Personal Background and Referral Source
Jake is an eight-year-old Caucasian boy with short wavy brunette hair. He was initially resistant
to joining the therapist when called out of class, as evidenced by him complaining “Why do I
have to be the one to go?”. He appeared restless and maintained minimal eye contact during the
walk to the office, including during the initial session. He often looked away during conversation
and tended to sigh when asked a question. He was dressed appropriately for the weather, clean,
sporty, and well-groomed. His speech was clear, with a normal tone. He responded to questions
but was not expanding unless prompted by the therapist. The therapist conducted a mood check,
which he described as being “bored”. His affect was restricted, consistent with the mood he
shared. Jake was oriented to person, place, and time. He denied any hallucinations or delusions.
Suicidal and homicidal ideation/intent were not reported. There were also no indications of drug
or alcohol use.
Presenting Problem
The client was referred to school-based counseling at the request of his parents and teacher. Jake
has been getting into trouble in class for talking back to his teacher and arguing with his
classmates when doing group activities, especially regarding sharing. Jake himself reported
being “mad” because he doesn’t like getting in trouble. He also stated that he feels left out when
doing group projects and is “not liked” by his peers.
History of Problem
Treatment History:
Jake has never attended any psychotherapy treatments outside of or in school; therefore, no
Release of Information was necessary.
Family and Social history:
Jake is an only child living with his married parents in an affluent neighborhood. His mother
works in insurance, and his father is a business owner working in the housing industry. His
mother described a stable home environment in which Jake had everything he needed. His
mother describes their household as one with consistent rules and expectations. Both parents are
involved in his life, attend all of his school conferences, and regularly help him with his
homework. His parents identify their family as atheists. Jake reports having two friends because
he has trouble maintaining friendships. He likes to make the “decisions” when it comes to
playing and is not willing to cooperate with others. He also has a hard time sharing when playing
with other children, so arguments often arise during recess. He is not involved in any
extracurricular activity outside of school or any other social group.
Medical History
Jake is a healthy eight-year-old boy and his parents did not report any medical history, therefore,
No Release of Information was sought from her medical provider.
Diagnosis
Z55.9 - Academic or Educational Problem
Z60.4 - Problems Related to Social Environment
Justification of Diagnosis
Jake’s current symptoms include the following: acting out in class, talking back to his teacher,
getting into arguments with peers, and difficulties in cooperating with others. Due to his age and
the clinical setting of therapy, Z-codes are more appropriate to help understand the context of
his behavior by highlighting external factors that may contribute to his symptoms in school. The
Z55.9 code applies because Jake is struggling in his classroom and with his peer relationships.
The Z60.4 code is applicable because it addresses the impact his limited social experiences as an
only child might have had on his behavior and interactions with his teacher and his peers. There
were a couple of diagnoses in which the client presented with some symptoms but failed to meet
all the criteria to specify that diagnosis. With ADHD, the client only displayed impulsive
behavior when engaged in an argument with a classmate. This would involve him yanking
supplies away or blurting out to the teacher (instead of raising his hand) when he was frustrated
and things didn’t go his way. He does not present with other ADHD symptoms. Additionally, his
symptoms are just present at school, his parents report not experiencing this behavior with him at
home. Another diagnosis that was considered but ruled out was Oppositional Defiant Disorder.
As previously stated, Jake’s behavior is only present at school and with specific interactions with
his classmates. For an ODD diagnosis, his behavior must be consistent across multiple
relationships, and presently is more situational. There also hasn’t been any inclination of a
pattern of anger (aside from feeling mad when he’s in trouble) or spiteful behavior. His
frustration seems to stem from sharing or following group rules, indicating difficulties with
social skills as opposed to an ODD diagnosis. Because his behaviors don’t meet the criteria
required for ADHD or ODD, his behavior seems better understood within the context of social
challenges and/or social skills deficits that have to do with frustration tolerance when dealing
with peers.
Theoretical Orientation and Clinical Case Conceptualization
I will treat Jake with the orientation of CBT and the model of Play Therapy. This orientation fits
his reasoning for engaging in school-based counseling to address the problems he is currently
experiencing. This is developmentally appropriate for Jake, an eight-year-old boy, in that it
combines cognitive-behavioral theory with play-based interventions that are congruent with his
emotional and cognitive level of development. CBT provides a directive and goal-oriented
structure for Jake to identify/change negative behaviors and thoughts, while the use of play
therapy provides a child-friendly way for expressing emotions, cognitive exercise, and skill
acquisition. His difficulty with managing emotions, arguing with others, and frustration can be
related to maladaptive cognitive processes and immature social-cognitive abilities.
