Help Needed

15 Disruptive, Impulse-Control, and Conduct Disorders

This chapter contains an amalgam of disruptive, impulse-control and conduct disorders (CDs) characterized by externalizing behaviors previously spread throughout many chapters of earlier DSM editions. However, these disorders are no longer categorized by age (e.g., disorders of infancy, childhood, and adolescence), and all share the loss of restraint (i.e., poor control) in terms of an individual's emotional or behavioral responses that are demarcated by an infringement on the rights of others or breach of social norms. Attention should be paid to the symptom overlap that these diverse disorders share with Attention Deficit/Hyperactivity Disorder (ADHD) (which can be found in  Chapter 2  on Neurodevelopmental Disorders); Disruptive Mood Dysregulation Disorder (DMDD) (which can be found in  Chapter 5  on Depressive Disorders); Substance Use Disorders (SUDs) (the adjoining  Chapter 16 ), as well as Antisocial Personality Disorder (which has a dual recording in both this chapter and in  Chapter 18  on Personality Disorders) ( APA, 2013 ).

   First on the hierarchical spectrum of externalizing disorders in this chapter is Oppositional Defiant Disorder (ODD). An individual with must display at least four out of eight symptoms/behaviors with an individual who is not a sibling for at least 6 months from the following three categories: (1) angry/irritable mood; (2) argumentative/defiant behavior; and (3) vindictiveness. For example, argumentative/defiant behavior symptoms include: being argumentative; demonstrating a lack of compliance with authority figures' requests; annoying others deliberately; and blaming others for his or her mistakes. The anger/irritability category symptoms include loss of temper; getting easily upset and/or annoyed, and anger/resentment. The final category has only one symptom vindictiveness or spitefulness demonstrated at least two times within the previous 6 months ( APA, 2013 ).

   Many symptoms of this diagnosis are commonly displayed during normal childhood/adolescent developmental stages. Therefore, in an effort to help differentiate the symptoms that are characteristic of this diagnosis, practitioners are cautioned to consider the persistence and frequency of behaviors. For example, in young children under the age of 5, the symptoms must occur for the majority of days for at least 6 months. For older individuals, the symptoms must occur at least once weekly within a 6-month period. However, for vindictiveness regardless of age, the criterion is the same, twice within the previous 6-month period. Along with frequency, other factors must be taken into consideration, such as symptom intensity, and whether symptoms are normal given the individual's age, developmental stage, gender, and culture. In addition, the symptoms must cause significant suffering in the individual or in his/her immediate relationships (e.g., family, friends, peers) as well as impairment in psychosocial functioning. Further, the symptoms cannot manifest only during the development of another mental disorder, and diagnostic criteria for DMDD are not satisfied. Also, severity must be identified and is tied to the number of settings that symptoms present at, with mild equal to symptoms present at only one setting (e.g., home) to severe with symptoms present at 3 or more settings (e.g., home, school, peers). For further details refer to the DSM-5 ( APA, 2013 ).

   The next disorder in this spectrum is Intermittent Explosive Disorder. The key criteria are a minimum age of at least 6 years (or developmental equivalent) and recurrent episodes of failing to resist aggressive impulses that manifest as either verbal and/or physical aggression, twice weekly for a 3-month period (that do not result in actual assault and/or property destruction); or three physically aggressive behavioral outburst that are destructive and injurious to either an animal/individual over the course of a year. Other criteria stipulate that these destructive outbursts are impulsive (not intentional) and the degree of aggressiveness involved is judged to exceed a reasonable response to the specific provocation. The symptoms must cause significant suffering, and/or negative consequences (i.e., legal fees), and/or psychosocial impairment. The final criterion is ruling out a wide range of other medical and mental disorders that could include such outbursts. Moreover, this diagnosis can be made in addition to ADHD, conduct disorder, ODD, and autism spectrum disorder when symptoms are severe enough to merit additional clinical focus ( APA, 2013 ).

   Conduct Disorders involve behaviors and activities that violate developmentally appropriate social norms often of an illegal/criminal nature. This diagnosis requires that the individual has engaged in three or more symptomatic behaviors or activities over a 12-month period, with at least one characteristic behavior presenting in the previous 6-month period. These behaviors are classified into four broad categories: (1) aggression to people or animals; (2) destruction of property; (3) deceitfulness or theft; and (4) serious violations of rules. These behaviors are chronic, repetitive, and form a pattern that significantly impairs social, academic, or occupational functioning and is primarily diagnosed in childhood ( APA, 2013 ).

   If one or more symptoms are displayed before the age of 10, the child is diagnosed with Conduct Disorder, Childhood-Onset Type. If there is no evidence of these behaviors before the age of 10 and the pattern of behaviors is diagnosed after the age of 10, then the child would be diagnosed as having Conduct Disorder, Adolescent-Onset Type. If diagnostic criteria are met, but information is unavailable to help determine the age at which symptoms first developed, then Conduct Disorder Unspecified Onset is appropriate. Individuals with childhood onset are more likely to have coexisting ADHD, poorer peer relationships, demonstrate more aggression, and develop a more chronic pattern of this disorder into adulthood ( APA, 2013 ).

   Research has lead to the creation of the limited prosocial emotions specifier in order to help distinguish individuals who may need more clinical attention. This specifier is used when an individual who meets the diagnostic criteria for conduct disorder also displays two or more behaviors characteristic of the following categories (1) lack of remorse or guilt and (2) callous—lack of empathy. However, practitioners are cautioned to use great care when employing this specifier due to the serious implications that may accompany it. For further details on the very specific criteria (i.e., multiple information sources from multiple settings) clinicians should consult the DSM-5. Additional terms indicate the level of severity of the disorder: Mild, Moderate, or Severe. The practitioner considers the number of conduct problems and the degree of harm to others in assessing these levels of severity ( APA, 2013 ).

   The next two externalizing disorders' criteria are related to building and relieving tensions by the conclusion of the involved impulsive behavior. In Pyromania, the client is involved in premeditated fire setting for more than one occasion, and demonstrates a general fascination with fire. Again, the fire setting is not motivated by receiving material gain, expressing some ideological viewpoint, or concealing other criminal activity. It is not in response to anger/vengeance or to a delusion, or the result of diminished judgment. Also, various other mental disorders should be ruled out including conduct disorder, antisocial personality disorder, and bipolar disorder ( APA, 2013 ).

