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What this case practices

• Suicide risk and level of care, with a firearm in the home
• When a depressive episode counts as “recurrent”
• Responding to self-judgment without correcting it
• Weighing a family member’s account against the client’s
• Sharing only what a release allows
• Transferring care safely before a move

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The whole case, to read on the page

This is the same case as the timed version above. If you want a clean first try, take the timed version first, because reading the questions here gives them away.

Part One: Intake and Ten-Day Follow-Up

Intake: Initial visit through ten-day follow-up

Clinical Presentation

You are the counselor in an integrated behavioral-health clinic for older adults. The client is a 65-year-old divorced man who uses he/him pronouns and receives services through a retiree employee benefit. His sister urged him to schedule after finding two utility shutoff notices beneath unopened mail. He says, “I am not trying to die. I just do not see much point in waking up.”

For seven weeks he has felt depressed nearly every day and has lost interest in woodworking, cooking, sex, and visits with friends. He sleeps his usual hours but wakes tired, eats little, has lost eight pounds, struggles to follow television plots, and describes himself as “a burden with a toolbox.” He has missed bill payments and stopped repairing a neighbor’s porch rail halfway through the job.

He reports fleeting wishes not to wake but denies intent, a suicide plan, preparation, or past attempts. A hunting rifle is stored unlocked in a bedroom closet.

He drinks one beer on some weekends and denies other substance use. He is oriented, speaks coherently, and shows no hallucinations, delusions, or gross cognitive deficit.

His sister and adult son are reasons for living, and he can state how he would obtain urgent help. Before he leaves, he and the counselor complete a written safety plan. He declines temporary off-site storage of the rifle; with his permission, his brother-in-law confirms he will install a cable lock today and hold the only key. Screening and interview findings are complete, and he asks whether telling you this means he will be sent somewhere.

He saw his primary care physician a month ago at his sister’s insistence; the physical examination, thyroid panel, and bloodwork were all unremarkable, and he was told nothing needed following up. He has taken the same two long-standing prescriptions at unchanged doses for several years, started nothing new in the months before the low mood began, and says the weekend beer has been the same one beer for as long as he can remember.

Symptom Course

The client had comparable depressive episodes at ages 41 and 57. Each lasted several months, responded to treatment, and was followed by more than a year without significant depressive symptoms. He has never experienced elevated or persistently irritable mood accompanied by increased energy, decreased need for sleep, pressured speech, grandiosity, or risky behavior. His longtime partner died six years ago; he grieved intensely but returned to baseline and does not connect the present episode to an anniversary. During the present seven-week period, depressed mood and anhedonia occur with five additional symptoms and impaired functioning; mania, psychosis, substances, and a sufficient medical cause are absent.

Initial Session

Before setting broader goals, the counselor asks the client to open one of the unopened utility envelopes he brought to session. He reads the notice twice, loses his place, and says the task proves he can no longer manage ordinary life. The counselor slows the exercise and separates depressive concentration problems from permanent incapacity. He chooses one concrete re-entry task: open the remaining utility notice beside his sister, then text his brother-in-law about the unfinished porch rail. He declines a generic productivity worksheet, explaining that it would become another test he could fail.

Treatment Plan

The client identifies as gay; he divorced his son's mother in his thirties, and his longtime partner died six years ago. An earlier clinician assumed his only family was his sister and son, although his late partner's brother, whom he still calls his brother-in-law, is the person he trusts most locally.

Reduced bus service makes morning visits difficult. He is interested in CBT and a primary-care medication consultation.

Ten days after intake, primary care starts low-dose sertraline after reviewing risks and alternatives; he reports taking it daily. He currently eats one or two meals daily, has not used his woodworking bench in six weeks, and says a full project feels impossible while two brief tasks may be manageable.

PHQ-9 scores, meals, activities, suicide risk, bill paying, and social contact are available measures, but he asks which should define early improvement. He signs a purpose-limited release for medication and safety coordination. Written material needs large print and concrete steps.

Follow-Up

A separate envelope contains a notice from the woodworking cooperative that his bench will be reassigned if dues remain unpaid. The client reads it as confirmation that other people have already decided he is finished.

His sister urges him to let her pay and call the cooperative; he refuses both, then says he may avoid the issue until the deadline passes. The counselor asks what part of the decision still belongs to him. He chooses to call while his sister waits in another room, ask for the exact date and payment options, and decide afterward whether keeping the bench serves recovery or obligation.

