Case Study: Adolescent with Adjustment Disorder
Related to Father’s Coming Out Process
A Paper Presented in Partial Fulfillment
of the Requirements of HS5254 – Child & Adolescent Counseling
Families who have a member that comes out as gay or lesbian sometimes have difficulty adjusting to this revelation. The current paper examines the case of 12 year old Chris, whose mostly-absent father recently came out to the family. Since his father revealed his orientation, Chris has been exhibiting adjustment problems, including inappropriate conduct at school toward female classmates, which has resulted in multiple disciplinary actions. A combination of Rational Emotive Behavior Therapy and Solution Focused Therapy is considered for treatment, and the effects of the family, community, and culture on Chris’ development of his condition are evaluated. Finally, the legal and ethical implications in this case are explored.
Chris is a twelve-year-old, Caucasian sixth grader who has been suspended for the second time for bullying female students on school grounds. He lives with his single mother who works two jobs. There are two younger children at home (ages 6 and 10, both boys). The biological father is a long-haul truck driver who sees his sons occasionally and has recently disclosed his homosexual orientation to the family.
Brief Foundational Description
Rational emotive behavior therapy (REBT) is based on the concept that individuals experience emotional distress when they experience irrational beliefs in connection to an event, which results in a maladaptive negative emotional reaction or dysfunctional behavior (Vernon, 2003; DiGiuseppe, 2007). REBT works by helping people identify their irrational beliefs, helps them learn to challenge those beliefs, and then to develop more rational beliefs to take the place of the old dysfunctional ones. Ellis (as cited by Watson, 1999) believed that people “can overcome the effects of past experiences by reassessing their perceptions of the past and re-evaluating their interpretations of its influence” (p. 8). This approach uses the A-B-C-D process. By examining an individual’s beliefs (B) about activating events (A), the therapist can help the client see that it is the beliefs about the events, rather than the events themselves, that result in the disturbing emotional or behavioral consequence (C). The therapist can then intervene to help challenge or dispute those beliefs (D), thus opening the way for the client to shift his or her perception and deepen his or her understanding of the self and the situation at hand. This should lead to a lessening of the disturbed emotion or dysfunctional behavior.
Chris is right at the edge of adolescence: old enough that some of the adolescent challenges are beginning to become apparent to him, while young enough that REBT might be especially effective. DiGiuseppe (2007) suggested that this approach is more effective with preadolescents than with adolescents, since the latter, although more cognitively mature and capable of following rational thought, often reject authority and believe that they know it all. With Chris, a rational emotive behavioral approach could help him uncover the irrational thoughts that lead to his disturbed feelings and result in his unacceptable behavior at school. This approach may also assist Chris in developing a more satisfying relationship with both his father and his mother. If successful, Chris may be able to continue to utilize the REBT process throughout his adolescence and beyond, potentially alleviating some of the stress and confusion of everyday life.
Strengths and Weaknesses
One of the strengths of REBT is its clarity and ease of learning the steps involved. This makes it especially good for use with children and adolescents (Vernon, 2007). Yet, REBT also utilizes several different types of techniques, focusing on behavioral, cognitive, and emotional spheres (Vernon, 2003), giving the therapist more flexibility for assisting the client in the disputation and rehearsal phases of the approach.
The two most significant limitations of this approach are the lack of empirical research supporting its efficacy (DiGiuseppe, 2007; Vernon, 2003), and the risk that this particular client will not accept that he has anything that needs changing. If Chris refuses to acknowledge that his behavior is unacceptable and that his beliefs/thoughts that lead to that behavior are irrational, the therapist will be at a stand-still with him. It is imperative, therefore, for the therapist to build a strong therapeutic alliance with Chris before engaging in any cognition disputation (DiGiuseppe, 2007).
Solution-Focused Family Therapy
Brief Foundational Description
In SFFT, therapists don’t categorize people by their behavior, preferring instead to focus on the solution rather than analyzing how the problem developed (Nichols & Schwartz, 2008). Solution-focused therapists also describe a family’s problems as “normal life-cycle complications,” rather than a flaw or a failure of the family (Nichols & Schwartz, 2008, p. 348). Families are viewed as resourceful and able to adapt to change, although sometimes they need a bit of guidance to shift their perspective and to remember how to deal with their own problems. The therapist would work with this family through asking exception questions, scaling questions, and coping questions to help them to see where they already have the resources within themselves (both individually and within the family system) to find resolution to the problems they’re experiencing. The therapist would use compliments to reinforce their individual and collective sense of efficacy regarding their ability to cope and to find and adhere to solutions (Nichols & Schwartz, 2008).
