Case Study
Patient Demographic: Name: Becky Clinical Issues: Behavioral problems Diagnostic Category: Disruptive/Impulse-Control/Conduct Disorders Provisional Diagnosis: F91.1 Conduct Disorder, Childhood-onset Type Age: 10 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Not Assessed Ethnicity: White Marital Status: Not Applicable Modality: Family Therapy Location of Therapy : School  
Mental Status Exam: Appearance: Female with crossed arms, avoiding eye contact, and a blank expression.    Affect: Flat affect.    Speech: Responses are brief and monotone, lacking emotion.    Thought Process: Poor focus, easily distracted, and unable to maintain a cohesive conversation.    Thought Content: Negativity-focused on herself, blaming others for her difficulties; no suicidal or homicidal ideation reported.    Perception: No evidence of hallucinations or delusions.    Cognition: Difficulty with problem solving, difficulty shifting focus between tasks, and poor organization skills.    Insight/Judgment: Poor insight into her situation; judgment impaired due to her inability to see the consequences of her actions.
Presenting Problem: First session You are a school counselor and often work with families whose children are having behavioral issues. A 10-year-old female student named Becky comes to your office with her parents. Becky's teacher notified you of behavioral problems she noticed in the classroom. You arranged to meet with Becky and her parents to discuss the teacher's concerns and determine how you can best support Becky's needs. You explain your role as a school counselor, providing short-term counseling for students and making referrals if long-term therapy is deemed appropriate. Becky's parents tell you that "it wasn't a surprise to get your phone call," as their daughter's behavior is poor at home, too. They are at their "wit's end" due to their daughter's constant "back talking" and "arguing" with them and any other authority figures in her life. Becky blames others when confronted at school and has become physically aggressive toward her classmates and teacher. You attempt to build rapport with Becky, but this proves challenging as she is not responsive to your efforts.    Becky seemed to be quite guarded and disconnected during the initial assessment. She demonstrated defensive behaviors, such as crossed arms, avoiding eye contact, and evasive responses. She appeared to be dissociated from her current environment and seemingly uninterested in the conversation. However, she did demonstrate a certain level of compliance when her parents attempted to redirect her focus.    Her parents reported that Becky has been displaying these behaviors for months, escalating in intensity as time has passed. She has been increasingly defiant and aggressive both at home and at school. They are concerned that her behavior could pose a risk to her safety and have already attempted different strategies to help her, such as removing privileges and providing additional structure. Still, she continues to be uncooperative and argumentative. Clearly, the family was feeling overwhelmed and needed help managing Becky's behaviors.  Fourth session You have been meeting with Becky for 30-minute sessions once a week for the past three weeks. You have been collaborating with her parents and sharing strategies for how they can support their daughter at home. You have also been communicating with Becky's teacher to monitor Becky's behavior in the classroom. Today is your fourth session with Becky, and she is accompanied by her mother. The mother reveals that her daughter has stolen money from her purse. The mother has also received a call from Becky's teacher informing the parent that Becky was seen removing items from the teacher's desk. When confronted with this information during the session, Becky loudly denies stealing anything, calls her mother a liar, grabs a coffee cup from your desk, and throws it on the floor.    You respond to the situation by remaining calm and utilizing a nonjudgmental approach. You remind Becky and her mother that it was a safe space to discuss their feelings and that it was important to express them appropriately. You then explored Becky's feelings about her mother's accusation to understand her perspective and encourage Becky to take ownership of her behavior. Finally, before Becky and her mother leave, you provide them with tools to practice at home to manage their emotions, suggesting they focus on communication, problem-solving, and finding healthy ways to express their feelings.  Seventh session Today, you meet with Becky and both of her parents. Her father demands to be included in the treatment process. He is adamantly opposed to his daughter being placed in special classes, but the mother expresses her belief that placement in a special class is the best solution. The parents continue to disagree. Finally, Becky screamed out her support for her father's side of the argument.    Becky's reaction in support of her father's position only further escalated the disagreement between her parents. Her mother seemed to be taken aback by Becky's outburst and tried to explain calmly why she believed special classes would be the best solution for their daughter. At this point, the conversation became more heated. Her mother expressed her frustration with her husband, saying he always seemed to take Becky's side regardless of the situation. This further agitated the father, and he began to raise his voice in protest. Sensing the tension in the room, Becky suddenly crossed the room and sat on her father's lap. The parents' discussion escalated into an argument, with Becky's mother finally walking out of the office.
Other Contexts:  The client is currently failing in school. Her teacher has called for a conference to begin the process of making an individualized education plan (IEP) to address the client's disruptive behavior. The client has been referred to you for therapy. She has a history of aggressive behavior toward peers and teachers, including physical attacks and verbal aggression. She has also been observed to demonstrate non-compliant behavior, such as refusing to wear a face mask when interacting with other students.    Additionally, she has been observed to demonstrate oppositional behavior, such as sticking her tongue out at the teacher. These behaviors have been consistently reported by the teacher and other school staff and have been increasing in frequency and intensity. These behaviors have significantly impacted the client's academic performance and have resulted in her current failure in school. Her teacher has called for a conference to begin the process of making an individualized education plan (IEP) to address the client's disruptive behavior. 

Question: In which of the following are you demonstrating conflict tolerance appropriately in a therapy session?
(A): Recognize that clients in therapy should express strong feelings and seek to elicit such responses from the client
(B): Recognize that conflict is the problem and, as such, steer the discussion to a more rational framework
(C): Recognize that expressing strong feelings during a session provides a window to the client's underlying issues
(D): Recognize that the participant initiating conflict should seek separate individual therapy to cease being a roadblock to progress.

Correct Answer: Recognize that expressing strong feelings during a session provides a window to the client's underlying issues
Explanation: Conflict during a session is expected, and a therapist's ability to manage it is key. Therefore, the correct answer is (C)
Competency: counseling skills and interventions