Case Study
Patient Demographic: Name: Andie Clinical Issues: Gender identity development Diagnostic Category: Gender Dysphoria Provisional Diagnosis: F64.1 Gender Dysphoria Age: 12 Sex Assigned at Birth: Male Gender and Sexual Orientation: Female, Questioning Ethnicity: Caucasian Marital Status: Never married Modality: Individual Therapy Location of Therapy : Agency  
Mental Status Exam: The client is quiet in the session and clingy toward his mother. His head is bent down, and he refuses to make any eye contact. When an attempt is made to engage the client in conversation, he responds with short statements such as, "I guess; I don't know."
Presenting Problem: First session You are a mental health therapist for an agency where two parents and their 12-year-old child named Andie present for their first counseling session with you. The father looks irritated, and the mother seems depressed. She expresses that they have been concerned for some years regarding their son's confusion around his gender identity. They feel he is too young to make any decisions that will affect the rest of his life. The father speaks up, saying, "He's getting all of this nonsense from school just to fit in, and it needs to stop." The mother expresses that Andie always likes to dress up in his sister's clothes and believes that one day he will become a girl. Andie appears anxious and is afraid of the father as evidenced by his withdrawing behavior. You discuss your role as therapist and tell Andie that your job is to help make people feel better. You also provide the parents with your initial observations and make a recommendation to start therapy with weekly appointments.
Other Contexts: The client has three sisters, loves his mother but has difficulties with his father. His parents differ in child-rearing styles. The client is the youngest and has three older sisters and wishes that he had been born a girl. He acts out at home when he feels that he's not being "understood" by his parents. He withdraws from his family quite often (will not leave his room) and usually has "screaming matches" with his father in regard to his expression of his preferred gender. The client does not get along with the other boys in his class but relates to the girls without difficulty. Before the initial interview with the client, his father related that he is concerned about his son's long-standing "girlish ways." His son avoids contact sports but has expressed an interest in ballet. 

Question: What is the most appropriate response when the client expresses that he does not want to go to school anymore due to the bullying from other boys?
(A): “I understand it’s frustrating when you hear those hurtful words from those boys. I am sorry you are going through that. Those boys should not be allowed to act in such a negative manner. Give me the names of the boys bullying you, and I will report them.”
(B): "I understand it’s frustrating when you hear those hurtful words from those boys. I am sorry you are going through that. Perhaps changing schools is an option we can explore with your parents. I'm sure they would not want you to be in such hurtful situations. How would you feel about transferring to a different school?"
(C): “I understand it’s frustrating when you hear those hurtful words from those boys. I am sorry you are going through that. Even though we want others to understand, sometimes they take a little longer to get there. What is something about school that you look forward to?”
(D): “I understand it’s frustrating when you hear those hurtful words from those boys. I am sorry you are going through that. It could be that they don't understand how hurtful they are being. Maybe you should tell them how you feel and tell them to stop.”

Correct Answer: “I understand it’s frustrating when you hear those hurtful words from those boys. I am sorry you are going through that. Even though we want others to understand, sometimes they take a little longer to get there. What is something about school that you look forward to?”
Explanation: This response demonstrates empathy for what he is going through but also reframes school into a positive experience. It gives him a chance to look at the benefits of school. This statement then further explores current coping skills and what the client perceives as a positive experience. Therefore, the correct answer is (C)
Competency: counseling skills and interventions