The call reveals a two-week extension. He does not sound relieved, but he writes the date on the utility envelope and identifies returning one borrowed tool as the next action. The exchange adds a meaningful role decision without converting his sister into a financial manager or treating one completed call as remission.

Question 1. Which initial objective best turns the client’s chosen brief activities into a measurable activation target?

1. A. Begin the chosen tasks when his guilt has eased, noting whether motivation shows up before action.
2. B. Complete two brief chosen tasks this week, recording completion and their effect on daily functioning.
3. C. Discuss the chosen tasks in weekly CBT, using session attendance as the primary outcome.
4. D. Track the chosen tasks this week, counting success by how much enjoyment each one produces.

Question 2. The client says, ‘I am not trying to die. I just do not see much point in waking up.’ Which opening response best combines attunement with safe assessment?

1. A. “You sound worn down by how little feels worthwhile”; finish the PHQ-9 first, then screen for intent, plan, and access.
2. B. “Thank you for telling me that”; pause for his reply, then ask directly about intent, plan, and access.
3. C. “Your sister and son give you strong reasons to stay”; stress those protections, then check for intent or a plan.
4. D. “That sounds passive, not active”; classify the wish now, then confirm he has no plan or means.

Question 3. If it emerged later, which finding would require you to reconsider the provisional diagnosis?

1. A. His anhedonia has lasted longer than the seven weeks recorded at intake.
2. B. His sister has taken over his bill paying this month.
3. C. His thyroid panel and bloodwork from last month both came back within normal limits.
4. D. He recalls a past week of elevated mood and unusual energy while needing little sleep.

Question 4. The client loses his place in the utility notice and says it proves he can no longer manage ordinary life. Which response is best?

1. A. “Losing your place in one letter does not mean you cannot manage your life.”
2. B. “Let us set the notice aside and I will read it aloud for you.”
3. C. “Reading it twice and losing your place felt like proof that you cannot cope anymore.”
4. D. “Many people with depression struggle to concentrate, and that improves with treatment.”

Question 5. Based on the completed risk assessment, which disposition is most appropriate now?

1. A. Arrange inpatient admission today, treating the unlocked rifle as decisive despite his absent intent.
2. B. Continue diagnostic assessment over two more visits and settle level of care at that point.
3. C. Refer him to an intensive outpatient program this week, given the rifle and his weight loss.
4. D. Begin close outpatient care once the rifle is secured, using the written safety plan.

Question 6. Which longitudinal pattern is required before the current major depressive episode can be classified as recurrent?

1. A. An earlier depressive syndrome ran unbroken into the present one with no symptom-free gap.
2. B. A relative had recurrent depression, and the client's own earlier symptoms had stayed below the episode threshold.
3. C. An earlier major depressive episode was followed by at least two consecutive months without meeting episode criteria.
4. D. A bereavement-related low period years ago never met major-episode threshold, unlike the current one.

Part Two: 24 days after intake · Two Accounts of the Same Week

Session 3: 24 days after intake

The Score and the Kitchen Tell Different Stories

The client reports eating most planned meals and completing the neighbor's porch-rail repair with his brother-in-law. His sister, invited for one agreed segment, reports finding untouched meal containers and several unopened utility notices. He experiences her account as an accusation and says the clinic should rely on his lower PHQ-9 score.

A day-by-day review shows that meals improved on four days, mail was opened once rather than twice, and the repair occurred as reported. He says activation “worked only halfway”: his energy and activity have improved, but pleasure has lagged behind.

Passive death wishes have been absent for twelve days, and the rifle remains cable-locked with the key held by his brother-in-law. The counselor has not yet decided how to integrate the discrepant reports.

Help Has Terms

The sister says she wants to take over bills until he is well; the client says that would confirm he is incapable. The counselor asks each to define a limited experiment. The client will open and sort envelopes while his sister sits nearby, but she will not read or pay them unless he asks about a specific notice. He will also photograph prepared meals for his own record for one week, not send the images to family. Under the purpose-limited release, primary care confirms daily sertraline use, mild dry mouth, no activation, and a scheduled dose review. The client describes the shared repair as companionable but adds, “If I need help, I have failed.”

Question 7. The client authorizes contact with primary care for medication and safety coordination. What would you send?

