Case Study
Patient Demographic: Name: Gregory Clinical Issues: Behavioral problems Diagnostic Category: Disruptive/Impulse-Control/Conduct Disorders Provisional Diagnosis: F91.3 Oppositional Defiant Disorder Age: 14 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: Black Marital Status: Not Assessed Modality: Individual Therapy Location of Therapy : Private Practice  
Mental Status Exam: The client appears obese and his clothing is unkempt. His behavior is uncooperative. He finds people "annoying" and can at times be vindictive toward people he finds "annoying." His mood is angry and affect is irritable. His flow of thought is coherent and goal-directed. His overall responses at times show themes of low self-esteem. He denies any current thoughts of suicide or homicide. He does not display any signs of hallucinations or delusions. His vocabulary is age-appropriate, but his speech is at times sarcastic. He answers questions coherently. Thought process is linear and coherent. He is oriented X3. Memory is intact for recent, remote, and immediate. Insight and judgement are poor.
Presenting Problem: First session You are a mental health counselor working in private practice. Gregory, a 14-year-old male, presents to the initial session with his mother. She reports that her son has been skipping school, hanging out with a negative peer group, and his grades are starting to slip. He refuses to listen to his mother, saying she is "strict and unfair." Gregory, who up to this point has been sitting quietly with his arms crossed, rolls his eyes and says, "She should be in therapy, not me."    Gregory's mother continues on to express concern over his decline in school performance, noting that "he is having problems with some teachers and staff." Last week, he got up in the middle of class and when told to sit down, he said, "I have to go to the bathroom." He walked out and slammed the door behind him. He was sent to the principal's office as a consequence. He has also become vindictive toward certain classmates. When asked why, he states, "because they think they're better than me."    His mother reports that at home, Gregory has become increasingly isolated, spending most of his free time alone in his room or out with a group of teenagers she does not recognize. He has has become increasingly hostile and verbally abusive toward his mother and brothers, resulting in frequent arguments. He routinely ignores his curfew and refuses to participate in family activities.    You thank the mother for sharing her concerns and ask to speak with Gregory alone to give him a chance to express himself freely. You want to obtain his assent to join in therapy and understand what is causing him to act out.  Third session Today is your third session with Gregory and you are meeting him on a weekly basis. Last week, you met with him alone and explored his feelings about his family and triggers for his anger and irritability. He reiterated that his mother and brothers were the problem, not him. You recommended meeting with Gregory and his mother for today's session to develop a treatment plan to address Gregory's issues. As you prepare for his appointment, you hear yelling in the waiting room and find Gregory screaming at his mother. She is sitting in the chair, shaking her head. You call them both into your office. His mother yells, "I've had enough of you today! This time, I'm going to talk!" Gregory rolls his eyes and mocks her. According to his mother, Gregory was "caught by the school resource officer today with a vape on him." She chokes back tears, saying, "I don't know who my son is anymore." Gregory responds, "You're overreacting. That's all you do. Big deal. It's just a vape. Get over it." His mother looks at you and says, "He's not getting better even with therapy. He won't listen to anyone, and dealing with him is a constant pain. He's spiteful and working against me. How do I get my son back?"    Gregory has been exhibiting increasingly concerning behaviors since he began using a vape. He has become easily frustrated, struggles to regulate his emotions, and often resorts to aggressive outbursts. He continues to be defiant and uncooperative, straining his relationship with his mother. Despite her best efforts, Gregory remains uninterested in following your guidance, further complicating his mother's efforts to help him.  10th session You have been seeing Gregory for therapy every week for the past three months. You have worked to improve the parent-child relationship and incorporated parent-management training into his treatment plan. You have taught Gregory's mother techniques to improve his behavior and support his emotional functioning. Also included in Gregory's treatment plan is improving impulse control, learning problem-solving skills, and improving social skills. You have used CBT interventions, structured activities, games, and role-playing exercises with Gregory to achieve these goals.    Today, Gregory begins the session by taking a paper from his backpack and handing it to you. You see that he received a high grade on his mid-term in Global Studies. You praise him for his hard work. Then, you ask him how it felt to get his grades back up. There is a long silence. Gregory is fidgeting with the string on his backpack. He turns, looks out the window, and whispers, "Good, I guess." You notice the client has tears in his eyes. You draw his attention to his behavior and affect and ask, "Why are you upset after being successful with your exam?" He shrugs his shoulders, looks at you, says, "Would you stop asking me so many questions?" and walks out of the office. You follow him into the waiting room and hear him tell his mom, "I'll be in the car." His mom looks confused. You say to her, "Is something going on or did something happen with Gregory that I should know about? He seemed upset after showing me his good exam grades." She thinks for a moment and tells you that he found a box of old family pictures and has been going through them. She wonders if this is related to his reaction today.
Other Contexts: The client resides with his mother and three older brothers. He describes his brothers and mother as "annoying" and tells you that none of them listens to him. 18 months ago, his father passed away after a long illness. The client says that his dad was the only family member who understood him.    The client feels he has no one to talk to and does not get along with his family members. He reports difficulty trusting others and is guarded in his relationships. He has become more irritable and vindictive since his father's death.  The client denies drug or alcohol use and responds to your question, saying, "What? Are you an idiot? Do I look like someone that would be stupid enough to do drugs?" The client scoffed and continued, "Why would I waste my time and energy risking my future for something so pointless." He then crossed his arms and stared defiantly, clearly not interested in discussing the matter further.

Question: Given Gregory's behavior in the session and his mother's disclosure, what topic may need further exploration in the next session?
(A): Bullying at school
(B): Unprocessed grief
(C): Sibling rivalry
(D): Nicotine withdrawal

Correct Answer: Unprocessed grief
Explanation: Gregory's emotional response was incongruent with improved functioning in school performance. Given what his mother told you, his angry response could be a secondary emotion tied to unprocessed grief related to his father's death. Therefore, the correct answer is (B)
Competency: intake, assessment, and diagnosis