Case Study
Patient Demographic: Client Age: 4 Sex: Female Gender: Female Sexuality: Unknown Ethnicity: Caucasian Relationship Status: Not applicable Counseling Setting: Private Practice Clinic Type of Counseling: Family Therapy Presenting Problem: Foster Care; Disengaged Child; Behavioral Problems Diagnosis: Provisional Diagnosis of Reactive Attachment Disorder (F94.1)
Mental Status Exam: Mental Status Exam: The client is disengaged, and when the foster parents prompt her to answer questions, she ignores them and continues playing. The client appears oriented to person, place, time, and situation because she answered questions about these topics. The client appeared more responsive to your questions than her foster par
Presenting Problem: You are a private practice counselor specializing in working with children with developmental disorders. The 4-year-old female client is referred to you by her PCP and arrives with her foster parents, who join her in the first session. The client has been with her foster parents for the last 13 months after being removed from the care of her biological parents due to their incarceration for drug trafficking and attempted armed robbery. The foster parents are worried because the client exhibits minimal positive mood, irritability without an obvious trigger, and behaviors that appear to be clearly connected to attachment with caregivers. She experienced emotional and physical neglect from the birth parents and changes in primary caregivers. The foster parents also report that the client does not seek comfort when something happens that upsets her. The client did not engage very much in the intake session and was instead playing with the toys provided by the counselor. During the session, the client becomes upset with her foster parents when they prompt her to answer some questions. She hits the foster father, runs out to the lobby, and sits down with the toys. You leave the office and meet her in the lobby.
Other Contexts: ents. Family History: The client entered foster care 1 year ago when her parents were arrested on charges of drug trafficking and armed robbery. The client has been with the same foster parents for the past year. The client experienced emotional and physical neglect by her birth parents and was separated from her 5-year-old brother and 2-year-old sister when she entered foster care. He appears to have had trouble with attachment to the foster parents per the foster parents’ report

Question: When the client leaves the room, which of the following is the most important to consider for an effective counseling intervention with your client?
(A): Encouraging the client to return to the office with the foster parents
(B): The manner in which you enter the lobby and approach the client
(C): Discussing the need for safety and refraining from hitting
(D): Confidentiality when leaving the foster parents in your office

Correct Answer: The manner in which you enter the lobby and approach the client
Explanation: When considering effective counseling interventions for this client, you must first identify the underlying purpose of the behavior that must be addressed. In this case, while hitting is not an appropriate behavior, it was the client’s method of communicating a feeling of insecurity. Effective counseling to address the feeling of insecurity must start with creating an environment that is comfortable and secure for the client, which is first communicated through the manner in which you enter the lobby and approach the client. Doing so calmly and without judgment will ensure that you are not there to reprimand, but to support. Only if the client feels secure, would discussing the need for safety and refraining from hitting be received and the possibility of the client returning to the office with her foster parents be realistic. Confidentiality when leaving the office is important (and can be enforced by locking your computer and/or taking your notebook so that neither are available to the parents), but this does not directly address an effective counseling intervention with the client. Therefore, the correct answer is (B)
Competency: counseling skills and interventions