dog institute- they help increase awareness about mental health issues and the
communities boost individuals up by motivating them to look forward to life.

7COUNSELLING CASE STUDY
7. For each of the services described above, give an example of information you might supply
Mena in order to assist her decision-making process.
In case of CBT, I would tell her stories about my other clients who have benefitted from the
therapy and how it has helped them in the long term. For headspace, I would show her the
application available on Google play and give her an idea about how calming the effect of
mindfulness programs can be. I would give explain to her, how the black dog institute helps
people cope with depression and anxiety.
8. Outline your legal and ethical responsibilities relating to the assessment, referral and
reporting process for Mena, in the following areas:
a) Privacy, confidentiality and disclosure-
There a number of National Privacy Policies that I have to maintain.
 There are certain rules foe what kind of personal data can be collect from the client as
well as from the third parties and the what are the things that we need to let the clients
know.
 There are rules about disclosure of the person’s private information.
 The information of the clients needs to be up- to- date.
 The information are to be kept secure an private.
 The individuals have the right to access their information at any point.
 The personal information are usually kept anonymous.
 Higher standards need to used for handling sensitive information.

8COUNSELLING CASE STUDY
b) Duty of care-
Duty of care is my legal responsibility to make sure and that others are not being harmed, this
means that I need to exercise my duty to a standard, which can reasonably be expected from
someone in my position with the training and knowledge that I have in my role.
c) Informed Consent –
This is a “statement for collection of personal information” provided to the client explaining
about the information that is about to be collected, the reasons why the information is being
collected and the certain individuals (individuals associated with providing support) who will
have access to those information. The document will be provided to the client in plain English,
community languages, large prints and simple languages. Interpreter according to the client’s
preferred language would be provided. The client will have to sign the declaration suggesting
their consent.
9. In a case as complex as Mena’s, explain why it will be important for you to be aware of
and work within the limits of your role, and seek assistance from others as necessary.
According to my Duty of Care, it is essential that I make sure to not harm anybody in the process
of assessing and helping Mena out. I need to be aware of the work and be in my limits of
knowledge because; assessments outside my expertise would give some wrong outcomes. It is
essential to collaborate with other specialists who are experienced and adept at the task that is
out of my hands. Also some assessments have the qualifications mentioned in the guidelines and
it would be illegal to perform them without the required qualifications. Mena is at a very
complicated place in her life and a proper help must be provided to her so that she she can cope
with the situation and live a healthy life.

9COUNSELLING CASE STUDY
10. Outline at least three risks that might be associated with Mena’s case and the delivery
of services to her.
The three risks that may be associated with Mena’s case includes-
 Risk to self – this may include self-harm or suicide which might cause her to being
hospitalized,
 Risk to her daughter- there are evidences of physical abuse reported by Ahlia’s therapist.
There might occur a risk of the same taking place again.
 Risks of Trauma.