Case Study
Patient Demographic: Name: Gary Clinical Issues: Behavioral problems Diagnostic Category: Disruptive/Impulse-Control/Conduct Disorders Provisional Diagnosis: F91.3 Oppositional Defiant Disorder Age: 10 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: White Marital Status: Not Assessed Modality: Individual Therapy Location of Therapy : Agency  
Mental Status Exam: The client reluctantly enters the session accompanied by his mother. He is slightly overweight for his age and is wearing clothes that appear too small for his physique. He is sitting in the chair with his arms crossed, refusing to make eye contact with you. His mood is angry, and his affect is irritable. His attitude during the initial part of the examination is defiant. Speech characterized by short responses and refusal to engage in conversation. Client refuses to discuss feelings or issues. He appears to have difficulty focusing. He lacks insight into his behavior and impact on others. Judgment and impulse control are poor. He denies suicidal or homicidal ideation.
Presenting Problem: First session You are a mental health therapist in an agency, and a 10-year-old male is referred to you due to behavioral issues. The client and his mother arrive at your office, and you note that he has an irritable look on his face. The two are arguing with each other. His mother threatens him with punishment if he does not cooperate with you and says that this is his "last chance". He glares at her and then stares at the floor. You introduce yourself and explain what you do as a therapist. The client barely says a word and keeps his head down with his arms crossed over his chest. You ask the mother to describe the issues that prompted her to seek help and she begins to tell you the story.    She explains that her son has difficulty listening to adults and gets into verbal altercations with his peers. She informs you that he got suspended again from school because he lost his temper in the cafeteria when the student in front of him in the lunch line "wasn't moving fast enough". When you ask about how often his temper outbursts occur, the mother pauses for a moment to think and says, "It seems like he's always losing it, but I guess maybe a few times a month? The rest of the time, he's just angry, mostly at me and other adults. No matter what I do, he seems like he hates me." As she tells you this, you notice that the client is not paying attention and continues to look down at the floor, appearing disinterested in the conversation. His mother goes on to say that the school is threatening expulsion if her son's behavior does not improve.    After thanking the mother for sharing this information with you, you look toward the client who has been sitting quietly the entire time. You explain that you understand it must be hard for him to be here and that you are not here to judge or criticize him. He looks up at you with a surprised expression on his face. He slowly nods and mumbles something under his breath. You let him know that you want to help him find ways to better manage his emotions so he can get along better with the people in his life. He looks away again, but this time there is a hint of curiosity in his eyes. You sit in silence for a moment. The client finally looks up at you and says, "It's just...everyone's always telling me what to do and they never listen to me. They think they know everything, but they don't. I can't help it if I get angry, but then everyone looks at me like I'm a monster. It's not fair." His mother looks away, tears in her eyes. You thank the client for expressing his feelings and explain that it is normal to feel upset when things are unfair. You further emphasize that you are here to help him find positive ways to handle his anger and other emotions. You then address the mother, "Parenting can be challenging, especially when it feels like your child is angry or upset with you. I'd like to work with both of you to improve your communication and relationship. It might be helpful to schedule separate sessions for you and your son, as well as joint sessions, so we can address individual concerns and work on improving your relationship together." The mother agrees, and you proceed to discuss a plan of action, including setting up regular weekly therapy appointments and providing resources to help support the family.
Other Contexts: The client's father left the family two years ago. The mother, still married to him, retains sole legal custody of the client. Since his father left, the client will not help out around the house, seems angry, and sometimes loses his temper when he does not get his way. The client receives frequent but inconsistent corporal punishment from his mother. His mother made the appointment with you but did not tell him where they were going. The relationship between the client and his mother has been strained as the mother does not know how to handle the abandonment of the father. The client is in fifth grade and has been skipping school for the last six months and refuses to do any homework. His school records were released to you and show A's and B's through third grade, but C's and D's during the past two years. His decline in grades coincides with his truancy. He is also known as a "bully" at school and has been suspended and given detention a few times due to his behavior. He has a history of walking out of classrooms, running down the hallways, refusing to sit in his chair, and running away from the school counselor or anyone in an authoritative position. Personal/Social Relationships: The client does not have friends his age in the neighborhood, and parents do not want their children playing with him because they believe he is a "troublemaker". In addition, children in school avoid him because they are afraid of upsetting him. He does not seem interested in making friends and does not care to engage in any play time with the neighborhood children. Instead, he spends most of his time alone playing video games. 

Question: What is the most effective way to build rapport with this client?
(A): Explain the boundaries and purpose of therapy and how it will help him
(B): Engage in activities that involve two-way dialogue, such as role playing and problem solving
(C): Reschedule for a different day when the client is in a better mood
(D): Allow the client to control the sessions and follow his lead

Correct Answer: Engage in activities that involve two-way dialogue, such as role playing and problem solving
Explanation: This is the most effective way to build rapport with this client because it allows him to open up and feel heard and understood. Engaging in activities that involve two-way dialogue encourages active participation, which can help foster a more collaborative relationship between therapist and client. Therefore, the correct answer is (B)
Competency: counseling skills and interventions