Case Study
Patient Demographic: Client Age: 4 Sex: Female Gender: Female Sexuality: Unknown Ethnicity: Caucasian Relationship Status: Not applicable Counseling Setting: Private Practice Clinic Type of Counseling: Family Therapy Presenting Problem: Foster Care; Disengaged Child; Behavioral Problems Diagnosis: Provisional Diagnosis of Reactive Attachment Disorder (F94.1)
Mental Status Exam: Mental Status Exam: The client is disengaged, and when the foster parents prompt her to answer questions, she ignores them and continues playing. The client appears oriented to person, place, time, and situation because she answered questions about these topics. The client appeared more responsive to your questions than her foster par
Presenting Problem: You are a private practice counselor specializing in working with children with developmental disorders. The 4-year-old female client is referred to you by her PCP and arrives with her foster parents, who join her in the first session. The client has been with her foster parents for the last 13 months after being removed from the care of her biological parents due to their incarceration for drug trafficking and attempted armed robbery. The foster parents are worried because the client exhibits minimal positive mood, irritability without an obvious trigger, and behaviors that appear to be clearly connected to attachment with caregivers. She experienced emotional and physical neglect from the birth parents and changes in primary caregivers. The foster parents also report that the client does not seek comfort when something happens that upsets her. The client did not engage very much in the intake session and was instead playing with the toys provided by the counselor. During the session, the client becomes upset with her foster parents when they prompt her to answer some questions. She hits the foster father, runs out to the lobby, and sits down with the toys. You leave the office and meet her in the lobby.
Other Contexts: At the start of the session, the foster parents ask the client if she would mind meeting alone with you; she agrees and asks to have access to the toy bin in your office. You and the client begin to play together, and you ask her if she talked to her birth parents. The client says “yeah, Mommy talked about coming home in a few years.” You ask how she feels about living with her mother again, and she says she does not want to be with her because her mother does not want to be with her. You try to process this with the client, and she says that she likes her house and her school and does not want to leave. You meet with the foster parents and the client at the end of the session, and they report that spending quality time with the client on a daily basis has been helpful in improving their relationship. They state that they think they had been too afraid to overwhelm her and that at times they were trying to give her space, but they realize that the intentional time together has been helpful. You empathize with the foster parents and encourage them to continue to spend quality family time with her

Question: Which of the following terms describes the client’s belief that “no one wants me”?
(A): Thought stopping
(B): Automatic thought
(C): Schema
(D): Transference

Correct Answer: Schema
Explanation: A schema is a core belief that one has about themselves based on what has happened to them. Schemas may be irrational or unhelpful at times, but a healthy schema leads to a strong sense of self-worth and self-esteem. Although cognitive therapy approaches might not be directly helpful for the client, the parents can assist in adjusting schemas. Automatic thoughts occur when a situation triggers a thought that is unconscious and can be negative or positive. Thought stopping is a technique that focuses on stopping a negative or irrational thought. Transference is when an individual redirects feelings and emotions about one individual to an entirely different individual. Transference is likely happening from the birth parents to the foster parents. Therefore, the correct answer is (A)
Competency: intake, assessment, and diagnosis