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!”  You arrive at school one morning and find the child’s father in the main office. He is requesting to talk to you about his son

Question: You arrive at school one morning and find the child’s father in the main office. He is requesting to talk to you about his son. What is the best way for you to proceed?
(A): Tell the father that you can listen to his concerns but cannot disclose any information.
(B): Explain to the father that you can only see him if the client’s mother provides written consent.
(C): State that you cannot disclose whether or not the child is your client and cannot meet with him.
(D): Tell the father you only work by appointment and arrange to see him the following week.

Correct Answer: Tell the father you only work by appointment and arrange to see him the following week.
Explanation: You can arrange to meet with the father by appointment, which would not breach confidentiality as he is the client’s biological father. Since this client’s mother has physical custody, the father also has the right to participate in counseling when clinically appropriate. When determining applicable legal and ethical guidelines regarding confidentiality, it is essential for you to first differentiate between legal custody and physical custody. Parents with legal custody can make unilateral decisions regarding their child’s treatment. In cases where the courts have established legal custody, you must obtain a copy of the court order before initiating counseling services. With physical custody, the issue of consent is irrelevant. That is, both parents can make treatment decisions on behalf of their child, and both parents have the right to request their child’s mental health records. By making an appointment with the father, you establish professional boundaries and allow yourself time to seek supervision and consultation for this complex ethical matter. Although state laws vary, if there is a court order (ie, an emergency protective order (EPO) or a domestic violence order (DVO) against the father, then he would be violating this order simply by being at the child’s school. If you believe the father poses an imminent risk to the child at any point in therapy, you are mandated to make child protective services (CPS) report. You may also refuse to see the father if you feel that your safety is compromised or believe your contact with the father is detrimental to the client’s treatment. In these complex cases, you must follow an ethical decision-making model and seek supervision and consultation to determine the best course of action. Therefore, the correct answer is (C)
Competency: professional practice and ethics