Case Study
Patient Demographic: Client Age: 9 Sex: Male Gender: Male Sexuality: Unknown Ethnicity: Caucasian Relationship Status: Not Applicable Counseling Setting: School Type of Counseling: Individual Presenting Problem: Severe Temper Outbursts Diagnosis: Disruptive Mood Dysregulation Disorder (DMDD), Provisional (F34.81)
Mental Status Exam: Mental Status Exam: The client’s affect is irritable and angry. He sits with his arms crossed and exhibits poor eye contact. His appearance is somewhat disheveled. Mother reprimands the client multiple times, requesting that he “sit up straight” and “answer the lady’s questions.” The client mumbles responses at his mother’s prompting and is otherwise minimally engaged. The client reports that he “gets mad” daily and feels unjustly “blamed for everything.” His motor activity is somewhat fidgety. Speech and language skills are developmentally appropriate. The client states he “sometimes” feels sad and denies feeling worried or scared. His appetite is good and his sleep is poor. The mother attributes his sleep difficulties to the client staying up late playing video games.
Presenting Problem: You are a school-based mental health clinical counselor conducting an initial intake evaluation. A 9-year-old 3rd-grade male is accompanied by his mother, who reports that the client has been in several school and neighborhood altercations. She states she is at her “wit’s end” with him and is about to lose her job due to constant calls from his school. The client’s teacher reports that the client has daily temper outbursts, and his mother says that his mood is irritable for most of the day, every day. The client was recently suspended from school for flipping over his desk when his teacher told him he lost recess privileges. The mother first noticed these behaviors when her son was in kindergarten. The client recently kicked a hole in his wall after losing a video game. His grades are poor, and the school is currently evaluating him for special education services. The client was reluctant to take part in the intake. He shrugged his shoulders when asked if he would agree to participate in counseling.
Other Contexts: You have attempted to arrange a family session with the mother, but she is unable to take off work to attend. The client arrives for his second session eager to share that he is “on green” this morning, which means the client’s behavior for the day has been good. You praise him for staying in his seat and keeping his hands and feet to himself. The client responds well to your praise. When engaging in a feelings identification activity, the client identifies feeling unhappy and worried when his father doesn’t show up for scheduled visitation. The client explains that his parents frequently argue about “how to take care of me” and “sometimes push each other.” He quickly abandons the feelings activity and asks if he can go back to class. You deny the client’s request to leave and instead give him the option of selecting another activity. The client refuses to do so and begins to kick your file cabinet repeatedly. He proceeds to knock papers off your desk. When redirected, the client’s behavior escalates. He quickly becomes inconsolable as he cries and yells, “I hate counseling, this school, and everyone in it!”  During the feelings identification activity, you respond to your client’s disclosure by stating, “You’re feeling sad and miss your dad. And on top of worrying about him, it sounds like you feel responsible for some of your parents’ grown-up problems

Question: During the feelings identification activity, you respond to your client’s disclosure by stating, “You’re feeling sad and miss your dad. And on top of worrying about him, it sounds like you feel responsible for some of your parents’ grown-up problems. Am I getting this right?” This is an example of a(n):
(A): Additive encourager
(B): Advanced paraphrase
(C): Clarification
(D): Complex reflection

Correct Answer: Complex reflection
Explanation: Complex reflections go beyond simple reflections and paraphrasing by addressing the client’s underlying or implicit thoughts, feelings, and experiences. In this response, you validate the client’s feelings (sad and worried), allude to additional feelings of being overwhelmed (and on top of worrying), and attempt to counter any personal responsibility for “grown-up problems” Since the client is still in the early stages of therapy, it is often helpful to ask if your interpretation is correct. (“Am I getting this right?”) This response helps subtly shift the power dynamic from that of an authoritative adult to one who understands the child and the world around them. An encourager or lead is a prompt used to help the client continue expressing themselves. Encouragers can be both verbal (“Please, go on”) or non-verbal (head nodding) and are used to convey interest in what the client is expressing. Additive empathy is a core counseling attribute (rather than an additive encourager). Clarification is used when the client’s statement is vague or confusing. (Client: “I’m just done” Therapist: “Can you tell me what it means for you to be done?”) Paraphrasing selectively focuses on the client’s intended message or meaning. Paraphrases are different from reflections in that paraphrases solely concentrate on the content of the client’s statement. Paraphrases do not involve reflecting the client’s feelings. Therefore, the correct answer is (A)
Competency: counseling skills and interventions