   Quite similarly, the diagnosis of Kleptomania involves cycles of growing internal discomfort and a sense of relief when performing the theft as part of the diagnostic criteria. This disorder's key feature is the continuous inability to resist the urge to steal. Further, the objects stolen are not needed for personal or monetary use or to express anger or revenge toward their owner and cannot be in response to a delusion. Again, several other mental disorders should be ruled out before making this diagnosis such as those mentioned above in pyromania ( APA, 2013 ).

   The final two disorders in this section Other Specified Disruptive, Impulse-Control, and Conduct Disorder and Unspecified Disruptive, Impulse-Control, and Conduct Disorder are similar in that they are used when the symptoms characteristic of the disorders in this chapter cause significant distress and impairment but are not able to meet diagnostic criteria. In the first, the clinician chooses to specify why criteria were not met, and in the later, the clinician lacks enough information to make this determination.

Assessment Instruments

The Child Behavior Checklist (CBCL;  Achenbach & Rescorla, 2000 , 2001) is one of the most widely used, paper-based, screening measure of a broad range of behavioral and emotional problems in children. This questionnaire can be self-administered or given by interview and is available in multiple versions and varies by respondent (i.e., parent, teacher, self), age assessed (e.g., preschool: 1.5 to 5 years, school age: 6 to 18 years) and total items (e.g., range from 100 to 120). Answers to the CBCL questionnaire can be grouped to produce 7 syndrome scales, an internalizing scale, an externalizing scale, and total problem scale as well as 5 DSM-oriented scales (including ODD and conduct disorder). The CBCL has demonstrated strong psychometric properties including validity and reliability ( Achenbach & Rescorla, 2000 ,  2001 ;  Hudziak, Copeland, Stranger, & Wadsworth, 2004 ). Although very well respected, some of the disadvantages to this instrument include the cost associated with training/interpretation and scoring. Further information can be obtained in  Chapter 2  on Neurodevelopmental Disorders or on the author's website—The Achenbach System of Empirically Based Assessment (ASEBA) at  www.aseba.org .

   The Child and Adolescent Functional Assessment Scale (CAFAS;  Hodges, 1997 ) is a multidimensional rating scale designed to measure emotional, behavioral, and psychological problems in children (aged 7 to 17). A preschool version (PECFAS) for younger children is also available. This clinician-administered scale rates functional impairment over a given time period across 5 to 8 domains depending on the version employed. The child subscales include: school/work, community, home (which are combined into role performance for the 5-scale version), moods/emotions, moods/self-harm (which are combined to form the mood/emotions for the 5-scale version), behavior toward others, thinking, and substance use. In addition, two scales assess caregiver functioning including material needs and family/social support but are not included in the child scores ( Bates, 2001 ).

   For the child subscales, each item is given a functional impairment score based on a behavioral descriptor and rated on a 4-point scale from “0” to “30” (by increments of ten), with “0” = minimal or no impairment to “30” = severe disruption/impairment. Scale scores can be used independently or summed to produce a child total score. Total scores can range from 0 to 150 for the 5-point scale or 240 for the 8-point scale. Higher scores indicate greater impairment. Although it can take only 10 minutes to administer, specialized training is required. The practitioner can customize to assess which behaviors to measure that best meet their need (i.e., frequent display of anger toward others, angry outbursts).

   Over 25 years of published research exist on this scale and demonstrates good psychometrics including reliability and validity.  Hodges and Wong (1996)  reported good inter-rater reliability with Pearson correlations of .74 to .99 for 4 child subscale domains (role performance, behavior, moods/emotions and substance use) and total score correlations from .92 to .96 as well as satisfactory internal consistency (.63 to .78). However,  Bates (2001)  contends that the alpha values were too low to construe good internal consistency. Predictive validity in terms of service utilization and costs has also been reported in numerous studies ( Hodges, Wong, & Latessa, 1998 ). Total score was also found to be predictive of future contacts with the law and school attendance in a study set using national evaluation of the demonstration service grants ( Hodges & Kim, 2000 ).

   The Eyberg Child Behavior Inventory (ECBI,  Eyberg & Robinson, 1983 ) is a frequently utilized and validated measure of disruptive behaviors in children that was developed in the late 1970s and published by Psychological Assessment Resources in 1999. This brief, 36-item, parent-rated scale is designed to measure the frequency and severity of behaviors associated with conduct, aggression, and attention problems in children and adolescents from ages 2 through 17. The ECBI can also rate how troublesome this behavior is for the parent/guardian. Moreover, this scale can differentiate children with conduct problems from those without as well as measure change in behaviors due to treatment ( Corcoran & Fischer, 2013 ).

   Each item is rated by whether it is a problem for the parent/caregiver dichotomously (problem scale) and by intensity of behavior (intensity scale) on a 7-point Likert scale (1 = never to 7 = always). Higher scores indicate greater disruptive behaviors and the need for treatment. Scoring for the problem scale is accomplished by summing the number of items marked “yes” (total score range from 0 to 36) with the suggested clinical cutoff score of 11. Scoring for the intensity scale (total score range from 36 to 252) is the total frequency of behaviors with the suggested clinical cutoff score of 127.

   Numerous studies have validated this instrument with excellent internal consistency (alpha = .91 for the problem scale; .93 for intensity scale) and good concurrent validity, discerning children with conduct disorders from nonsymptomatic children ( Corcoran & Fischer, 2013 ). Good test–retest reliability has been reported for the problem and intensity scales across a 3-week period (.88 and .86 respectively) by  Robinson, Eyberg, and Ross (1980) , and across a 10-month period (.75 and .75) by  Funderburk, Eyberg, Rich, and Behar (2003) . A factor analysis by  Burns and Patterson (2000)  identified three clinically significant dimensions for possible subscales: oppositional defiant, conduct problem, and inattentive behaviors and provided screening cutoff scores. However, others suggest that the full ECBI scale may be more useful than screening dimensions/components ( Weis, Lovejoy, & Lundahl, 2005 ).

Emergency Considerations

It is easy to infer how aggressive behavior, fire setting, and poor impulse- and self-control, the key characteristics of many disorders in this chapter, can pose possible threats to the individual and society at large. Moreover, when conduct disorder coexists with ADHD, ODD, and substance use disorders it can result in worse outcomes ( APA, 2013 ). Furthermore, research shows that individuals with conduct disorder have higher rates of suicidal ideation, suicide attempts, and completed suicide ( APA, 2013 ).

