Relationship Status: Single
Counseling Setting: Outpatient – community counseling office
Types of Counseling: Individual and Family
Presenting Problem: Aggressive, lack of remorse, impulsivity, anger, noncompliant
Diagnosis: Conduct Disorder, childhood-onset type, callous-lack of empathy
The client was accompanied by his mother to the counseling office after an incident related to a neighbor's complaint. The mother expressed frustrations and stated up front that she had lost control in how to raise her son, saying, "He needs a reality check in how to get along with people. He is unable to develop and maintain a prosocial relationship with his peers and is much like his father. Neither one of them has behavioral boundaries and do not know when to stop. They act out immediately without thinking until something bad happens." The mother was hesitant in correcting the client when he did not express any type of greeting when meeting the counselor. The client immediately took a seat directly in front of the therapist and took out his cell phone. The mother presented with a degree of helplessness and ineptness in managing and raising her son. The given reason for this appointment was she believed he acted out again; this time driving their golf cart across a neighbor's front lawn and tearing up the sod. The neighbor called the police to report the incident and shortly thereafter the police appeared at the client's door. The client was present when the officer reported the disturbance and asked him if he commited the act. The client denied doing so and blamed other teenagers.
The client is of average intelligence, communication was minimal and rather abrupt. His first statement to the interviewer was that he did not have answers for the policeman's insinuations. He added to this statement indicating his mother has all the answers. He appears to have a maturity gap which is likely to be a result of an extended period of dependence (unsubstantiated). When asked about his family, he said his father was often mean, harsh, and his mother seemed like she lacked warmth and was detached from his world. When his mother was sharing her observations about the purpose of the counseling appointment, he interrupted her with, "You don't know the facts, it was not like that and come on, you are making it worse than it really was." The mother appeared embarrassed and said, "That is how he is with everyone." When these interchanges took place, the interviewer asked the client to let his mother finish and it would be his turn to relate his thoughts. The client's reply was in a style of argumentative stance. He said, "If you are making the decisions, it is important that you know the facts." He presents with signs of a lack of inhibitory control, cognitive shifting, and emotional dysregulation.
The mother said there was turmoil in the family for most of the time before the divorce three years ago. Her son seemed to be affected more than she or his sister. He seemed to blame her for the divorce, yet his father was mentally and physically mean to him. She feels responsible because she was not a good mother. When he was born, she went through a bad time knowing she was not ready for a child. She is aware she was not there for him in the early years and did not model good parentification skills. She worked through that period and the bad times with her husband, but dearly wants the best for her son, as she does love him. The father is described as a distant person who had difficulty revealing his feelings other than irritability and a strong need for control. While married, she did not intervene in family discipline because her husband was the master of the house and belittled any efforts of hers to contribute. The divorce prompted her to find full-time employment. Both children are essentially latch-key children because of her work responsibilities. She was reported to the county agency and visited by a social worker to respond to the charge of 'children unattended.' She is aware of her son's increasing social and maybe legal inappropriateness. When the golf cart incident was brought to her attention, her son did not admit to being responsible. When the officer left, she began to cry and raised her voice and said, "How could you?" The son turned his back and retreated to his room without a response. He has cut classes at school and things have been missing from the home. He will leave the house in the evening and often does not meet a set curfew. At times, when he has not met her curfew, she has not held him responsible for his actions. They have had arguments and shoving episodes although he has not hit her. He tussles and has gotten physical with his sister but nothing hurtful except for feelings. He likes to be the tough guy in the neighborhood which has ended in a couple of fist-fights. She cares about him and wants him on the right track.
Counselor deliberations prior to first session:
The primary symptoms to be managed and treated were addressed prior to and during the first session including:
1) counseling setting for individual, residential treatment facility and/or hospitalization, parent training, parent/child training
2) primary symptoms to be addressed include callous-unemotional traits (CU), reciprocal relations, limited prosocial emotion (LPE), emotional dysfunction, emotional self-regulation, executive function (inhibitory control, cognitive shifting, and working memory). The counselor provided a definition and understanding for each symptom and specific psychosocial treatment. The treatment was to focus on emotions and self-management that cut across several of the symptoms. A counselor concern is to develop a working alliance since the client appears resistant to counseling and symptoms reflect a lack of trust.