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 The client’s behavior was withdrawn, argumentative, and la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: Since the fourth session, child protective services investigated the client’s abuse allegations and determined that they were unfounded. You discuss this with the client and he says he was lying because he was mad at his parents that day. You praise the client for being forthright today regarding the allegations and discuss how false allegations can be incredibly harmful to others and can strain his relationship with his parents further. You and the client process several situations similar to this in which he avoided responsibility. You empathize with the client and support his reflection on his behavior.  The client is resistant to making changes to his behavior

Question: The client is resistant to making changes to his behavior. Which of the following conversations might you have with the client to encourage more appropriate behavior?
(A): Continue the current course of treatment because you have developed a good rapport and he continues to participate; therefore, he will be ready to make changes when the time is right for him.
(B): Assist him in identifying how he often receives negative consequences. Reiterate that the consequences of his actions do not make him happy, so it is worth trying something different.
(C): Discuss the reward system to see if it can be made more motivating.
(D): Empathize with the client regarding his desires and help him identify that more appropriate behavior can help him get what he wants more so than what he is doing now.

Correct Answer: Empathize with the client regarding his desires and help him identify that more appropriate behavior can help him get what he wants more so than what he is doing now.
Explanation: Empathizing with the client and showing him that you are on his side and want him to live a happy life is likely going to be the most encouraging approach for this client. This also empowers the client to understand that he can play by the rules and get what he wants instead of breaking the rules, not getting what he wants, and suffering consequences. Focusing on the consequences alone does not address that you acknowledge his wants and needs and that you want to support him in meeting these needs. It may be helpful to reexamine the reward system, but the reward system is not a long-term tool and is not focused on the client’s internal motivation. Although the client may continue to improve and eventually agree to make changes with different rewards, this is not a proactive strategy because it does not foster internal motivation. Therefore, the correct answer is (C)
Competency: counseling skills and interventions