Case Study
Patient Demographic: Name: Michael Clinical Issues: Separation from primary care givers Diagnostic Category: Anxiety Disorders Provisional Diagnosis: F93.0 Separation Anxiety Disorder Age: 10 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: Guatemalan American Marital Status: Not Applicable Modality: Family Therapy Location of Therapy : Agency  
Mental Status Exam: Michael appears clean and dressed in appropriate clothing. He often fidgets with his hands and insists on sitting next to his father during the session. Speech volume is low, and pace is fast. He has a slightly flattened affect. He exhibits minimal insight consistent with his age.
Presenting Problem: First session You are a licensed mental health counselor at a pediatric behavioral health center. Michael, a 10-year-old male, presents along with his father. You conduct a thorough psychological exam, including a mental status examination. During the initial interview, you take note of Michael's behavior. He sits very close to his father and looks fearfully around the room. The father tells you Michael has been having trouble at school and home for the past few months and it has been getting worse. When you ask how Michael is doing in school, the father tells you there have been several incidents, including difficulty waking up for school, crying in the morning, and refusal to get dressed and ready. The father also tells you that Michael has been showing signs of frustration with his teachers and classmates. On the home front, the father mentions that his son has become "a nuisance for his babysitter, especially during bedtime." Both parents are paramedics on a 24-on/48-off shift rotation. Michael often calls his parents while at work, complaining that he feels sick and cannot fall asleep. He worries that someone might break into the house or that "something bad will happen" to his parents. The father reports that he and his wife have tried to reassure Michael, but their efforts have been unsuccessful. They are perplexed as to what is causing Michael's distress. The father tells you that Michael has always been a bright and energetic child, but now he seems overwhelmed and anxious.    You conduct a more detailed interview with Michael alone, focusing on his current environment and daily routines. You ask him how he feels about school, and Michael denies having any issues. He tells you that he does not want to go because his new school is "boring." However, when you probe further, he admits to feeling scared and alone. He does not want to be away from his parents, and he imagines "all the ways they could be hurt" while they are not with him. You say, "I can understand why you might be feeling scared and anxious, Michael. It sounds like a lot has been going on recently. I'm here to help you and your parents understand what's causing your worries so you can start to feel better."    You reconvene with Michael's father and provide a brief summary of your findings. You explain that you suspect Michael's anxiety is likely due to the family's recent relocation and having to adjust to a new school. His fears are also likely rooted in his parents' profession, which may lead him to worry about their safety while they are away from home. You have personal experience in dealing with pediatric anxiety and consider briefly sharing your story with Michael and his parents as you believe it may help them to feel supported and less alone in their struggles, while also providing a practical example of how to work through difficult times. You suggest developing an intervention plan to address Michael's distress and recommend meeting with Michael and his parents for weekly sessions.  Fourth session When you arrive at your office today, you realize that you inadvertently left therapy notes on your desk after work on Friday, which included information about Michael's case, and the notes are not where you left them. The weekend cleaning crew lets you know that the notes were discarded in the trash. You take the appropriate action in managing this breach of confidentiality, following your practice's guidelines and policies. You also take time to reflect on how this incident could have been prevented and use it as a learning opportunity for yourself.    When you met with Michael and his parents during the previous two sessions, you gathered additional information about his symptoms, thoughts, and feelings. You provided psychoeducation about separation anxiety and recommended that Michael's parents make an appointment for him to see his pediatrician. You also began to formulate a treatment plan with the overall goal of tolerating separation from his parents without severe distress.    Michael and his parents present for today's session on time. The parents begin by reporting that their son's symptoms continue to be a problem. School refusal is still an issue. His mother has had to come home from work three times this past week. His outbursts were so loud that the neighbors came by to check on him. The mother says, "My boss has been patient with me so far, but pretty soon, I'm going to be at risk of losing my job if we can't get a handle on our son's behavior. What are we doing wrong?" Your focus during this session is on helping the parents understand their role in the therapy process. You start by reviewing some of the psychoeducation you provided in prior sessions, focusing on the importance of consistency in parenting approaches and providing structure for Michael at home. You discuss different strategies they can use at home to help build their son's coping skills. You also provide some relaxation exercises that Michael can do when he feels anxious.    At the end of the session, you thank Michael and his parents for coming in today and assure them that they are on the right track. You take time to summarize the key points of the session and emphasize the importance of follow-through with what was discussed in order for progress to be made. You provide them with resources to further support their efforts and suggest a follow-up appointment in one week.  