Case Study
Patient Demographic: Age: 9 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private practice Type of Counseling: Individual counseling Presenting Problem: The client has been engaging in behavior that has gotten him suspended from school several times over the past year, which also causes significant distress for the client’s family at home. Diagnosis: Conduct disorder, childhood-onset type, with limited prosocial emotions, severe (F91.1)
Mental Status Exam: Mental Status Exam: The client was minimally engaged in the session. The client’s behavior was withdrawn, argumentative, and la
Presenting Problem: You are a professional counselor, and you specialize in working with children and adolescents. The client comes to this session with his parents. You review informed consent with the client and his parents and begin to ask the client about what brings him to counseling. The client responds by saying “shut the hell up” and leaves the room to go to the lobby. The client’s father gets up and follows him out, and after a few minutes they return. The client sits down and faces away from you. The client does not engage in the intake session aside from cursing at his parents when they report specific behavioral incidents and he disagrees with them about the facts of the events. The client’s parents say that he has had “bad behavior” over the past 2 years and that his behavior has “gotten worse” over the past 5 months. The parents outline the following behavioral problems that the client engages in, in all settings: bullying, physical fighting, kicking and throwing items at his dog, intentionally breaking others’ property, lying to others to get items or have access to activities, stealing items from others, truancy, and leaving the house at night without permission or supervision.
Other Contexts: You meet with the client alone, and he appears to be more comfortable with you because he comes in and starts talking about a video game that he plays. You share that you have played that video game before. During the session, the client mentions that his parents got his first report card of the year and found out that he was failing most of his classes. He started to say that he was worried that his dad was going to hit him because of his grades. You ask if his father hits him often, and he replies that he does several times a week. You try to inquire about the manner of hitting his father uses because a certain level of corporal punishment is legal in the state that you work in. The client says that he is not going to talk any more about this. You remind the client that you likely will need to report this to child protective services and he says, “I don’t care” in response. You spend the rest of this session processing his relationship with his parents, and he discloses that he does love them, but that they are not his real parents. You meet with the client’s parents near the end of the session, and, while talking with them, they report that he was neglected while in foster care because the foster parent was “just in it for the money.”  The client becomes upset at the end of this session after talking about the alleged physical abuse, and he begins to throw toys and any items within arm’s reach

Question: The client becomes upset at the end of this session after talking about the alleged physical abuse, and he begins to throw toys and any items within arm’s reach. Which one of the following would be the LEAST helpful response when considering the client’s current emotional state?
(A): Use an open body posture and a calm voice
(B): Use the 5-4-3-2-1 grounding technique
(C): Attempt to process the client’s present thoughts and emotions
(D): Disengage with the client with regard to the subject at hand

Correct Answer: Attempt to process the client’s present thoughts and emotions
Explanation: When the client escalates to using physical aggression, he is likely not able to engage in processing his thoughts and emotions. It may escalate the behavior further if you attempt to have a conversation with the client. Using the 5-4-3-2-1 grounding technique is helpful because it focuses on engaging the senses and it can help the client calm his body down. Using an open body posture and a calm voice supports the client in not feeling threatened. When the client’s level of intensity is not matched, he is more likely to reduce the level of intensity of his emotions to match the counselor’s. It can be assumed that the client’s behavior is an attempt to avoid talking about a difficult topic. In behavior therapy, you would not want to allow the avoidance to occur; however, this might be related to a trauma response because it is about a physical abuse allegation. Therefore, you should strive to be understanding and sensitive about possible trauma. Therefore, the correct answer is (A)
Competency: counseling skills and interventions