Clinical Case Simulation · Practice

The Case of Elena M.

Persistent low mood following the death of a spouse · Adult outpatient

Items: 9 multiple-choiceFormat: Intake + 2 sessions

I Intake Summary

First Contact

Elena M. is a 58-year-old retired teacher who comes to counseling at the urging of her adult daughter. Eleven months ago her husband of thirty-one years died after a brief illness. For the first several months, Elena says, she "functioned on autopilot" — handling the funeral, the paperwork, the casseroles from neighbors. In the last three months, however, she has felt progressively worse rather than better.

She describes waking before dawn unable to fall back asleep, little appetite, and a heaviness that makes ordinary tasks feel enormous. She has stopped attending her book club and church, places she once loved, and says she feels "guilty for still being here" when her husband is not. She is tearful describing this but denies any intent or plan to harm herself, stating, "I would never do that to my daughter."

Elena reports no prior mental health treatment. She drinks a glass of wine most evenings, which she says is "more than before, but not a lot." Her physician saw her last month and found no acute medical concerns.

Appearance & Behavior: Neatly dressed, slowed movements, frequent tearfulness, cooperative.
Mood / Affect: Reports sadness and guilt; affect constricted, mood-congruent.
Risk: Denies SI/HI, no plan or intent; cites daughter as protective factor. No reported access concerns.
Relevant history: Death of spouse 11 months ago. Increased evening alcohol use. No prior treatment.

Q1Intake & Assessment

Elena's symptoms began as grief but have intensified over the past three months. Which assessment consideration is <em>most</em> important in distinguishing a normal grief reaction from a co-occurring major depressive episode?

AGrief and depression are identical, so the distinction does not affect treatment.
BThe presence of pervasive depressed mood, early-morning awakening, anhedonia, and worthlessness/guilt that extend beyond the expected course of grief.
CWhether Elena cried during the intake session.
DThe fact that she sought counseling at all proves she has major depression.

Q2Intake & Assessment

Given Elena's increased evening alcohol use and her depressive symptoms, what is the most appropriate assessment step?

AIgnore the alcohol use because one glass of wine is never clinically relevant.
BImmediately refer her to inpatient detox.
CScreen her substance use further (e.g., quantity, frequency, change over time, and its relationship to mood and sleep).
DTell her to stop drinking entirely before the next session as a condition of treatment.

Q3Legal & Ethical

Elena says, "I feel guilty for still being here." What is the counselor's most appropriate <em>immediate</em> response?

ANote it and move on, since she already denied a plan.
BGently explore the statement directly to assess for suicidal ideation, intent, and any passive death wishes.
CReassure her that everything happens for a reason.
DEnd the session early to avoid distressing her further.

II Counseling Session One

Two Weeks Later

Elena returns and, when asked about the guilt, clarifies that she has no wish to die but feels she "doesn't deserve" to enjoy things without her husband. She has stayed home from two more book club meetings. She mentions that her late husband used to handle all the finances, and she now feels "paralyzed" opening the mail, which is piling up.

When you ask what a good day would look like, Elena pauses and says, "I honestly can't picture one anymore." She then adds that her daughter keeps urging her to "get back out there," which makes her feel misunderstood and more withdrawn.

Q4Interventions

Elena says her daughter's urging to "get back out there" makes her feel misunderstood. Which counselor response best demonstrates empathic attunement while keeping the focus on Elena?

A"Your daughter is right — you really should get back out there."
B"It sounds like even well-meant encouragement lands as pressure right now, and that leaves you feeling more alone."
C"Why do you let your daughter upset you so easily?"
D"Most people would be grateful to have a daughter who cares."

Q5Interventions

Elena reports feeling "paralyzed" opening the mail and managing finances her husband once handled. Which intervention best addresses this in a way consistent with behavioral activation?

ATell her the mail is not important and to throw it away.
BCollaboratively break the task into a small, specific first step she can attempt before the next session and plan to review how it went.
CTake over the task for her by contacting her creditors yourself.
DWait until her mood fully lifts before addressing any practical tasks.

Q6Treatment Planning

You and Elena are setting an initial goal. Which goal statement is best aligned with her presentation and written as a measurable objective?

A"Elena will get over her grief."
B"Elena will be her old self again."
C"Elena will attend one book club meeting in the next three weeks and rate her mood before and after."
D"Elena will try to feel better when she can."

III Counseling Session Two

Six Weeks Into Treatment

Elena attended one book club meeting and opened two weeks of mail with a friend present. She reports her sleep is "slightly better" and she cried less this week. She remains sad but says, "Maybe I can still have a life — a different one." She asks whether she might benefit from a grief support group, and separately whether she should consider medication, since a friend mentioned an antidepressant helped her.

Near the end of the session, Elena mentions she has cut her evening wine to a few nights a week on her own, noticing she sleeps better when she skips it.

Q7Treatment Planning

Elena asks about joining a grief support group. What is the most appropriate counselor action regarding continuity of care?

ADiscourage it, since group work would interfere with individual counseling.
BDiscuss how a peer grief group could complement her treatment, and, with her consent, help connect her to an appropriate resource.
CTell her she must choose between the group and counseling.
DRefer her to any group online without considering fit.

Q8Indirect Care

Elena asks whether she should consider an antidepressant. Which response best fits the counselor's role?

ARecommend the specific medication her friend took.
BTell her medication is unnecessary because she is improving.
CExplain that prescribing is outside your scope, discuss that medication is one option for depression, and offer to coordinate a referral to a prescriber with her consent.
DTell her medication is a sign of weakness and discourage it.

Q9Interventions

Elena says, "Maybe I can still have a life — a different one." From a grief-counseling perspective, this statement most likely reflects:

ADenial of her loss.
BA movement toward integrating the loss and reconstructing meaning, rather than "getting over" it.
CEvidence that she no longer needs counseling.
DA manic shift requiring urgent reassessment.

All cases0 / 9 answered