Cultural Issues

How symptoms of aggression and self-control are viewed within a culture can affect the diagnosis and prevalence of disruptive behaviors and impulse-control disorders ( Canino, Polanczyk, Bauermeister, Rohde, & Frick, 2010 ). In addition, it is important for all practitioners to be mindful of the cultural suitability and of possible bias of an assessment instrument. Research has shown that diagnostic bias may contribute to the overdiagnosis in youth of color of conduct disorder. Further, this misdiagnosis can lead to poorer outcomes for youth of color in contrast to their white peers in both the mental health and juvenile justice systems ( Mizock & Harkins, 2011 ). The disproportionate representation of minority youth in the juvenile justice system may be the effect of inconsistent treatment within the juvenile justice system or from dynamics within their social environment (e.g., poverty, school failures, and mental health problems) ( NAMI, 2007 ).

   The lower socioeconomic status of many ethnic and racial minority children has been shown to negatively impact mental health outcomes resulting in a wide range of difficulties including behavioral problems. Additionally, many of these children face violence and trauma in their homes and communities, which is associated with higher rates of mental illness and externalizing behaviors ( McFarlane, Groff, O'Brien, & Watson, 2003 ;  Moylan, Herrenkohl, Sousa, Tajima, et. al., 2010 ). Links have been made between child welfare and the juvenile justice systems worldwide. For example, a 2004 survey by the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom established that almost 40% of children in the child welfare and child protective systems had a conduct disorder ( NICE, 2013 ). In the United States, a National Institute of Justice study showed that children exposed to child abuse and neglect had an increased probability for juvenile arrest by 27%, adult arrest by 42%, and for violent crime by 18% ( Widom & Maxfield, 2001 ).

   Furthermore, the burden of persistent racism and discrimination increase the risk for the development of a mental disorder ( Alegria, Vallas, & Pumariega, 2010 ). Data from the 2007 National Survey of Children's Health (NSCH) demonstrated that higher prevalence rates of CD and ODD were linked to lower household educational levels and lower household income ( Perou, Bitsko, Blumberg, et al., 2013 ).  Moffitt, Arseneault, Belsky, Dickson, et al. (2011)  reported that a child's self-control could predict outcomes in terms of health (i.e., substance use/abuse), low economic status, and criminality by adulthood.  Fergusson, Boden, and Horwood (2013)  built upon this research by showing that childhood self-control from ages 6 to 12 years was linked to adult outcomes, and correlated with childhood conduct problems, SES, IQ, and gender. These studies expanded upon the findings of  Lahey, Loeber, Burke and Applegate (2005)  showing that an earlier diagnosis of conduct disorder in childhood (but not ADHD) among mental health outpatients from lower SES families, could predict the later development of antisocial personality. Similar findings were also reported in a longitudinal study of male youths with a history of ADHD, whereby ODD predicted the later development of CD and antisocial personality disorder, with greater risk for those with CD; but CD alone predicted the later development of psychoactive substance use disorders, smoking, and bipolar disorder ( Biederman, Petty, Dolan et al., 2008 ).

   Gender and developmental differences have been reported for conduct and disruptive and impulse-control behaviors. Males are more often diagnosed with childhood-onset CD and pyromania ( APA, 2013 ) with antisocial behavior predicting future crime ( Odgers, Moffitt, Broadbent, et al., 2008 ). Although females are diagnosed less frequently with CD, its prevalence over the past 20 years has risen substantially ( Fairchild, Hagan, Walsh, et al., 2013 ). Some debate the validity of current CD diagnostic criteria citing gender bias (i.e., emphasis of overt versus covert behaviors) and criterion bias as most studies used to validate criteria were primarily made up of males ( Klem, Klem, Parrish, & Brown, 2007 ). Females diagnosed with CD are at a greater risk of teenage pregnancy ( Odgers et al., 2008 ), have higher mortality rates, and a significant increase in criminal behavior in comparison to their normative peers ( Pajer, 1998 ). Furthermore, when girls with antisocial/delinquency behaviors are compared to boys with antisocial/delinquency behaviors they report higher rates of child abuse (92% versus 10% to 47%) as well as sex-related differences in coping with the abuse. Female offenders in comparison to their male co-offenders report more comorbid mental disorders, but they are less likely to access or complete treatment ( Future of Children, 2008 ). Developmental differences (as evident in onset subtypes) show that children with conduct disorder early-onset (versus adolescent type) are more likely to exhibit aggressive symptoms and continue into adulthood to develop antisocial personality disorder ( APA, 2013 ).

Social Supports

The economic and social costs of mental illness are great. Estimates of this cost come from the Agency for Healthcare Research and Quality, which found that over $57 billion was spent on mental health services in 2006, and this number excluded the indirect costs associated with loss of income due to chronic disability and social services that often start in early childhood ( Insel, 2011 ). The National Comorbidity Survey-Adolescent Supplement (NCS-A) revealed that a little less than one in every five children in the United States meet the diagnostic criteria for a mental disorder with severe impairment during their lifetime ( Merikangas, Jian-ping, Burstein, Swanson, et al., 2010 ). The prevalence range for CD is from 2% to 10% ( APA, 2013 ) with one study estimating the direct cost of care to be $14000/child with CD versus $2300/child without such a diagnosis ( Merikangas, Nakamura, & Kessler, 2008 ). According to the American Hospital Association (AHA), a mental health condition ranks fourth in terms of reason for hospitalization for American children. They also highlighted the inefficiency and ineffectiveness of the current fragmented intervention systems providing treatment to individuals with behavioral problems ( AHA, 2012 ).

   Preventing the negative trajectory from conduct disorder and antisocial personality disorder to adult criminality is well worth the investment in terms of dollars and lives saved. Incorporating intervention support services aimed at lessening chronic disruptive behaviors in children has been shown to reduce frequent violent behaviors and criminality in adulthood ( Wasserman, Keenan, Tremblay, et al., 2003 ). Effective and appropriate support services involve culturally sensitive interventions that are community-based (e.g., schools, community organizations) and that engage children and their families while protecting against various risk factors including: aggression/poverty, poor parenting, child abuse, early substance use, and deviant peers. The earlier services are implemented the more they appear to be of benefit and help to improve outcomes (e.g., early childhood versus adolescence).

   The following are a listing of Internet resources available for individuals suffering from conduct, disruptive, and impulse-control disorders.

·   www.aacap.org : The American Academy of Child and Adolescent Psychiatry is a nonprofit advocacy organization made up of psychiatrists and physicians dedicated to providing information and support resources to children, adolescents, and their families living with mental illness.

www.nami.org : The National Alliance on Mental Illness is the nation's largest nonprofit, grassroots mental health organization dedicated to advocating for people living with mental illness and their families by providing information and support group programs.

www.samhsa.gov : The Substance Abuse and Mental Health Services Administration (SAMHSA) is a government agency charged with improving the behavioral health of this nation's citizens through education, prevention, and treatment support services for substance use disorders and other mental illnesses.