Tenth session You have been working with Michael to develop and practice effective coping skills appropriate to his age. You have been using behavioral modification techniques to decrease his anxiety about being away from his parents. During previous sessions, you suggested that his parents leave your office space for progressively more extended periods. Michael has complied with these requests, although he was initially anxious and agitated. After five weeks, he is now able to tolerate being away from his parents for up to an hour. In today's session, the parents reflect on their son's progress since he started therapy. They believe that he has made a significant improvement. To date, there have only been "little incidents." The parents report that two days ago, Michael was reluctant to go to bed without them and had a minor fit. Instead of escalating the situation, they calmly reminded him of the strategies he had learned in therapy such as taking deep breaths when feeling anxious. To their surprise, Michael began using his coping skills and went to bed peacefully. Michael's mother tells you, "It finally feels like we've turned a corner. I'm so proud of him!" The parents have also received positive updates from Michael's teachers who say that he is doing much better in school. They report that he has made a new friend and was invited to a sleepover. Michael seems excited about the idea. His parents are not sure how he will handle being away from home overnight, but they are willing to try.    After providing you with an update, the parents leave the room to wait in the waiting room while you talk to Michael. He appears receptive and comfortable with this arrangement. He tells you, "I kind of feel dumb for being scared. I'm sorry for causing so much trouble." You respond affirmatively and validate his feelings. Next, you say, "I remember when you first came to my office with your mom and dad. You were having a lot of trouble being away from them. Do you think that's still a problem for you?" He shakes his head "No" and reports that he is now able to be away from his parents for longer periods of time without feeling scared or upset. You ask him what has been most helpful to him when he starts to feel anxious. He says, "The counting and breathing stuff you showed me how to do. Also, I think about something fun that I did with my mom and dad, like that time we went to the beach and built a giant sandcastle!" You tell him how proud you are of his progress and encourage him to keep using the coping strategies he has learned in therapy.    Near the end of the session, you invite Michael's parents back into your office to check in with them about next steps. The parents agree that Michael has made significant progress in tolerating separation and they feel that the treatment has been successful. You offer additional resources for follow-up care and suggest a plan for transitioning out of therapy. Lastly, you thank Michael and his parents for their dedication throughout the course of therapy and let them know that you are available if they have any further questions or concerns.
Other Contexts: Michael's parents have been married for nine years and both are dedicated to the well-being of their children. The father reports that he and his wife communicate openly with each other and make joint decisions about parenting issues. They also model healthy family dynamics, such as expressing affection and respect towards one another, being honest with one another, and sharing responsibilities. Michael has a five-year-old sister. His father characterizes the family as very close; they do everything together. The father says that he and his wife go to their children's sporting events and school meetings. Every weekend, the four of them are together doing family activities. Except when required to be away due to their work schedules as paramedics, the parents are home with the children at night. Prior to the family's move to a new state 6 months ago, Michael had been a successful student at school, typically performing at or above grade level. He was an active participant in the classroom, often volunteering to answer questions or participate in class discussions. Since the move, however, getting ready for school has been a struggle each day. He is struggling academically; while his grades haven't dropped drastically, he appears to be having trouble focusing and understanding the material. His parents have attended parent-teacher conferences and Michael's teachers have also reported that he seems distracted and uninterested in class. His parents also report that they are having difficulty getting him to stay on task when doing his homework at home. 

Question: When the client says, "I kind of feel dumb for being scared. I'm sorry for causing so much trouble." as a response to recognizing the efficacy of therapy, what response would be most appropriate?
(A): Reframe the client's statement into a positive affirmation of his recognition of growth.
(B): "You've been working really hard in therapy, and you should be proud of how far you've come."
(C): "It's understandable to feel scared in new or unfamiliar situations. It takes a lot of courage to face your fears and overcome them."
(D): "Don't be too hard on yourself. Everyone feels scared sometimes and you don't need to feel ashamed about that."

Correct Answer: "It's understandable to feel scared in new or unfamiliar situations. It takes a lot of courage to face your fears and overcome them."
Explanation: This response validates the client's feelings and recognizes his effort in overcoming his anxiety. It acknowledges that feeling scared is normal, and applauds the client for his bravery in tackling the challenge. This type of statement also helps to foster a positive therapeutic relationship by providing a nonjudgmental, affirming message. Therefore, the correct answer is (C)
Competency: core counseling attributes