Case Study
Patient Demographic: Name: Andie Clinical Issues: Gender identity development Diagnostic Category: Gender Dysphoria Provisional Diagnosis: F64.1 Gender Dysphoria Age: 12 Sex Assigned at Birth: Male Gender and Sexual Orientation: Female, Questioning Ethnicity: Caucasian Marital Status: Never married Modality: Individual Therapy Location of Therapy : Agency  
Mental Status Exam: The client is quiet in the session and clingy toward his mother. His head is bent down, and he refuses to make any eye contact. When an attempt is made to engage the client in conversation, he responds with short statements such as, "I guess; I don't know."
Presenting Problem: First session You are a mental health therapist for an agency where two parents and their 12-year-old child named Andie present for their first counseling session with you. The father looks irritated, and the mother seems depressed. She expresses that they have been concerned for some years regarding their son's confusion around his gender identity. They feel he is too young to make any decisions that will affect the rest of his life. The father speaks up, saying, "He's getting all of this nonsense from school just to fit in, and it needs to stop." The mother expresses that Andie always likes to dress up in his sister's clothes and believes that one day he will become a girl. Andie appears anxious and is afraid of the father as evidenced by his withdrawing behavior. You discuss your role as therapist and tell Andie that your job is to help make people feel better. You also provide the parents with your initial observations and make a recommendation to start therapy with weekly appointments.  Fourth session During the previous two sessions, you focused on making Andie feel comfortable and spent time learning about his interests and strengths. You have established a strong rapport with Andie. Today, he is quiet and reluctant to speak. He tells you about his family and that his dad is always yelling at him and calling him a "sissy boy." He states feeling sad and does not understand why his dad will not love him if he wants to be a girl. he also states that he feels confused by his mother's seeming acceptance of him, but her unwillingness or inability to "be on his side" when his father berates him.  He admits that he feels happy when he thinks of himself as a girl, especially when he is free to express himself in that way. He said all the boys at school are mean to him and call him names. he feels most at ease with the girls in his class, or with the teacher. You work with the client on how to express his thoughts and feelings appropriately to his father rather than holding them in.
Other Contexts: The client has three sisters, loves his mother but has difficulties with his father. His parents differ in child-rearing styles. The client is the youngest and has three older sisters and wishes that he had been born a girl. He acts out at home when he feels that he's not being "understood" by his parents. He withdraws from his family quite often (will not leave his room) and usually has "screaming matches" with his father in regard to his expression of his preferred gender. The client does not get along with the other boys in his class but relates to the girls without difficulty. Before the initial interview with the client, his father related that he is concerned about his son's long-standing "girlish ways." His son avoids contact sports but has expressed an interest in ballet. 

Question: What intervention would be most beneficial for the parents and client to address his behavior disturbances?
(A): The family is not your client; interventions should be client-specific.
(B): A behavior contract between the clients and the parents paired with the client keeping a self-reflective journal
(C): Setting up a positive reward system in the house for good behavior (an "if/then" chart for the client) and giving a list to the parents of appropriate restrictions for the client
(D): Discuss various disciplinary actions and their effectiveness with the parents, and instruct them on what is going to work best for the client

Correct Answer: A behavior contract between the clients and the parents paired with the client keeping a self-reflective journal
Explanation: These options are age-appropriate and are helpful to the client to engage in self-awareness and self-confidence building. Therefore, the correct answer is (D)
Competency: counseling skills and interventions