Case 15.1

Identifying Information

Client Name: Bobby Jones

Age: 9 years old

Ethnicity: African American

Educational Level: Fourth grade

Parent: Susan Jones

Background Information

Bobby, a 9-year-old African-American boy, attends Lewistown Elementary School and is in the fourth grade. He is the third child in a family of six children ranging in ages from 3 to 12 years old. He has two older sisters, a younger sister, and two younger brothers. His mother, Susan, is 30 years old. She is a single mother and works as the activities director of a nursing home. She has a high school education and an associate's degree from a technical college. She has had two previous marriages, with three children by each husband. Bobby's alcoholic father has never worked or paid child support.

   Bobby's teacher, Ms. Mathews, contacts you, the school counselor, about Bobby's behavior after the first 3 weeks of school. She states that Bobby has a very negative attitude about school, is disruptive, and never completes his work. She tells you that she has tried everything from rewards to “time out” in an attempt to change Bobby's negative behaviors. Ms. Mathews states that she doesn't know what goes on in Bobby's life outside school since he is rarely willing to share anything about his home life with her.

   You ask Ms. Mathews if she can tell you more specifically what kinds of behaviors she has observed in Bobby.

   “Well, ever since the first day of school, Bobby has been a major problem in class. He refuses to follow any of the rules, and when I confront him, he either stands there and just stares at me and won't say a word, or he says, ‘Make me.’ Several times when I have forced the issue, he has thrown a tantrum, pushing everything off his desk or knocking chairs over on his way to ‘time out.’ He never volunteers any information. I've tried talking to him one-on-one, and he refuses to talk to me. He won't tell me anything about how he's feeling or why he's angry. He just says, ‘I don't know.’ I am so frustrated I could scream. He disrupts the whole class. The other children don't want to be around him because he blames them when he breaks the rules. If he is on the playground with other children playing a game, he will begin fighting with them if he's not getting his own way. I just don't know what to do at this point. I've tried everything. Ms. Cameron, the third-grade teacher, told me Bobby was a handful, but I had no idea what a problem this child would be. Do you have any suggestions?”

   You ask Ms. Mathews if Ms. Cameron, Bobby's third-grade teacher, had similar problems last year with Bobby. She indicates that Ms. Cameron was always talking about Bobby's bad behavior in the faculty lounge.

   You state that you will try to talk to Bobby and also contact his mother. You feel that, perhaps, there are issues at home of which the school might be unaware. The following day, you talk with Bobby during lunch and free time at school.

Interview with Bobby

Bobby follows you down the hall to your office. Although you've asked him to come into your office and have a seat, he remains standing at the door looking as if he's trying to decide whether or not he will follow your directions. After some delay, he finally walks in and slouches down in a chair, crossing his arms in a defensive manner. When you ask him if he'd like to draw a picture, he tells you that he hates to draw. When you ask him what he would like to do, he points to the box of checkers.

   While playing checkers, you ask him about his behavior in class. Bobby never makes eye contact and simply states “I don't know” to every question you ask. When you ask Bobby what he would like to talk about, he replies, “Nothing.”

   After three games of checkers, you tell Bobby it's time for him to go back to class. Bobby slams his fist on the table and turns the checkerboard upside down, sending checkers flying all over the room. You say, “You must really be angry about something.” Bobby only shrugs his shoulders and begins walking to the door.

   You tell Bobby that before he can go back to his classroom, he must help you pick up the checkers. Bobby says, “It's not my fault the stupid checkers fell on the floor.” He quickly runs out of the room, slamming the door on his way out. You wait a minute or two and then go to his classroom to make sure he is there.

· 15.1–1 At this point, what symptoms have you noted?

 

· 15.1–2 Does Bobby display any strengths? If so, what are they?

 

· 15.1–3 Who are the other people involved with Bobby that you would like to interview in order to get more information?

 

Interview with Susan Jones

You call Susan at work and ask her if she can come in to the school to talk with you about Bobby. She states that she works until 4:30 every day but could come after she gets off work. You agree to see her at 5 P.M. Bobby attends the after-school program at the YMCA, which is open until 6:30 P.M.

   Susan is a bubbly, enthusiastic woman who is neatly dressed in blue pants with a matching print blouse. She is petite with long brown hair tied back in a ponytail. She states that she has been having a very hard time dealing with Bobby at home and is glad someone is taking an interest in him at school.

   You ask her what it's like at home with Bobby. She states that he argues with her about every little thing. She states that Bobby will be negative even about things she knows he would like to do. She explains, for example, “The other night I said, ‘Bobby, do you want to go have pizza?’ His response was, ‘Can't we get it delivered?’ When I finally convinced him that I was going out without him, he decided he'd go along. When we got to the restaurant, he argued about what kind of pizza to get, what kind of drink, and where to sit. I was so worn out by the time we got home, I just let him have his way. He wears me down. Every morning it's a tug-of-war getting him ready for school. He never wants to do as he's told.”

   You ask Susan about other negative behaviors like fighting with other kids or hurting animals. Susan tells you that he would never hurt an animal. She said they had a dog and a cat, and one thing Bobby does well is to take care of the pets. He likes to get the cat on his lap when he's watching TV, and he'll sit there petting him for hours. He also takes the dog out to play in the yard and seems to really care about the animals.

   On the other hand, when it comes to following the rules, Bobby never complies. “He fights me over every little thing,” Susan tells you. She rolls her eyes and rubs her forehead. “I just don't know what to do anymore. It's all I can do to get all the kids clothed and fed these days. My job doesn't pay much even though I got a college degree. It's hard to make ends meet with six kids.”

   “Does Bobby have any contact with his father?” you inquire.

   Susan looks out the window and sighs. “Bobby's daddy never paid any attention to any of his kids. He's a drunk, and I think it's probably better that he never comes around. Bobby thinks his dad is superman, though. He has this fantasy that his daddy will come to the house one day and ask Bobby to come live with him. I've tried to explain to Bobby that his daddy has a drinking problem and can't hold a job and won't ever take care of him. That makes Bobby mad as can be when I tell him that. He doesn't want to believe his daddy doesn't want him. I think that's what's making Bobby so angry all the time.”

   “It sounds like it might have been hard being married to Bobby's father. How long were you married to him?” you ask empathically.