The reason for selecting this approach is that it empowers the family and all its members to refocus on solutions, rather than getting mired in problems or the etiology of the problems (Nichols & Schwartz, 2008). It focuses on positivity and empowerment, and teaches the family skills it can use in the future. This learner prefers to approach people and life’s challenges from an optimistic perspective, believing in people’s inherent goodness and capacity or motivation to improve or change, and this approach supports those preferences and beliefs.
Chris and his family have several challenges they need to work through, including Chris’ aggressive behavior, the mother’s challenge of raising three boys while working two jobs, and the father’s coming out process and need to repair his relationships with his children. This therapeutic approach will help each member of the family to re-focus on the positives already in their lives, and will teach them to work together to seek solutions that will help each of them individually, and all of them as a whole. This will strengthen the family and will enable them to meet future challenges with more confidence.
Strengths and Weaknesses
Solution-Focused Family Therapy (SFFT) is known for its more positive, non-pathologizing approach, and its belief in the family’s capacity to fix its own problems. This is a strength in that it can help a family relearn how to approach the difficulties and challenges that come up, not just how to fix the current problem. This collaborative process empowers families by promoting “the creation of meaning, personal responsibility, and agency” (Lewis, 2003, p. 289). Lewis (2003) further reported that this form of therapy “makes maximum use of a number of the common factors influencing successful counseling and therapy” (p. 304), including highlighting a client’s strengths, imparting a sense of hope, and employing several techniques that promote change.
SFFT is also relatively straightforward and can easily be taught to families, so that they can apply its principles and interventions themselves in the future.
The primary limitation of this approach is inadequate research establishing its efficacy (Lewis, 2003). One of the challenges of trying to apply this form of therapy is when the family members can’t agree on a common goal (Gunn, Haley, & Prouty Lyness, 2007).
Combination of Approaches
The beauty of combining these approaches is that they both empower the family and give them skills to use to more effectively and productively handle future problems and challenges. Both of these therapies also focus less on figuring out where the problem comes from, and more on how to move beyond the problem, which is forward-thinking and helps the family to shift from frustration to accomplishment.
Analysis of Factors in General
Children are influenced in their development by their own internal processes (including biology, personality, adaptive behaviors, and motivations), by their family’s effects on them, and through the influence of their communities, their culture, and the society in which they live. Further, all of these realms of influence affect and are affected by each other in multiple, bi-directional ways.
The individual, internal factors that influence the development of disorders in children include their “reactions…to conditional love” (Presbury, McKee, & Echterling, 2007, p. 185) according to Rogers’ view of psychopathology. Freud felt that neurotic conflict was a result of internal conflict between different parts of the self (Merydith, 2007). Negative cognitive distortions also contribute to the development of disorders (Gilman & Chard, 2007), as do maladaptive beliefs and emotions (DiGiuseppe, 2007). Reality therapy suggests that children choose dysfunctional behavior as a way of avoiding (or because they feel incapable of dealing with) the pain of loneliness and failure (Fuller, 2007).
Families can contribute to children’s development of disorders through neglect or abuse, or pampering (Kelly & Lee, 2007); dysfunctional structure and patterns (Presbury, et al., 2007); inadequate parent training and practices (DiGiuseppe, 2007); irrational family beliefs regarding roles, rules, topics of discussion, and behavior (DiGiuseppe, 2007); and inappropriate boundaries (Gunn, et al., 2007). Absent fathers contribute to a child’s development in several ways. First, they tend to parent differently than mothers, who are more nurturing and verbal (Vander Zanden, Crandell, & Crandell, 2007). By contrast, fathers are more physically demonstrative and encourage achievement in their children. The effects of both parents’ parenting focus, style, and quality of love, influence the development of their children both physically and psychologically (Vander Zanden, et al., 2007).
Additionally, the fact that single mothers tend to make a lot less than their male counterparts means that a lot of children who grow up with an absent father may also experience more poverty, living in substandard housing, gaining an education in poorer schools, benefitting from less healthcare insurance, and less overall parental time (Vander Zanden, et al., 2007), all of which have been shown to contribute negatively to children’s mental health and self-esteem (Oberg, 2003).
Rates of psychosocial problems (such as crime, anxiety, unhappiness, and substance misuse) have increased sharply among young people in Western societies, with many studies documenting an association between poverty, marital disruption, and a wide range of deleterious effects in children’s behaviour and emotional state. (Timimi, 2005, p. 2)
The type of community in which a family lives, the availability of community resources, and the socioeconomic status of a particular community, can all influence a child’s development. According to Human Resources and Skills Development Canada, (1999), communities vary in the type of physical environment they exhibit (the quality of the homes in the area, whether or not graffiti is present, and how much green space is available) and in the social environment they create (which varies by the average income and education of residents, the diversity, the number of single parents, and number of children per adult resident). Communities also differ in what resources are offered (libraries, swimming pools, scouting programs, schools, parks, hospitals, police protection) and the collectivity of the community (the social cohesion and neighborliness). Finally, different communities exhibit varying degrees of involvement of community members working for the common good (making investments to improve the community, willing to intervene in fights, report incidents, and discipline or protect the children) It is on the community level where we see the effect of peer relationships on children’s development, as well. Especially as children approach and enter adolescence, the influence of their peers becomes much more pronounced.
