Case Study
Patient Demographic: Client Age: 13 Sex Assigned at Birth: Male Gender: Transgender; Gender Nonconforming (TGNC) Ethnicity: Caucasian Counseling Setting: Child and Family Agency, School-Based Services Type of Counseling: Individual and Family Presenting Problem: Truancy; Gender Dysphoria Diagnosis: Gender Dysphoria, Provisional (F64.1); Social Exclusion or Rejection V62.4 (Z60.4)
Mental Status Exam: Mental Status Exam: The client is dressed in age-appropriate clothing. They wear eye makeup and chipped black fingernail polish, and they have bitten most fingernails down to the quick. The client’s mood is irritable, and they are quick to show anger toward their mother when misgendered. Their thoughts are coherent, and they deny audio/visual hallucinations. The client acknowledges feeling sad and hopeless but denies suicidal ideation. They attribute increased levels of anxiety at school to bullying, particularly with select peers. They explain that a select group of students threaten the client and call them offensive and derogatory names. Family History and History of th
Presenting Problem: You are a school-based mental health counselor in a public middle school. Your client is a 13-year-old Caucasian 7th grader who presents for the initial intake with their mother. The mother says that the client has had several unexcused absences from school because “he is confused about his gender.” The client adamantly denies being confused and explains that they self-identify as transgender. The client’s preferred pronouns are “they/them.” The client further states that they have had a strong desire to be a different gender since early childhood, and this desire and their distress have recently intensified. The mother reports that the client is chronically irritable, spends a lot of time alone, and has “basically shut everyone out.”The client reports experiencingbullying—both verbal and physical—in school “nearly every day.” In addition to the bullying, the client says that certain teachers refuse to allow them to use the bathroom aligned with their identified gender. To prevent this conflict, the client does not eat breakfast or lunch at school.
Other Contexts: The couple acknowledge some improvement with communication, but they continue to feel significant levels of relationship distress. The client has been asking for what she needs, mainly when she is in pain and functionally limited, but she reports that the husband continues to do little to support her. The husband reiterates that he has a demanding job that depletes his energy and that he has little to give when he gets home at night. The husband’s child has been verbally abusive to the client, and her husband minimizes her concern. The client feels “stuck in the middle” when determining her stepson’s schedule and activities. The client states that her husband’s bitter ex-wife makes her new role as stepparent “nearly impossible.” To help with the postdivorce adjustment and lessen conflict, you provide information on local support groups, parent education programs through family court, and additional educational resources

Question: The client states, “His ex-wife makes coparenting nearly impossible, and he continues to do absolutely nothing about it!” You state, “Can you turn to him and tell him what that is like for you?” What are you trying to accomplish with your request?
(A): Increase change talk by reducing ambivalence.
(B): Assess for transference and countertransference.
(C): Help him “mirror” back the emotional content.
(D): Create new experiences of emotional attachment.

Correct Answer: Create new experiences of emotional attachment.
Explanation: You are hoping to create new experiences of emotional attachment. Emotionally focused couples therapy uses enactments to counterbalance negative interactions, uncover underlying vulnerabilities, and develop emotional attunement. Enactments increase awareness of emotional attachment by encouraging couples to engage with one another directly. Counselors using emotionally focused couples therapy enactments first work to identify the couple’s negative patterns of interaction. Counselors then help couples safely address vulnerabilities to create secure bonds with one another. Creating change talk by reducing ambivalence is a motivational interviewing technique. Although it is helpful to assess readiness for change with the couple, this is not accomplished by using enactments. Transference and countertransference are not present in this interaction. The technique of mirroring is used in imago couples therapy. Therapists use mirroring to encourage the message receiver to paraphrase or mirror back exactly what was conveyed by the message sender. Therefore, the correct answer is (A)
Competency: counseling skills and interventions