Case Study
Patient Demographic: Client Age: 9 Sex: Male Gender: Male Sexuality: Unknown Ethnicity: Caucasian Relationship Status: Not Applicable Counseling Setting: School Type of Counseling: Individual Presenting Problem: Severe Temper Outbursts Diagnosis: Disruptive Mood Dysregulation Disorder (DMDD), Provisional (F34.81)
Mental Status Exam: Mental Status Exam: The client’s affect is irritable and angry. He sits with his arms crossed and exhibits poor eye contact. His appearance is somewhat disheveled. Mother reprimands the client multiple times, requesting that he “sit up straight” and “answer the lady’s questions.” The client mumbles responses at his mother’s prompting and is otherwise minimally engaged. The client reports that he “gets mad” daily and feels unjustly “blamed for everything.” His motor activity is somewhat fidgety. Speech and language skills are developmentally appropriate. The client states he “sometimes” feels sad and denies feeling worried or scared. His appetite is good and his sleep is poor. The mother attributes his sleep difficulties to the client staying up late playing video games.
Presenting Problem: You are a school-based mental health clinical counselor conducting an initial intake evaluation. A 9-year-old 3rd-grade male is accompanied by his mother, who reports that the client has been in several school and neighborhood altercations. She states she is at her “wit’s end” with him and is about to lose her job due to constant calls from his school. The client’s teacher reports that the client has daily temper outbursts, and his mother says that his mood is irritable for most of the day, every day. The client was recently suspended from school for flipping over his desk when his teacher told him he lost recess privileges. The mother first noticed these behaviors when her son was in kindergarten. The client recently kicked a hole in his wall after losing a video game. His grades are poor, and the school is currently evaluating him for special education services. The client was reluctant to take part in the intake. He shrugged his shoulders when asked if he would agree to participate in counseling.
Other Contexts:     History of Condition: The client’s milestones were all developmentally appropriate; he was walking at ten months, toilet trained by 24 months, and speaking in complete sentences at almost 30 months. The mother describes the client as “moody” beginning in kindergarten. His temper outbursts began to escalate in intensity and duration within the last few years. During this time, there were no known associated stressors. The mother reports that the client has always had a hard time following directions and difficulty complying with authority figures. Family History: The client has two maternal half-brothers, ages 18 and 20, and has positive relationships with both of them. His parents divorced when the client was three years old, and the mother has physical custody of the child\. Before the divorce, the client witnessed verbal and physical altercations between his parents. The client’s father visits periodically, and he has been in and out of substance abuse treatment centers for most of the client’s life. When angry with his mother, the client tells her he wishes he could live with his father. The client’s maternal grandmother is diagnosed with bipolar disorder, and the client’s mother states she struggles “off and on” with depression. Aside from the father’s substance use disorder, a paternal history of mental illness is unknown

Question: Which of the following would best help create a therapeutic alliance with this client?
(A): Helping the client master coping skills he can successfully apply when feeling angry
(B): Using core facilitative conditions, such as reflection and validation
(C): Demonstrating universality to minimize transference and instill hope
(D): Sharing the treatment plan with the client to establish clear expectations

Correct Answer: Using core facilitative conditions, such as reflection and validation
Explanation: The use of humanistic, person-centered responses, including reflection and validation, significantly influence the therapeutic alliance. Helping the client to master coping skills to apply when he is feeling angry is an appropriate counseling intervention but is less likely to contribute to creating a therapeutic alliance. Including the client in the treatment planning process, rather than solely sharing the completed treatment plan, helps build and strengthen the therapeutic alliance. Presenting the client with a menu of goals and objectives is one way to include a child in developing a treatment plan. Universality and the installation of hope, part of Irvin Yalom’s curative factors, are therapeutic experiences associated with group therapy; these factors are not associated with minimizing transference. Therefore, the correct answer is (C)
Competency: counseling skills and interventions