Case Study
Patient Demographic:  Initial Intake: Age: 14 Gender: Male Sexual Orientation: Heterosexual Race/Ethnicity: Hispanic - Mexican American Relationship Status: Single Counseling Setting: School-based Type of Counseling: Individual
Mental Status Exam: Raul presents as irritable and anxious, with congruent mood and affect. Raul is casually dressed, appears to be overweight for his age and height, and is sweating with nervous hand motions. Raul has difficulty making eye contact, takes long pauses prior to answering questions, and often asks you to repeat the question after a long pause. Raul denies SI/HI or hallucination/delusion. He refers to an incident in his past he considers to be “trauma” but is uncomfortable discussing with you. When asked about his father, he sheds a tear which he immediately wipes away and returns to a scowl on his face with arms crossed, saying “there’s nothing to talk about.” Raul does admit to several instances of aggression with others such as “shoving a kid,” “kicking a desk” and “cursing out the principal.” You ask if he has ever been on medication for ADHD. He says, “No, I don’t think so. My doctor told my mom a few times to fill out some forms, but I don’t think she ever did.”
Presenting Problem: Diagnosis: Attention-deficit hyperactivity disorder, predominantly inattentive type (F90.0), Conduct disorder, unspecified (F91.9)
 

You are a counseling intern working for an agency that sends counselors into grade schools to work with their students on longer-term mental health issues. Raul is referred to you by his assistant principal for multiple in classroom infractions of interrupting, bullying, and being a “class clown.” In meeting with Raul and his mother, she shares that the principal accused Raul of bullying kids on the bus, and defacing property. She says, “Kids will be kids, they’re probably just too sensitive.” Raul’s mother works full-time and has an active social life, leaving Raul to stay at home alone frequently after school or on weekends. His mother appears very casual and does not seem concerned about Raul’s behaviors. She does mention Raul’s diagnosis of ADHD was given by his pediatrician, but he has never received psychiatric services. In front of his mother, Raul is quiet and acts well-behaved; after his mother leaves, he tells you he gets frustrated with her for leaving him alone but would never admit it to her directly. He refuses to state that he feels lonely, sharing that he spends most of his alone time playing live video games with other people across the country. He also denies bullying other kids.
Other Contexts: Education History:
Raul’s teachers inform you of his behaviors throughout his freshman year in high school, that have according to them been ongoing since Raul’s middle school years. Raul is often reported for being inappropriate in class by making impulsive remarks to try and get others to laugh, disrupting the class, or falling asleep and appearing distracted. The school is concerned with his academic progress and has discussed moving his status up a higher-level Tier so he can be monitored further and made available to special programming geared towards students in jeopardy of failing.
 
Family History:
Raul lives with his mother and occasionally one of his mother’s boyfriends who come and go intermittently. Raul has one older sister who lives in the next town. Raul’s father lives in Mexico with several of his half and step siblings with whom Raul has minimal contact. Raul’s father is unable to enter the U.S. and has been absent most of Raul’s life. Raul reports his father is an alcoholic, but that where he lives, they “don’t think of things like that” because that is what his father told him. Raul’s grandmother also lives in Mexico but has been a continual presence in his life via phone calls, mail, and is his primary caretaker when he does visit Mexico, which has occurred twice.

Question: After several more sessions with Raul over three months, you conclude he is intrinsically unmotivated for counseling and has no interest in applying taught skills or achieving stated objectives. He is continually resistant and demonstrates no insight into his behaviors. How should you proceed?
(A): Move up to twice weekly sessions.
(B): Proceed with discharge.
(C): Discuss alternate options with Raul and mom.
(D): Discuss alternate options with mom and school.

Correct Answer: Discuss alternate options with Raul and mom.
Explanation: When coming to a place with a client where they are not showing evidence of improvement, it is best to have a conversation centered around what is best for them moving forward. In this case, speaking with Raul and his mother are the only individuals necessary for this conversation. Discharging right away is not the best choice therapeutically for Raul unless this becomes both of their decision after a thorough discussion of the consequences of termination. Increasing frequency of sessions will not necessarily improve client motivation. Working to resolve meeting their needs in a variety of ways, or discussing referrals and community resources that might be helpful for them, is the best choice. Therefore, the correct answer is (C)
Competency: treatment planning