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: At the start of the session, the foster parents ask the client if she would mind meeting alone with you; she agrees and asks to have access to the toy bin in your office. You and the client begin to play together, and you ask her if she talked to her birth parents. The client says “yeah, Mommy talked about coming home in a few years.” You ask how she feels about living with her mother again, and she says she does not want to be with her because her mother does not want to be with her. You try to process this with the client, and she says that she likes her house and her school and does not want to leave. You meet with the foster parents and the client at the end of the session, and they report that spending quality time with the client on a daily basis has been helpful in improving their relationship. They state that they think they had been too afraid to overwhelm her and that at times they were trying to give her space, but they realize that the intentional time together has been helpful. You empathize with the foster parents and encourage them to continue to spend quality family time with her.  This is the first session in which the client expresses any significant thoughts or feelings

Question: This is the first session in which the client expresses any significant thoughts or feelings. Which of the following demonstrates a clinically appropriate response to the client’s expression of feelings regarding the statement “no one wants me” that keeps in mind the client’s need for comfort in sessions?
(A): Cognitive reframing.
(B): Continue playing and do not provide a response to her expression of emotions.
(C): Empathy.
(D): Use downward arrow questioning to find a deeper feeling behind this statement.

Correct Answer: Empathy.
Explanation: Empathy would support the client in feeling heard and would assist you in connecting emotionally with the client’s situation. Cognitive reframing may be developmentally difficult for the client and also might feel like you are pushing the client to move past her comfort level. It would not be helpful to continue playing and to refrain from acknowledging what the client said. Acknowledging the client’s expression of emotions would reinforce her with expressing herself and would demonstrate care toward the client. The downward arrow technique would likely seem aggressive to the client, and she might refrain from further engagement in this session. Therefore, the correct answer is (A)
Competency: counseling skills and interventions