Developmentally, Jake is in Erikson's "Industry vs. Inferiority" stage, a period when children
yearn for others’ approval and are learning to become capable. Having no siblings may have
limited Jake's ability to practice positive peer negotiation, compromise, and emotional regulation
in peer relationships. His need for control and dominance can indicate an internalized rigid
cognitive style, one that may have been brought up by the rigidity in his environment growing
up. The following symptoms: talking back to his teacher, his conflict with peers, and negative
self-statement, indicate that there may be an underlying core belief of “Things HAVE to go my
way to feel okay”. This distortion is leading to his behavioral reactions and emotional
dysregulation. CBT techniques such as emotional identification, cognitive restructuring, and
behavior rehearsal through role-playing will aim to target and replace his maladaptive
behaviors/thoughts with more adaptive and helpful ones. Aside from that, Jake has considerable
strengths that will aid in his therapeutic work. Jake's internal strengths include his ability to
engage in sessions when trust is established, an interest in drawing and art, and the ability for
insight. Some notable external strengths include consistent parental support, a structured home
environment, and school support through a planned social skills group.
Potential Limitations to Treatment
Maintaining a consistent schedule could be difficult due to the school activities, vacations, and
absences. The therapist is only at the school two times a week, so her availability is already
limited. The therapist will collaborate with the parent/teacher of the client if any missed sessions
occur to ensure continuity of care.
Treatment Plan
Goal One: Client will be able to have a safe and trusting therapeutic relationship, and success
will be evidenced by expressing emotions and communicating through play activities with
increased levels of session participation and verbal expression of feelings.
Intervention (a): Therapist will establish a secure and safe space centered on play in order to
increase his feelings of safety and encourage trust building.
(b): Therapist will reflect Jake's emotions and affect through non-directive play in order to help
make him feel seen, heard, and understood.
(c): Therapist will utilize developmentally appropriate mood check-ins (e.g., emotion meters or
feelings cards) in order to help Jake improve his ability to recognize and describe his emotional
states.
To be finished by: Session 4
Goal Two: Client will increase emotional regulation and tolerance of frustration, and success
will be evidenced by a decrease of behavioral outbursts by 50% and improved use of coping
strategies during group activities and discussions involving peers.
Intervention (a): Therapist will implement CBT-directed calming techniques (e.g., deep
breathing games, "calm down jar", STAR breathing technique) during play in order to enhance
Jake's ability to self-soothe and regulate.
(b): Therapist will use board games and turn-taking activities in order to model appropriate
behavior (e.g., impulse control and flexible thinking).
(c): Therapist will use role-plays to reenact frustrating scenarios in order to provide Jake the
ability to identify triggers and rehearse utilizing alternative coping strategies.
To be accomplished by: Session 6
Goal Three: Client will begin to recognize and dispute negative peer relationship thoughts (“no
one likes me”), with success evidenced by an increase in positive self-talk and decreased reports
of feeling left out or disliked.
Intervention (a): Therapist will use cartoon thought bubbles and play-based "thought detective"
activities in order to help Jake recognize and reframe unhelpful thoughts.
(b): Therapist will create stories or drawings with Jake that involve characters overcoming
rejection or social conflict in order to demonstrate alternative beliefs.
(c): Therapist will reinforce moments when Jake uses realistic or strengths-based thoughts during
session in order to boost his cognitive flexibility.
To be completed by: Session 8
Goal Four: Client will learn and implement social skills, with success evidenced by an increase
of cooperative behaviors in peer interactions (e.g., sharing) through teacher observation and
reports.
Intervention (a): Therapist will use figurines and storytelling activities in order to demonstrate
appropriate social behavior and negotiation skills.
(b): Therapist will involve Jake in cooperative games of taking turns and working toward
common goals in order to practice cooperation.
(c): Therapist will provide classroom challenges (e.g., an invitation to play with a new peer) and
process that experience with Jake in session in order to facilitate his generalization of social
skills.
To be completed by: Session 8-12
Course of Treatment
The therapist was able to see Jake for a total of 8 sessions before concluding this episode of care.
Jake was initially hesitant in the room with the therapist, and had limited verbal engagement. The
therapist initially aimed to create a welcoming and safe space for the client by giving him the
choice in selecting which activity or game to play with (G1,Ia). After Jake selected Connect4 to
play, Jake began ease up in the room and share information about himself such as, “I like school,
but I don’t like when my teachers or classmates get mad at me”. He shared feelings frustration
with some classmates who would not share stuff with him but expected him to share with them
and also expressed immense dissatisfaction at not being selected by his peers to join in their
games. For 4 months (scheduling conflicts/issues prolonged episode of care), Jake attended eight
therapy sessions. By the third session, Jake began demonstrating increased participation in the
sessions, particularly when they were engaged in storytelling or if the therapist used emotion
cards (G1/Ic). Jake expressed a great interest in drawing, so the therapist suggested they each
draw an animal with an expressive face that conveys what we each feel in moments when we
disagree with others. Jake drew a penguin with a sad face and a furrowed brow, and when the
therapist asked what the penguin was feeling, he said “He’s annoyed that he has to share his
stuff.” This was a particularly key moment in therapy; Jake’s drawing symbolized his frustration
he feels in class when called to share with peers and he was able to identify and express the
feeling through a drawing. (G1/Ic). Another key moment in therapy occurred in session 5 when
the therapist and Jake were playing Jenga and the tower had gotten progressively more
unbalanced. Without a prompt to do so, Jake paused his turn and took two deep breaths before
attempting to pick a difficult block that could result in destroying the tower and ending the game.
