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: You meet with the client 2 weeks after the initial intake because she refused to come for the session scheduled the past week. Because of the cancellation, you decide to change the focus of your session to meet the client’s needs for comfort and security over the foster parents’ need for guidance and skills. The client engages a little more in interacting with you, and you praise her for her involvement. At one point in the session, the client hits you and goes and sits down to continue playing. At the end of the session, you provide the foster parents with ways that they can increase attachment and positive interactions with your client. You empathize with the foster parents regarding their desire to help the client feel loved and cared for

Question: From a behavioral therapy perspective, which of the following interventions would demonstrate conflict tolerance in a manner that would meet the client’s needs when she hits you?
(A): You minimize your reaction and prompt the client to communicate her wants or needs.
(B): You redirect the client to another activity in order to support her with managing her strong emotions.
(C): You disengage from the client and provide no response so as to not reinforce the behavior.
(D): You engage the client in cognitive reframing to manage her strong emotions.

Correct Answer: You minimize your reaction and prompt the client to communicate her wants or needs.
Explanation: From a behavioral perspective, the function of the behavior would be to escape. In order to address this, you want to avoid reinforcing the behavior by providing a response, and you also want to prevent escape by encouraging her to communicate what she needs or wants. Encouragement to engage in cognitive reframing would not be developmentally appropriate because the client may not be able to use this skill and it is not a behavioral intervention. Choosing to disengage from the client and to not respond would not address the function of the behavior because when the function is “escape,” you would be allowing the client to escape by disengaging and would reinforce the behavior. It may be helpful to redirect the client to calm down; however, this would not address the function of the behavior. Therefore, the correct answer is (B)
Competency: counseling skills and interventions