   “Oh, I'd say too long,” Susan says with a little laugh. “Actually it was about 6 years. Jerry was mean when he got drunk. He'd get so mad sometimes that he'd haul off and hit me and the kids and threaten to throw us out of the house with no place to go. I was going to school so I could get away from him. It took about 2 years but I finally got up the courage and left. It was the hardest thing I've ever done, but I knew I had to do it for the kids.”

   “Wow, that took a lot of courage,” you respond. “How old was Bobby when you left?”

   “He was almost 6 years old, I believe,” Susan says. “He started being real disagreeable around that time, but he's never liked other people telling him what to do even when he was a toddler.”

   “When he gets so disagreeable, how do you usually handle that?” you ask.

   “Sometimes I just try to ignore his bad behavior,” Susan acknowledges. She frowns and begins tapping her foot on the floor. “Sometimes, when I just can't ignore it, I send him to his room. That doesn't always work, though, because he can throw a temper tantrum and tear up his room so it's almost destroyed by the time he gets through. Sometimes, I put him in the bathroom for ‘time out.’ I haven't really found anything that works very well.”

   “Okay, so perhaps one of the things we might work on is figuring out how to get Bobby to show more positive behaviors. What are some of the positive things you see in Bobby?” you ask.

   “Well, like I said before, Bobby is real good with animals. He can talk to them and show them a lot of affection that he doesn't seem to be able to do with other people. Another thing is that there are times when I can just tell that Bobby really wants to be close to me, but he doesn't seem to know how to do it. It always makes me sad when he seems to want it so much, and then when I try to give it to him, he rejects me or gets angry and tells me to get away. I think he's crying for help.”

   “So there are times when you see some kindness and tenderness in Bobby that maybe other people don't get to see very often. Is that correct?” you suggest to Susan.

   “Yes, that's absolutely right. I'm hoping this therapy will help Bobby and me to get closer and for Bobby to be able to get some control over all his anger,” Susan says with a sigh.

   “I think I can help you with both of those things, Susan. You are clearly very invested in helping your son, and that's a hopeful sign that we'll be able to help Bobby together. I'll need to be working closely with you in order to help Bobby since you are his mother. Okay?”

   Susan sits back in her chair and looks relaxed for the first time in the session. “Okay, that sounds like a very good plan.”

· 15.1–4 What strengths have you have assessed that Susan Jones possesses?

 

· 15.1–5 Who would you want to get permission to contact for additional information about Bobby's behavior?

 

· 15.1–6 What is your diagnosis for Bobby?

 

Case 15.2

Identifying Information

Client Name: Michael Barron

Age: 12 years old

Ethnicity: Caucasian

Educational Level: Seventh grade

Parents: Mandy and Jerry Collins (stepfather)

Intake Information

Mike, a 12-year-old Caucasian male, was referred to the Children's Counseling Center by the school counselor at the middle school where he attends seventh grade. You are a practitioner at the Counseling Center and have had other referrals from this counselor. The referral resulted from an incident in which Mike and a friend were picked up by the police for skipping school. Mike and Bobby were hanging out near a local pool parlor when two patrol officers questioned why they weren't in school. Although Bobby gave the officers his correct name and address, Mike told the officers his name was “Barry Burrito” and he lived in Chihuahua on the border of Mexico.

   When Mike and Bobby were taken to the local police station, Mike finally told the police his real name. He was given a citation, and his parents were called and interviewed at the station. Mandy works as a technician for a local computer corporation, and Jerry is a self-employed house painter and carpenter. At the request of the school counselor, Mandy made the initial appointment and arrived on time at 8 A.M. with Mike and her 2-year-old daughter, Elisa. Mandy is pregnant with her third child and is expecting to deliver in the next month.

Initial Interview

You greet the family in the waiting room and notice that Mike is sitting off in the corner looking very glum, while Mandy is reading a book to Elisa. You suggest that a student intern can stay with Elisa in the playroom while you talk with Mike and Mandy. Mike makes no eye contact with you but gets up and follows his mother to your office. Mandy appears to be dressed for work in a tailored pantsuit, while Mike is wearing baggy blue jeans and an oversized T-shirt with a rock band logo on the back of it. Mandy apologizes for needing to bring Elisa with her, but she takes her to the childcare center at her job.

   Mandy begins the session by stating that she feels as if she's losing control of Mike and is concerned about his risky behaviors and constant lying. “I just can't trust him anymore,” she says.

   The latest incident with the police is just one in a series of problems she has been having over the past year. She feels that Mike disregards any rules that are placed on his behavior. She states that on the day of the incident with the police she took Mike to school and told him to walk home afterward. She told him that she'd be home at 5 P.M. Mike and Bobby apparently decided to leave school during the midmorning break. They walked down to the local pool parlor where they were found panhandling to buy lottery tickets at the convenience store next door.

   “I think Bobby is a bad influence on Mikey. Bobby is 16 years old and has been nothing but trouble since becoming friends with Mikey. That's when Mikey began sneaking out of the house at night, lying about his whereabouts, and drinking alcohol at Bobby's house when his parents weren't home.” Mandy states that this is the first time the police have been involved and it's really scared her.

Interview with Mike

You decide to talk with Mike alone about the incident with the police, and ask Mandy if she'd like a cup of coffee in the waiting room. Mike remains slouched in his chair, looking disinterested and depressed. When his mother leaves the room, he states that she's always bugging him about school.

   “She's always griping about my grades and how I'm never going to get into college if I don't make good grades. I don't even want to go to college. I'm never going to make A's in school. I'm just dumb, I guess.”

   “What grade are you in, Mike?” you query.

   “Seventh grade, middle school,” Mike replies.

   You ask Mike if there's anything he likes about school, and he states that he likes to be with his friends and likes art class. “I don't like math; I hate language arts; science is okay, but I'm really not good at anything except art.”

   “What do you like to do in art?” you query. For the first time during the interview, Mike appears animated. “I like to draw, paint with watercolors or acrylics, and work with clay. One of my sculptures won a prize in the art contest last year.” You note that Mike seems to feel good about this accomplishment.

   You ask about any other activities Mike might enjoy. He states that he tried out for basketball but quit after being a substitute for part of the season. “It was so boring; I just sat on the bench the whole game.”

   “What about at home? How are things at home?”

   Mike shrugged his shoulders and said, “Okay I guess.”

   “How do you get along with your stepfather, Jerry?”

   Mike slumps back down in his chair and stares at the ceiling. “He's never home. He works all the time, and he's always telling me what to do. He's not my real father, and he doesn't care about me, just Elisa and the new baby.”

