Case Study
Patient Demographic: Name: Gary Clinical Issues: Behavioral problems Diagnostic Category: Disruptive/Impulse-Control/Conduct Disorders Provisional Diagnosis: F91.3 Oppositional Defiant Disorder Age: 10 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: White Marital Status: Not Assessed Modality: Individual Therapy Location of Therapy : Agency  
Mental Status Exam: The client reluctantly enters the session accompanied by his mother. He is slightly overweight for his age and is wearing clothes that appear too small for his physique. He is sitting in the chair with his arms crossed, refusing to make eye contact with you. His mood is angry, and his affect is irritable. His attitude during the initial part of the examination is defiant. Speech characterized by short responses and refusal to engage in conversation. Client refuses to discuss feelings or issues. He appears to have difficulty focusing. He lacks insight into his behavior and impact on others. Judgment and impulse control are poor. He denies suicidal or homicidal ideation.
Presenting Problem: First session You are a mental health therapist in an agency, and a 10-year-old male is referred to you due to behavioral issues. The client and his mother arrive at your office, and you note that he has an irritable look on his face. The two are arguing with each other. His mother threatens him with punishment if he does not cooperate with you and says that this is his "last chance". He glares at her and then stares at the floor. You introduce yourself and explain what you do as a therapist. The client barely says a word and keeps his head down with his arms crossed over his chest. You ask the mother to describe the issues that prompted her to seek help and she begins to tell you the story.    She explains that her son has difficulty listening to adults and gets into verbal altercations with his peers. She informs you that he got suspended again from school because he lost his temper in the cafeteria when the student in front of him in the lunch line "wasn't moving fast enough". When you ask about how often his temper outbursts occur, the mother pauses for a moment to think and says, "It seems like he's always losing it, but I guess maybe a few times a month? The rest of the time, he's just angry, mostly at me and other adults. No matter what I do, he seems like he hates me." As she tells you this, you notice that the client is not paying attention and continues to look down at the floor, appearing disinterested in the conversation. His mother goes on to say that the school is threatening expulsion if her son's behavior does not improve.    After thanking the mother for sharing this information with you, you look toward the client who has been sitting quietly the entire time. You explain that you understand it must be hard for him to be here and that you are not here to judge or criticize him. He looks up at you with a surprised expression on his face. He slowly nods and mumbles something under his breath. You let him know that you want to help him find ways to better manage his emotions so he can get along better with the people in his life. He looks away again, but this time there is a hint of curiosity in his eyes. You sit in silence for a moment. The client finally looks up at you and says, "It's just...everyone's always telling me what to do and they never listen to me. They think they know everything, but they don't. I can't help it if I get angry, but then everyone looks at me like I'm a monster. It's not fair." His mother looks away, tears in her eyes. You thank the client for expressing his feelings and explain that it is normal to feel upset when things are unfair. You further emphasize that you are here to help him find positive ways to handle his anger and other emotions. You then address the mother, "Parenting can be challenging, especially when it feels like your child is angry or upset with you. I'd like to work with both of you to improve your communication and relationship. It might be helpful to schedule separate sessions for you and your son, as well as joint sessions, so we can address individual concerns and work on improving your relationship together." The mother agrees, and you proceed to discuss a plan of action, including setting up regular weekly therapy appointments and providing resources to help support the family.  Fifth session It has been over one month since you first began working with the client. You've been meeting with him for individual therapy and have implemented parent training with his mother. During previous counseling sessions, you focused on building rapport with the client and talked about different triggers for his outbursts. He said that he often gets angry when people do not listen to him or when they try to tell him what to do. You also discussed strategies for managing these triggers and the importance of communicating his needs in a respectful way. Last week, as part of your parent management training approach, you assigned the mother homework to read from a parent training handbook.    When the client arrives for today's session, he is clearly upset, saying that he does not want to be here. His facial expression is one of anger and frustration. His mother is exasperated and apologetic. You calmly remind her that it is all right, that this is a normal part of the process. You ask if she would like to accompany them into your office, but she declines, saying that she needs some time to herself and she would like to wait in the waiting room for the first half of her son's session. Once inside your office, you start by asking the client why he does not want to be here. He says that he is tired of talking about his problems and he does not think it will make any difference. When you ask him to tell you more, he glares at you and says, "Why do you care? You're only asking because you want to get paid." You acknowledge how difficult it can be to keep coming back, but emphasize that whatever feelings he is having in this moment are valid and important. The client then looks away and sighs. He slowly says, "I don't know why I have to keep coming here...it feels like no matter what I do, nothing changes. I still get mad, my mom and teachers still get mad at me, and the school still threatens to kick me out."    