Case Study
Patient Demographic: Name: Barry Allen Clinical Issues: Behavioral problems Diagnostic Category: V-codes Provisional Diagnosis: Z62.898 Child Affected by Parental Relationship Distress Age: 13 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: White Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : Agency  
Mental Status Exam: The client is dressed in DC Comic attire and lives for cosplay. He is well groomed and sensitive to his appearance. Eye contact is minimal. His behavior is tense and purposeful. He demonstrates a limited affect and is minimally responsive. The client denies any current suicidal or homicidal ideation.
Presenting Problem: First session The client and his father present at the community counseling center where you practice as a marriage and family therapist. The father reports that his son has not been doing his homework or contributing to family chores. The client's mother is "at her wit's end" and told her ex-husband to get their son help. The school has called several times out of concern for the client's withdrawn behavior. He is not paying attention, is sleeping in class, and appears sad and irritable. You notice that he is disinterested, withdrawn, and does not want to be involved in therapy. The father minimizes his son's behavior and does not want any responsibility related to therapy. At the same time, he wants you to improve his son's attitude.    Through open-ended questions and careful exploration, it is revealed that the client has been having difficulty establishing relationships with peers and adults. He has been feeling overwhelmed by his parents' relationship distress and his mother's new family dynamics. Furthermore, he has been struggling to manage the transition of living in two different homes between his parents. His father reports that his son appears to be increasingly isolated and has difficulty regulating his emotions. The client reveals that he is feeling lonely, depressed, and anxious due to the stress and uncertainty of his parents' relationship issues. He feels as though he is caught in the middle of his parents’ conflict and unable to meet their expectations. It appears that the distress caused by his parents’ relationship is affecting the client's overall wellbeing. You explain to the client and his father that therapy can help him process his feelings, build healthy coping strategies, and develop better communication skills with both of his parents.  Third session During the previous session, you met with the client and his father. You recommended meeting with the client for weekly individual sessions with parental check-ins periodically. Today, you are seeing the client by himself. You use a video game to attempt to engage with the client; he is responsive. While the client is playing the video game, you proceed to gather information. You determine that his major difficulty is his struggle with rule inconsistencies between his parents' homes. He says that his father allows him more freedom than his mother, which results in frequent arguments. When the client is at his father's house, he is allowed to stay up later and watch television for longer periods of time. His mother has stricter rules about bedtime and screen time, which creates tension between the client and his father when he visits his mother's home. The client struggles with navigating these different expectations from both of his parents, leading to feelings of confusion and depression. Additionally, the client expresses frustration over feeling like an unwelcome guest in his soon-to-be step-family members' home due to their lack of acceptance toward him. The client tells you that his soon-to-be step-siblings are "mean" and tease him. He tells you that sometimes he thinks about running away and fantasizes that he has a special power like "The Flash, the superhero who is the fastest human on Earth." You validate his feelings and share a brief personal story with him about who your favorite superhero was when you were his age.    You explain to the client that it is important for him to understand his emotions, and help him think of healthy ways to cope with them. You mention the idea of him joining the school track team. The client appears excited about your suggestion. You also explain how communication is key in creating successful relationships. Since he is feeling overwhelmed by all the rule inconsistencies between his parents' homes, you suggest developing a consistent rule system with both of his parents. This way, the client can feel secure in knowing what kind of behaviors are expected from him regardless of which home he visits.    You observe the client as he processes all that you have discussed during the session. You encourage him to continue talking and share his thoughts with you. He acknowledges that it is difficult for him to switch between his parents' homes, but he feels a little more hopeful after talking with you today. You remind him of the importance of communication, expressing his needs in a respectful manner, and maintaining healthy boundaries with others.  Sixth session The client has been making progress and has joined the track team at school. He is the fastest runner on the team and has already broken some school records. He says that the team is becoming like his family. The coach has become his mentor and provides stability for the client. According to the client, he does not have the support for his new activity from his parents. His mother is tired of picking him up from track practice, and his father is not very enthusiastic about his son's involvement on the track team either. The client expresses feeling sad about his parents' reaction. He says, "I feel like my parents don't care about me." You contact both parents and suggest a session with all the adults responsible for the client's care. The mother immediately agrees, but the father expresses reluctance to participate in therapy. The client's father expresses his concerns about his involvement in therapy sessions, saying that he does not see how that will help his son. He is also worried that you will "side with" the client's mother and that he will end up getting blamed for the problems in the family. Despite his reservations, he agrees to attend the session, along with his ex-wife.    You facilitate a session with the client's parents, focusing on helping them understand their child's point of view in order to develop more effective communication between them. You emphasize the importance of expressing love and support for the child, even if they are not able to provide a unified front when it comes to rules and expectations. You explain that having different rule systems is not uncommon among divorced couples but also encourages both parents to work together to come up with consistent boundaries that can be enforced by both households. The mother expresses understanding while the father remains skeptical.    In response to the father's skepticism, you explain that working together towards a common goal is essential in developing successful communication and strengthening the parent-child relationship. You encourage both parents to discuss their expectations with each other and come up with a plan of action that works for them as well as their son. You also suggest that they attend family counseling sessions if needed, as this can help them better understand one another's point of view and work through any unresolved issues that could be causing distress in their relationships. You remain hopeful that by taking these steps, the client will feel more secure in his environment and ultimately benefit from the unified support of both of his parents.
Other Contexts: The client's parents have been divorced for five years. The client's father shares parenting responsibilities of his only son, age 13, with the client's mother. The father, who is not currently in a relationship, "tries to get along" with his ex-wife but finds this challenging. The client's mother is living with her new fiancé. The fiancé is twice divorced and has three children from previous marriages. Both sets of the client's maternal and paternal grandparents have passed away.  

Question: Which of the following responses demonstrates your use of constructive confrontation?
(A): "As parents, you are not making the changes to keep up with your son's progress. What are you going to do about it to get up to speed with his success?"
(B): "Are both of you, as parents, up to the challenge of being better parents for your son?"
(C): "It's time to make some changes as parents. As you watch your son's continued success, what can you do to match his progress?"
(D): "As parents, what positive steps are you taking in your lives to ensure the continued success of your son with his obvious continued improvement and personal success?"

Correct Answer: "As parents, what positive steps are you taking in your lives to ensure the continued success of your son with his obvious continued improvement and personal success?"
Explanation: This is a good, soft example of beginning to initiate more confrontation of the parents in this case. Constructive confrontation can be a useful counseling intervention which can help clients become more self-aware. If used effectively, therapists can help their clients identify certain behaviors they may overlook as well as address unresolved issues which they may be avoiding. This will help improve their overall well-being. Therefore, the correct answer is (A)
Competency: counseling skills and interventions