   “Do you ever get to see your real father?” you ask.

   “He doesn't live here anymore and got married to someone else. I haven't seen him in about a year, and he never calls. My mom is always saying he never pays his child support. I don't really care about him. He and my mom got divorced when I was just 5 years old, and all I remember is that he was drunk all the time and used to yell at my mom and sometimes hit her.”

   You ask Mike if there's anything else he likes to do. He states that he likes to go to the mall with his friends; he likes to surf the Internet and play Nintendo. “My mom is a computer nerd. She knows everything about computers. I wish I had my own computer like hers.”

   “It sounds like you have some things you do very well and other things that you aren't so happy about. Maybe we can talk more about these things.” Mike nods his head and plays with his belt buckle.

   Mike appears to be getting noticeably more uncomfortable sitting still and talking. He taps his feet, fidgets with his fingers, and appears distracted by every sound in the hallway. You decide to stop the interview with Mike at this point and talk further with Mandy. You escort Mike back to the waiting room and give him some paper and colored pencils, asking him if he can draw a picture for you. He sits on the floor, using the child's table to spread out the paper and pencils, and seems occupied with the project. You tell him that you are going to talk to his mother about the family situation and his childhood. Mike shrugs his shoulders and says, “Okay.”

Interview with Mandy

You ask Mandy if she would mind coming back to your office to talk about the family situation when Mike was younger. You start by explaining to Mandy that you'd like to get some information about the years when Mike was growing up and the family situation at the time.

   “I'd like to start at the beginning and find out as much as I can about your experience with Mike as your son. So, I'd like to go back to the time before Mike was born and ask you about the pregnancy and birth and so forth,” you begin.

   Mandy nods and says, “Well, the pregnancy was fine. I had some morning sickness for about 3 months in the beginning, but it wasn't that bad and went away by about the fourth month of pregnancy.” She goes on to tell you that she and her former husband, Tim, hadn't really planned on having a baby, but they were happy about her pregnancy. She states that nothing unusual occurred during the pregnancy and she had a normal birth without any complications.

   Mandy goes on to say that shortly after Mike was born, she began having problems in her marriage due to Tim's drinking all the time. “He worked construction, and when he came home, he'd just sit in front of the TV and drink one beer after another. At first, he'd just fall asleep in front of the television, but then he began getting belligerent and would pick fights with me over little things.”

   Mandy describes a great deal of marital discord in the first 5 years of Mike's life. She finally decided to leave Tim and went to live with her mother for a couple of years while attending a community college to learn computer programming.

   Mandy states that Mike seemed like a normal, happy, but very active little boy and didn't have any problems until he got to kindergarten. At that point, he began having trouble getting along with other kids in his class. He was so active that he would sometimes aggravate the other children, and the teacher called several times that year and said Mike just refused to follow the rules. It was apparent that Mandy was focused on her marital situation, as well as busy going to school, and had felt that he would just grow out of it.

   In first grade, Mike had difficulties with his letters and numbers and seemed to be a little behind other kids his age. The teacher felt that he had a developmental problem and was maturing more slowly than other kids but didn't seem too concerned about it. In the second and third grades, it became apparent to Mandy that something more than just immaturity was going on, so she had him tested by the school psychologist, who told her Mike had ADHD and should be seen by a physician.

   Mandy took him to a pediatrician who put him on Ritalin during the weekdays. He did not take Ritalin on the weekends. She said it helped his activity level, and he seemed better able to pay attention in class. His grades improved a little; he was making B's and C's instead of D's after he started taking the Ritalin. He still got into trouble for his conduct, especially on the playground. He couldn't seem to get along and never had many friends.

   Mandy mentions an incident in sixth grade that really worries her. Apparently, Mike had walked into a neighbor's house through the back door and stolen some cookies that were sitting out on the counter, as well as a jar of loose change that was within eyesight. He had hidden the jar of change under his bed. Jerry walked into his room one night when he was sitting on his bed counting the money. Mandy was chagrined, and Jerry was livid. Jerry thought that Mike had stolen the money from his drawer in the bedroom, but Mike confessed he'd taken it from the neighbors' house. Jerry made Mike go over to the neighbors' and tell them he'd taken the money and apologize. Luckily, the neighbors didn't call the police or try to prosecute him.

   Mandy relates another incident that occurred about 5 months ago. Mike had been to the swimming pool in the neighborhood one day during the summer and met another little boy over there who had some firecrackers from the Fourth of July. Mike and the other boy were found throwing the firecrackers at some cats who belonged to a neighbor who lived near the pool. The cats had been injured, and Mandy and Jerry made Mike work the rest of the summer to pay the vet fees for the injured cats. “The thing that bothered me the most,” Mandy sighs, “was the fact that Mike didn't show any remorse about having hurt the animals. That really bothered me.”

   Mandy states that Jerry and Mike have never gotten along very well, and she's had to restrain Jerry on a couple of occasions when he wanted to whip Mike with a belt as punishment. “Jerry is very traditional. He thinks I've just been too lenient with Mike and all he needs is a good spanking. I really don't know what to do with Mike these days. He's getting bigger and older, and I'm afraid he's going to get into big trouble with the law if he doesn't learn how to follow the rules.”

   You tell Mandy that you feel you have an understanding of what some of the problems have been for Mike but that you would also like to know about some of his strengths.

   Mandy tells you that Mike's biggest strength is his artistic abilities. “He is extremely artistic, which he probably gets from my father, who was an amateur artist. He can draw almost anything, and he paints and sculpts and can make beautiful pottery out of clay.” Mandy states that he used to be helpful around the house, but recently, he won't do anything she asks. She states that she's concerned about the time she'll have to focus on the new baby when it arrives and how that will affect Mike.

· 15.2–1 What are some of the underlying issues that may be affecting Mike's behavior?

 

· 15.2–2 What are some of Mike's strengths?

 

· 15.2–3 What are some underlying fears that you imagine Mandy is having concerning her son?

 

· 15.2–4 Who would you like to get permission to talk with outside the family concerning Mike's behavior?

 

· 15.2–5 How would you initially diagnose Mike?

 

Case 15.3

Identifying Information

Client Name: Sandra Jenkins

Age: 38 years old

Ethnicity: Caucasian

Marital Status: Married

Occupation: “Retired” attorney

Children: Jessica, age 6

Referral Information

Sandra has been mandated to get counseling as one of the terms of her probation for a conviction of shoplifting from a local department store at the mall. She stated that she meant to pay for the diamond earrings that were found in her coat pocket, but she got distracted and forgot. From her probation records, you discover that she has had two prior convictions of shoplifting, but because she retained a well-known lawyer, she was given community service without probation. This time, however, the judge placed her on probation and mandated her to counseling for the duration of the probationary period.

