Case Study
Patient Demographic: Name: Logan Clinical Issues: Bullying Diagnostic Category: V-codes Provisional Diagnosis: Z60.4 Social Exclusion or Rejection Age: 11 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: Asian American Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : School  
Mental Status Exam: The client is wearing clean clothes appropriate to his age. Initially hesitant and withdrawn, he becomes more relaxed and responsive as the interview progresses. He is soft-spoken but articulates clearly. Mood is depressed, anxious, and irritable. Affect is euthymic with occasional sadness. Thought process is logical, goal-directed, and organized. No evidence of any cognitive deficits. Good insight into the impact the bullying has on his emotional well-being and his ability to make appropriate decisions is intact. No suicidal ideation was reported.
Presenting Problem: First session You are a school counselor seeing an 11-year-old male named Logan. He presents to your office with his mother. His mother reports that her son has been struggling in school and has been the target of bullying. She tells you that he recently started at a new school after their neighborhood was re-zoned. The bullying started a few weeks ago when he was sitting alone in class during lunch. A group of boys, whom Logan had never seen before, sat beside him and began teasing him about his clothes, shoes, and hair. When Logan tried to ignore them, they started calling him names. He went home that day feeling embarrassed and alone. Since then, the boys have devised new ways to make fun of Logan. They sneak behind him in the hallways, push him around when the teacher is not looking, and push him into the bathroom.    Logan has been refusing to go to school, saying he has stomach aches. His mother says, "He used to love school. He even loved doing his homework. How many parents are lucky enough to have a child who likes doing homework?" When questioned, Logan says that he now hates school and wants to be home-schooled. He says he is being bullied throughout the day, and it does not stop until he leaves the bus. Logan's mother has been worried about him and wants to know how to stop the bullying. At first, she thought it was just "kids being kids" when they tease each other, but she is now concerned that it has gone too far. She also asks if you can help him to make friends in his new school.    During today's session, you notice that Logan appears anxious and withdrawn. As you gently probe further, Logan shares that he feels overwhelmed by the constant bullying, which has begun to affect his self-esteem. You observe that he appears hesitant to discuss the specifics of his experiences, suggesting that he may fear rejection by you or be embarrassed by what was done to him. This indicates that the situation has caused significant distress and has started to erode his resilience.    As you explore Logan's support network, he hesitantly reveals that he has been unable to make new friends since starting at the new school. The fear of being targeted by bullies has made it challenging for him to approach other students or engage in extracurricular activities. Consequently, Logan feels increasingly isolated and struggles to see a way out of his current situation. This lack of social connection exacerbates his feelings of loneliness and despair. As part of his treatment plan, you include developing and maintaining positive relationships with peers to work on his tendency to isolate himself.    Toward the end of the session, Logan's mother inquires about possible strategies to address the bullying. You acknowledge her concerns and emphasize the importance of a collaborative approach involving the school, family, and community. You suggest initiating communication with Logan's teachers and school administrators to create a safe and supportive environment for him. Additionally, you recommend Logan's mother encourage her son's interests and hobbies outside of school to help him build self-esteem and form new friendships. Meanwhile, you will continue to work with Logan on developing coping strategies and strengthening his emotional resilience in future sessions.  Third session As the session progresses with Logan, you notice that he seems more withdrawn and less willing to participate in your planned activities. You ask him how he has been feeling since your last session and if he has progressed in handling the bullying situation at school. Logan hesitates to answer your questions, looking down and avoiding eye contact. He eventually shares that the bullying has intensified and he feels overwhelmed and helpless. He tells you about the boys in his gym class calling him names and making fun of him. He says they continue to bully him, says he "won't ever go to school again," and "hopes those boys die."    As an REBT practitioner, you emphasize the importance of determining some of his core issues contributing to his distress. You ask him to share some of the thoughts he has had about the bullying and the boys in his gym class. Logan admits that he believes he is "worthless" and "deserves the bullying" because he is not "cool" enough. You help him recognize that his self-worth is not dependent on the opinions of his bullies and that he does not deserve to be mistreated.    You also address Logan's intense emotions and help him understand the relationship between his thoughts, feelings, and actions. You encourage Logan to reflect on the possible consequences of wishing harm upon his bullies and discuss alternative, healthier ways of coping with his feelings. You introduce Logan to relaxation techniques, such as deep breathing exercises and progressive muscle relaxation, which he can use to manage his emotional distress.    