After a few moments of silence, you ask the client if he remembers what goals were set for the session today. He looks away and mumbles something under his breath. You gently remind him that you want to help him learn how to manage his emotions in a healthier way so he can get along better with the people in his life. He gradually relaxes and you ask him what strategies he has been using in the past week to work toward this goal. He thinks for a few moments before recounting an incident at school where instead of getting angry, he took a deep breath and walked away from the situation. You use behavioral modification techniques to encourage this positive behavior. You then move into today's activity, which is a role-play exercise. Once you have completed your planned tasks with the client, you invite his mother in to your office to provide her with feedback on her son's progress and discuss next steps with parent training.  Eighth session The client and his mother arrive for today's session. You begin by meeting with the client alone and plan to speak with his mother afterwards. You ask the client how he has been doing since last week. He is quiet and shrugs his shoulders. You take a moment to notice his non-verbal cues and then gently ask him, "It looks like something is on your mind. Do you want to tell me about it?" He hesitates for a moment and then says, "I don't know. My mom told me that I have to stop playing video games so much. She said it's getting in the way of my homework. But I don't have any friends and video games are the only thing that makes me feel better. It's not fair. My mom gets to do whatever she wants." You listen attentively and validate his feelings. You explain to him that it is important to have a balance between recreational activities and taking care of responsibilities, like doing your homework. You say, "Your mom has a job, right? Sometimes she has to take care of things like going to work or paying bills, and it's the same when we have responsibilities at school. It takes time and effort, but if we do it, then it can free up some time for fun activities like playing video games." He shrugs and says, "Yeah, I guess."    You continue the session by discussing his behavior in school and ask him if he can think of any positive experiences he has had since the last session. He thinks for a moment, then starts to shout excitedly, "Yes! There was something!" You intervene by giving him a choice of writing down his feelings or starting over with a quieter tone. He stops, takes two breaths, then proceeds to tell you about his experience in the school playground, where he managed to stay calm when he was provoked by a classmate. He said that his teacher was watching and praised him for staying calm. She gave him a sticker and told him that he could choose the game they would play at recess. You congratulate him on his success and praise him for his efforts.    After you conclude the session with him, you invite his mother to your office and direct the client to wait in your waiting room. You talk to his mother to determine how her home parent training is going and review the client's treatment plan with her. His mother states that when she tried to set boundaries on gaming time, he had a "melt down". You suggest that she could consider increasing the amount of time he can play his video games in increments if he meets certain goals, such as completing all of his homework or cleaning up his room. She agrees to try this during the upcoming week. She also mentions that her son continues to struggle socially. When she told him that he could invite a friend over for pizza, he said, "What friend? Making friends is dumb. Who needs them anyway?"    Following the session, you receive a phone call from the client's father who states that he has recently reconnected with his family. He says, "My wife told me that you've been working with my son. I know he's got some issues. I'm trying to get back in his life and make things right. What should I do?"
Other Contexts: The client's father left the family two years ago. The mother, still married to him, retains sole legal custody of the client. Since his father left, the client will not help out around the house, seems angry, and sometimes loses his temper when he does not get his way. The client receives frequent but inconsistent corporal punishment from his mother. His mother made the appointment with you but did not tell him where they were going. The relationship between the client and his mother has been strained as the mother does not know how to handle the abandonment of the father. The client is in fifth grade and has been skipping school for the last six months and refuses to do any homework. His school records were released to you and show A's and B's through third grade, but C's and D's during the past two years. His decline in grades coincides with his truancy. He is also known as a "bully" at school and has been suspended and given detention a few times due to his behavior. He has a history of walking out of classrooms, running down the hallways, refusing to sit in his chair, and running away from the school counselor or anyone in an authoritative position. Personal/Social Relationships: The client does not have friends his age in the neighborhood, and parents do not want their children playing with him because they believe he is a "troublemaker". In addition, children in school avoid him because they are afraid of upsetting him. He does not seem interested in making friends and does not care to engage in any play time with the neighborhood children. Instead, he spends most of his time alone playing video games. 

Question: What defense mechanism is the client exhibiting when he talks to his mother about making friends?
(A): Reaction formation
(B): Denial
(C): Rationalization
(D): Projection

Correct Answer: Denial
Explanation: By denying his feelings about how it makes him feel, he acts as if he does not care. Clients who engage in denial believe that expressing genuine emotion would make them vulnerable, so they mask their true feelings with an "I don’t care" façade. Therefore, the correct answer is (B)
Competency: intake, assessment, and diagnosis