Initial Interview

Sandra Jenkins, a 38-year-old Caucasian female, is a very poised, attractive woman who attended a prestigious college and graduate school. She received a law degree when she was 26 years old and worked as a corporate tax lawyer making over $100,000 per year. Sandra reports that she has excellent analytical skills and a very high IQ. She met her husband, Jim, during her first year of practice. Jim is also a corporate lawyer.

   Sandra and Jim married a year after their first date. They live in a wealthy suburban neighborhood with their only child, Jessica, age 6. Sandra states that she had two miscarriages before having Jessica and doesn't plan on having other children. Sandra quit her job after Jessica was born and has engaged in volunteer work at the hospital for the past 4 years.

   Sandra's grandparents were from Italy, and they passed away by the time Sandra was 5 years old. Her paternal grandfather had a history of alcoholism. Sandra's parents moved to the United States when she was only 2 years old. She had two older brothers and a younger sister. Sandra came from a lowincome family and worked her way through college and law school. Her mother suffered from depression and stayed at home. Her father worked in the garment industry in New York.

   In giving this information, Sandra appears to be nonchalant and unconcerned about the shoplifting incident, but also a bit defensive in her responses to your questions. After talking for some time, however, she begins to seem more willing to engage in a relationship with you as the counselor.

   Beginning where the client is, you ask Sandra what she would like to work on during these sessions. She states that she is concerned about her marriage and isn't sure if she wants to stay married to Jim.

   “Life has seemed so unfulfilling lately. Jessica is in school all day, and I just don't know what to do anymore to fill the hours I have to myself. I feel bored and lonely a lot of the time. I admit I need a lot of stimulation in my life. I've always gotten bored easily. Jim says I should be happy not having to work and that I can do anything I want to do. Besides, I'm bored in our relationship, too. We used to go on trips and have a very exciting sex life, but now, it's just dull. Jim doesn't want to go to interesting places. He likes to go to the beach and fish. And we don't even have sex that often anymore. Partly because it's boring to me, but Jim doesn't seem that interested either. I don't know; maybe I just need a change.”

   “Do you think these feelings are related to the shoplifting incident?” you ask.

   Sandra looks flushed and guiltily turns her head away. “I just don't know what comes over me. I go into a store thinking I'm just going to do some window-shopping. I don't really intend to buy anything, and then this intense urge to take something just overwhelms me. It's not like I couldn't just buy it. We have plenty of money. I don't know what happens, but I just feel like I've got to have something and I take it.”

   “How does it feel once you've taken the item?” you query.

   “Actually, I feel better—unless I get caught, and then I feel terrible about myself,” Sandra relates.

   “Can you tell me how many times this has happened when you haven't gotten caught?” you ask.

   Sandra eyes you warily. “Who says I've ever done it when I wasn't caught?”

   “You did just a few minutes ago when you were telling me how it made you feel,” you suggest.

   “Well, I guess there have been a few times when I didn't get caught. It wasn't anything expensive though. Just some fake jewelry and stuff like that. I didn't even really like the things I took,” Sandra responds.

   “What do you usually do with the items you take from the store when you get home?” you ask.

   “I just throw them in a drawer in my dresser or put them away in the closet. The urge goes away for a while and then it comes back again.”

   “How often do you have this urge? Is it once a week or once a month or just every once in a while?” you ask her.

   “It's really odd. Sometimes, I feel the urge every time I go shopping, about twice a week. Then, it disappears for months at a time before it comes back. If you want to know the truth, it's been happening to me for years. Even back in college, I was taking stuff from stores. Sometimes I'd take stuff I didn't even need and give it to other girls in the dorm. In fact, most of the time, I stick it in a drawer and end up throwing it away without ever having used it,” Sandra states.

   “Do you have any idea what causes this urge to come over you?” you ask.

   “No idea whatsoever,” Sandra states. “I just see it, I begin to feel this intense urge to take it, and then after I have it, the urge goes away and I feel better. I know it's against the law. After all, I'm a lawyer, for goodness sake. What do you think is wrong with me?” Sandra wonders.

   “I think that's what we're going to work on when you come in to see me for these sessions. You're required to come to counseling on a weekly basis for a year. Hopefully, by our working together, you'll be able to change some of these behaviors you've been engaging in. Are you willing to work on making some changes?” you ask.

   Sandra agrees to come for weekly counseling sessions. You feel that you've established some initial rapport with her since she was willing to admit some of her past behaviors.

· 15.3–1 Sandra has several strengths. List three of them.

 

· 15.3–2 Are there other questions you would like to ask Sandra? If so, what are they?

 

· 15.3–3 What are some resources that might be helpful to Sandra?

 

· 15.3–4 What diagnosis would you give Sandra?

 

Case 15.4

Identifying Information

Client Name: Mary Searcy

Age: 34 years old

Ethnicity: Caucasian

Educational Level: High school graduate

Occupation: Waitress

Intake Information

Mary Searcy called the Truluck Mental Health Center, a public, governmentally funded agency, and requested an appointment with a counselor. She stated that she's about to lose her third job in 6 months due to an anger problem. When the intake worker asked her if she could expand on what she meant by anger problem, Mary stated, “It's just out of my control.”

   She further stated that her manager told her if she didn't get some help, he'd have to let her go. An appointment with you was scheduled for the following day.

Initial Interview

Mary arrives at the mental health center wearing her waitress uniform and her hair pulled back in a ponytail. She is sitting calmly in the waiting room reading a magazine when you arrive to greet her. She smiles and tells you she came a few minutes early because she's going to have to leave in an hour in order to get to work. She tells you as you're walking to your office that she can't afford to be late or she'll lose her job.

   “So, you've been worried about your job lately?” you inquire.

   “Yes, I just can't lose this job because I might never get another one,” Mary says.

   “What's been happening that makes you think that?” you ask. You wonder if Mary is being realistic or if she is exaggerating the problem.

   “Well, it's my anger, I think,” Mary tells you. “Although I'm not really sure my anger is the problem. But it must be.”

   “You think you may have a problem with your anger, but you're not sure,” you suggest.

   “Yes, you see it doesn't happen often, but when it does happen, it's really out of control,” Mary says. She looks nervously around the room as though she's searching for the right words to express her thoughts.

   “You mean your anger?” you ask.