1. A. Send the full counseling record, treating shared care as authorization for the whole chart.
2. B. Send a summary covering his medication response and current safety status, matching the release he signed.
3. C. Send his appointment dates and attendance, leaving clinical content out of the exchange.
4. D. Send the notes from sessions where medication was discussed, including his comments about side effects.

Question 8. How should the counselor integrate the discrepant outcome reports?

1. A. Weigh the sister's collateral against his self-report and treat her observations as the more objective record.
2. B. Anchor progress to the day-by-day log and let the PHQ-9 drop settle which account is credible.
3. C. Combine the day-level evidence from both accounts, crediting verified gains and continuing impairment alike.
4. D. Reconcile the two accounts by averaging the meal, mail, and repair reports before judging overall progress.

Question 9. Your client says activation “worked only halfway.” What review would be most useful?

1. A. Treat the partial result as a practice error and re-teach the activation steps.
2. B. Separate his energy gains from the pleasure lag and size the next task to match that evidence.
3. C. Stop activation for now and return to it when his pleasure and interest have fully recovered.
4. D. Reassure him that enjoyment usually follows behavior and assign a larger activity next week.

Question 10. Which intervention would best test his belief, “If I need help, I have failed”?

1. A. Review the belief verbally in session by listing reasons that needing help is not failure.
2. B. Arrange for his brother-in-law to offer reassurance ahead of each request he makes.
3. C. Teach a coping statement he can repeat each time the failure thought arises.
4. D. Set up one real help request and compare his prediction with what actually happened.

Part Three: 17 weeks after intake · A Confirmed Move

Session 8: 17 weeks after intake

Transfer Becomes Concrete

The client now prepares meals, pays bills on time, and spends one afternoon weekly woodworking. His son has found an apartment in another state near a cooperative shop, and the client chooses to move in six weeks.

Sorting financial papers uncovers a tax notice that triggers shame and one passive wish not to wake. He has no intent, plan, or preparation; he calls his son, confirms that the rifle remains inaccessible and will stay with his brother-in-law when he moves, and keeps the appointment.

The review supports outpatient care and also shows that the move is a chosen role transition, not a rescue imposed because symptoms once became severe. He opens the notice with an accountant, names the first payment question, and continues packing one workbench drawer at a time.

A Planned Ending

The counselor and client map the remaining clinical tasks before transfer: two stable visits, direct reassessment if death wishes recur, a medication appointment, and a receiving counselor selected by the client. He authorizes a focused summary of diagnosis, treatment response, current risk formulation, and the plan for renewed symptoms; his son receives only the steps the client wants him to know. The client asks what he should do if unopened mail, skipped meals, or burdensomeness thoughts return during the move. Termination is tied to continuity and the client’s relocation goal, while the brief tax-notice response is addressed within that transition.

Question 11. Which safety-plan revision would you make after the tax-notice episode?

1. A. Document the passive wish as resolved, given that he coped with the notice on his own.
2. B. Record financial notices as a warning sign with stepped responses for each level of risk.
3. C. Schedule daily counselor check-ins as his main response to financial notices this month.
4. D. Obtain a signed no-harm agreement covering the remaining weeks at this clinic.

Question 12. What should occur before you begin spacing these counseling sessions?

1. A. Begin transfer planning now because the move date is confirmed and his son lives near the new apartment.
2. B. Reduce visit frequency now because woodworking and paid bills show his recovery is holding.
3. C. Conduct the full intake battery at each remaining visit to document stability.
4. D. Rehearse his responses to early warning signs before the visits become less frequent.

Question 13. If the planned receiving counselor becomes unavailable one week before the move, which response best protects continuity?

1. A. Review other referral options with him and arrange legally permitted interim coverage until a handoff is set.
2. B. Continue the sessions by video after he moves and confirm the interstate practice rules afterward.
3. C. Keep the original end date, and give him a vetted referral list with the crisis numbers.
4. D. Ask his son to pick a replacement counselor and inform the client once scheduled.

Question 14. After the tax-notice death wish, which response would most compromise proportionate reassessment?

1. A. Assess his current intent, plan, and preparation directly at this visit.
2. B. Review recent changes in meals, bill paying, and woodworking as part of the reassessment.
3. C. Increase contact for a short period while the risk formulation is updated.
4. D. Treat his improved functioning as reason enough to postpone direct suicide questioning.