In this session, you also explore Logan's social support network to identify potential allies to help him deal with the bullying. You ask him about friends, family members, or other school staff who he trusts and feels comfortable talking to about his experiences. Logan mentions a few friends who he thinks might be willing to help. You discuss ways he can approach these individuals and ask for their support, emphasizing the importance of open communication and honesty.    When he gets ready to leave, you notice a cigarette fall out of his backpack. You ask him about the cigarette, and he admits that one of the boys in his gym class gave it to him. He says the boy said if Logan smoked it, he would be "cool" and finally accepted by them. You explain to Logan that smoking is not an excellent way to fit in and can harm his health. Instead, you encourage him to find other ways to express himself, such as participating in activities he enjoys or joining clubs at school.    Following today's session, you check in with Logan's mother. You also advise her on how she can support her son by having conversations with him about the importance of making good choices and helping him find healthy ways to cope with his feelings.  Ninth session Logan arrives at the session a few minutes late and apologizes. He says that he was outside playing kickball with his class. He reports that he has been feeling better about being in school lately. His classmates are friendlier to him, or at the very least, "they don't bother me so much," He is now eating lunch back in the lunchroom. He is learning to play soccer and plans to ask his parents if he can join the summer league. Next, you call Logan's mother and share his progress in counseling with her. Finally, you examine Logan's care plan and assess for any changes needed.    Logan's progress in counseling has been notable as he has demonstrated increased social engagement and involvement in extracurricular activities. It appears that the therapeutic interventions implemented have successfully addressed his initial concerns regarding social anxiety and peer relationships. In addition, Logan's newfound interest in soccer and desire to join a summer league further demonstrates his willingness to engage with peers and develop new skills.    In conversation with Logan's mother, you emphasize the importance of fostering a supportive home environment to encourage Logan's growth and self-confidence. The mother expresses gratitude for the improvements in her son's well-being and commits to facilitating Logan's involvement in the summer soccer league. Additionally, she agrees to maintain open communication with the counselor to address any potential concerns that may arise in the future.    Upon reviewing Logan's care plan, the counselor determines that the current therapeutic goals and interventions remain appropriate and relevant to Logan's ongoing progress. However, it may be beneficial to introduce supplementary strategies to further enhance his self-esteem and resilience and promote effective communication and problem-solving skills. By doing so, Logan will be better equipped to navigate any challenges that may emerge as he develops and maintains positive relationships with his peers.    After the session, you receive a phone call that your wife has passed away. In the midst of the sudden loss of your beloved wife, you find yourself struggling to maintain your usual level of composure, which is understandable, feeling overwhelmed and emotionally drained during this difficult time. Being a therapist, you recognize the weight of your emotional burden and decide to reach out to your supervisor to discuss your struggles. After a heartfelt conversation, you feel a sense of relief and connection with your supervisor, who has provided you with support and understanding.    As the conversation draws to a close, you make an unexpected request of your supervisor: that she attend your wife's memorial and wake so that she can meet your family and share in the memories of your loved ones. This request may seem a lot to ask, but you feel comforted by the thought of having someone close to you share in this challenging time. You also ask if she can take over your caseload as you deal with your wife's passing.
Other Contexts: The client has a large supportive family. The extended family often gathers together for Sunday dinners. The client says that he has fun playing games with his cousins. The client's mother states that their family is very close, and she and her husband make a concerted effort to prioritize shared time with the extended family.  

Question: What are some preventative skills to consider in helping this client prepare to continue without the support of weekly counseling sessions with you?
(A): Indicate to the client that he can return to therapy if necessary.
(B): Reinforce the importance of family support.
(C): Explore external supports for the client.
(D): Establish and coordinate an effective aftercare plan.

Correct Answer: Establish and coordinate an effective aftercare plan.
Explanation: Participation in Tier 1 preventive interventions include involvement with social-emotional lessons that are used in the classroom, behavioral expectations taught by teachers, counselors coming into the classroom to model strategies for responding to or reporting bullying, and holding classroom meetings among students and teachers to discuss emotionally relevant issues related to bullying or equity. Universal interventions could also include guidelines for the use of digital media, such as youth’s use of social network sites with group support. Therefore, the correct answer is (D)
Competency: treatment planning