   “Well, I don't really know what else to call it, but it feels like anger. You see, it started about 2 years ago. I had a job out in California making good money waiting tables at a really upscale restaurant. I was doing a good job, and my boss wanted to make me head waitress. He gave me all the big parties, and I was finally getting some bills paid and keeping up with my rent and car payments. Then one night, this other waitress said something to me like, ‘Could you hand me that pitcher of water?’ She had a huge platter of food, you know, lobster and steak dinners, and I don't know what came over me, but I just hauled off and knocked the tray up against her and hit her upside the head. She landed on the floor, and the tray landed on top of her. Or at least that's what she said happened. I don't clearly remember, you see. It's all kind of a blur. I don't really remember being angry, but I guess I was. Anyway, $185 worth of food hit the floor, and my boss was so angry with me I knew I was going to lose my job. So, I just walked out of the restaurant and never went back.”

   “Did you have problems with this other waitress before the incident occurred?” you ask.

   Mary scowls and rubs her forehead. “I think we got along okay as I remember,” she says. “I remember I'd had trouble earlier in the day with my landlord claiming I owed him money for getting the carpet cleaned. I hadn't asked anyone to clean the carpet and didn't think I should have to pay for it. I also remember having an argument with my boyfriend because I had to work that night and he thought I was off and wanted to go out. So, I guess it had been a hard day before I ever got to work,” Mary ponders.

   “Do you remember how you were feeling at work that night?” you ask.

   “I just remember being irritable, like in a bad mood,” Mary suggests. “But I don't think I was really angry at Sue, the waitress I knocked down, just tense. Then when she asked me for the water pitcher, I just exploded.”

   “How often would you say this type of situation has occurred over the past 2 years?” you ask.

   “Well, I'd say it's been happening once a month or so but not always at work. It's happened at home several times, and I've had two relationships that broke up because I just lost control of myself. One guy told me that I needed to get help after I'd thrown the frying pan through a window at the house, and he just left and never came back. That happened about a year ago. At the time, I didn't think he knew what he was talking about, but now, I think maybe he was right. I've had three jobs in the last 6 months, and I just can't afford to lose this one.”

   “So, you lost two jobs in the last 6 months because of your anger?” you inquire.

   “Yes, well, it was the same type of thing that happened in California. I had this one job that I liked and I thought was going pretty well, and one day I came to work and had a big party of eight people I was waiting on by myself. Then the hostess gave me another party of six. Normally, I could handle it. But, I remember getting real tense because I didn't have any help, and I was rushing around trying to get all the orders. One obnoxious guy at the table of eight kept asking me for more coffee. I was doing my best, but I couldn't get to him right away. Finally, he puts his arm out and grabs me around my waist and says, ‘Why are you ignoring me?’ I just lost it. I took the whole pitcher of water and dumped it on his head and was yelling, ‘Can't you see I'm a little busy here? I'll get your damned coffee when I get a chance.’ The guy tipped back in his chair so far that he fell over onto the floor and threatened to sue the restaurant. Needless to say, I lost that job.”

   Mary sinks into the chair and looks very unhappy. It sounds as if this is the first time she's admitted to having a problem or identifying her behavior as a problem for her.

   “Looking back on it now, I'm not sure why I dumped the water on his head. He was obnoxious, but I've dealt with a lot of obnoxious people in my job, and I never went to that extreme or got that upset,” Mary remarks. “The most recent thing that happened wasn't that bad. I just knocked a hole in the wall in the kitchen at work. It surprised me that I had that much strength, if you want to know the truth. Anyway, my boss said I better get control of my anger or he'd send me packing. I really don't want to lose this job. I've got bills to pay, and I'm tired of moving from one job to the next. You've got to understand. I'm really not a violent person. Something just comes over me and I blow,” Mary tells you.

   “Okay, so it sounds as if you've been having a lot of trouble controlling these sudden outbursts that seem out of proportion to the problem you're trying to handle. Is that correct?” you ask.

   “Yes, I think that's pretty accurate,” Mary says.

   “What about other aspects of your life?” you inquire. “Do you live by yourself? Do you have a boyfriend now? Are there other things bothering you right now?”

   “I'm living by myself right now, although I do have a boyfriend. We haven't been dating that long though, maybe 6 weeks. He's a nice guy and we get along. I don't want to ruin that relationship either. I've been having a little trouble paying all my bills but nothing out of the ordinary. Other than that, everything has been okay, I guess.”

   “Have you been sick at all recently?” you inquire. “Have you been taking any medications for any medical problems?”

   “No, I'm a fairly healthy person. Don't get sick much. Maybe a cold in the winter, but that's about it,” Mary replies.

   “So, you're not taking any medicine right now?” you ask again.

   “Only birth control, but nothing else,” Mary responds.

   “What about your family?” you inquire. “Has anyone in your family ever had similar problems to the one you've been experiencing?”

   “I don't think so,” Mary states. “My mom died when I was 12 years old, and my dad remarried about a year later. I never remember my mother getting upset about anything. She was a fun person who loved to take us out shopping and to the movies. My dad is kind of the quiet type, if you know what I mean. He sort of blends in with the walls. He's a carpenter and likes to build stuff. He was always out in the garage making something—a pretty easygoing fellow.”

   “What about your sister?” you ask. “Is she your younger sister?”

   “Yes,” Mary replies, “she's 4 years younger than I am. She still lives out in California, and I don't see her very often. She was the smart one in the family. She teaches preschool at a nursery out there and has two kids of her own. I guess she's like my mom. Loves children.”

   “And how would you describe yourself?” you ask.

   “Well, I think of myself as a pretty outgoing person. I like talking to people and being outdoors. I run and ride bikes and like to go sailing when I have the chance. Most people tell me I have a good sense of humor, too,” Mary responds.

   “So these outbursts seem to come out of nowhere and don't necessarily fit with your personality,” you suggest.

   “Right, I mean I do begin to feel this tension building up inside me, but I don't know what it's about. It seems out of sync with what's actually going on at the time. And then I just have to get rid of it somehow—I just explode over some small thing,” Mary says.

   “Okay, I think I have the picture,” you respond. “I think I can help you figure out what's going on and how to get your feelings under control. Would you like to make another appointment so we can talk again?” you ask.

   “Yes, I think I really could use some help with this problem,” Mary states.

· 15.4–1 What are some of Mary's strengths?

 

· 15.4–2 What has Mary already done that you would consider resourceful?

 

· 15.4–3 What is your initial diagnosis for Mary?

 

· 15.4–4 Are there other diagnoses that you would want to rule out in this case?

 

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