The therapist had introduced Jake to a couple of breathing techniques he could use when
frustrated or if feeling uneasy in session 3 (G2/Ib). This indicated that Jake was beginning to
increase his ability to self-regulate and suggested an internalization of at least one coping
strategy that was introduced. Another key moment of change occurred in session 7 during a role
play where Jake and the therapist were acting out a scenario in recess. Jake’s teacher had
previously shared that Jake tended to get mad, yell, and leave if his classmates didn’t invite him
to join games or activities. The therapist decided to incorporate role plays to provide Jake the
opportunity to consider alternative behaviors (G2/Ic). After numerous role plays in which the
therapist modeled appropriate ways to engage in such interactions, Jake concluded with, “I will
just ask them if I can play once they’re done or I can start a new game with my friend.” This
statement demonstrated his cognitive growth throughout the therapy.
Human Diversity Considerations
Jake is an eight-year-old caucasian boy from an upper-middle-class household. As an only child,
Jake's family structure is influenced by intense parental focus. Although his parents offer a
stable, ordered environment, such a structured environment could also have the effect of adding
to Jake's stress and need for predictability and control, especially in school, where he is forced to
work with others and abide by group expectations. Additionally, as an only child, he did not have
opportunities to learn conflict resolution or negotiation skills. Jake's struggle with sharing and
with enduring frustration might be the result of this. Without these early relationship
experiences, this may explain why he resorts to his usual behavior as a way of managing the
emotional distress he experiences in group settings. His difficulties with peer relationships,
including the way he likes to take control or feels disliked, suggest that he is struggling at the
stage of psychosocial development he is at. According to Erik Erikson, Jake is currently in the
“Industry vs Inferiority” stage, where if he is successful, he will learn to feel confident and
capable in his self, or develop a sense of inferiority. Lastly, as a young child, he is likely to
experience the therapeutic relationship as imbalanced and view the therapist as another authority
figure. The therapist should be mindful of this and approach Jake with respect and allow
autonomy to ensure he feels empowered to participate in the therapeutic work.
Legal and Ethical Issues
There were a few legal and ethical issues in this client's case. Since the child is a minor, the
therapist requires parental consent, which was obtained. I also discussed my cancellation policies
and rescheduling difficulties due to my limited time on the school campus with the mother of
Jake. The therapist also addressed her expectations as a mandated reporter to Jake’s mother and
Jake, and limits to confidentiality were also discussed in an age-appropriate manner.
Treatment Outcome
Jake completed eight sessions of school-based counseling before terminating services due to his
upcoming participation in a school-facilitated social skills group. The ending sessions focused on
reviewing his progress and preparing Jake for termination. Termination was planned and
communicated to Jake and his mother in advance. His mother was informed of his progress,
including an increase in emotional expression and a slight improvement in frustration tolerance.
Jake was reluctant to end therapy, so the therapist planned an activity where they could draw
anything they wanted to give to each other. Jake drew the therapist a poke-ball and said, “At
least I can say hi when I see you in school!”. The therapist also reviewed a few tools learned
throughout treatment (particularly the breathing technique and the STAR breathing technique he
liked) and affirmed his growth in emotional language and behavioral regulation. Jake felt at ease
and content at the end of the last session. The therapist found no termination issues or safety
concerns at the time of closure.
Prognosis and Referrals
Jake’s prognosis after therapy is generally a positive one. The therapist provided the mother of
Jake with 3 referrals to support his continued improvement. The therapist encouraged the mother
of the client to sign Jake up for a local sports team to help him continue building on his social
skills, especially since it would be a dynamic environment where he can continue practicing his
emotional regulation skills and cooperative play with peers. Additionally, the therapist
encouraged the client to participate in the social skills group that will be facilitated by the school
counselor. This group will continue to build on their peer problem-solving and cooperation
skills. Lastly, the therapist also referred the mother of the client to outside therapeutic support if
she felt that her concerns were worsening in the future. Jake has strong protective factors in place
and his motivation to engage in treatment and progress in school-based therapy point to continual
improvement if he continues building on the skills he acquired.