Children first start learning how to fit into society through the process of cultural transmission (called socialization) from their parents and families, whereby they learn “the knowledge, skills, and dispositions that enable them to participate effectively in group life” (Vander Zanden, et al., 2007, p. 279). Culture and society have significant effects on children’s mental health. The values a culture holds that influence how children develop disorders include individualism vs. communalism, consumerism, and how youth are valued (Timimi, 2005). Cultural values also dictate what child-rearing practices are acceptable, particularly along the dimensions of warmth vs. hostility, control vs. autonomy, and consistency vs. inconsistency. The culturally-influenced parental choices along these axes have significant effects on a child’s growth and development (Vander Zanden, et al., 2007).
Children learn social values and internalize them through interactions with others in their society. They also internalize these values through the behaviors of their parents, who themselves act from a place of internalized social values. For instance, parents who grew up in the United States tend to believe in the societally-acceptable practice of instilling independence in their children, starting soon after birth, by putting their infant in a separate room (Vander Zanden, et al., 2007). We live in a “societal climate of competition that exaggerates and intensifies the tendency of children and adolescents to strive toward self-serving goals and accomplishments at the expense of others and to the detriment of cooperative, social living” (Kelly & Lee, 2007, p. 144). The effects of school and public policy can also take their toll on children’s development and mental health (Vander Zanden, et al., 2007).
The individual, whose biology and conditioning have predisposed him or her to react in certain ways, reacts to the behaviors of his family members, who have all been influenced by their community, which reflects the current sociocultural values, and in turn affects all of these levels of existence through his or her actions and reactions. All five levels interact and influence one another, until it’s sometimes difficult to tease out the cause and effect processes in the cycle.
Factor Analysis Applied to Current Case Study
Chris, at twelve years old, is just entering the adolescent developmental phase which comes with a host of challenges. According to Erikson’s stage development theory (as cited by Vander Zanden, et al., 2007), the major developmental task associated with adolescence is the search for identity. This is also the time during which an individual’s cognitive capacity expands, allowing for self-reflection and a developing self-awareness (Vander Zanden, et al., 2007). While teens are busily trying to individuate from their parents and create their own unique identities, the fact is, Chris is at the very beginning of this stage and likely still strongly identifies with his father. Chris’s mostly-absent father has recently come out to the family as homosexual, which challenges Chris’ understanding of his father and thus of himself. It is likely that some of Chris’ issues stem from the need to differentiate earlier from his father than he might normally have, due to a strong negative reaction to the news of his father’s homosexuality. Chris is probably also experiencing some negative, possibly irrational, cognitions about his father, due to societal and peer-related stereotypes about gay men.
The fact that Chris’ father is often absent from home due to his occupation has some bearing on the case, as well. As mentioned earlier, absent fathers influence their children’s development by not being present to give them the love and parenting that is associated with the father’s role (Vander Zanden, et al., 2007). Chris’ mother is essentially a single parent, trying to raise three boys, and is likely struggling to give them enough attention while also holding down two jobs outside the home. The boys are likely alone much of the time, without clear boundaries, and when their mother is home, she is probably exhausted and short-tempered. This would result in a less-than-ideal home environment, which could cause Chris to be acting out, trying to get attention, and having no appropriate outlet for his own frustrations.
The community in which Chris and his family live is likely on the lower end of the socioeconomic spectrum. If his mother has to maintain two jobs to support them, it is unlikely that they live in an upscale neighborhood. Given that assumption, it’s also probably safe to assume that Chris and his family don’t have access to many community resources, which could alleviate the pressure of Chris’ difficult home life, giving him fewer outlets for working through his frustrations. Additionally, many of his peers may come from broken homes, where fathers are absent to varying degrees, so that Chris and his friends are all having to figure out how to grow into their masculinity, without many positive male role models around. This leads to irrational and incorrect information and cognitions being transmitted among the members of his peer group. For instance, prior to his father’s coming out, Chris may have participated in the joke telling about “fags” with impunity. Now, because Chris and his peers don’t actually understand that gay men present in a number of ways, with effeminate affectations only used by some, he may believes that his Dad is a “girly-man,” and so must keep that secret in order to keep the respect of his peers. Further, he must act out and feels additional pressure to exhibit his masculinity through stereotypical manly acts, like being overly-aggressive and pushing girls around.
In Chris’ case, the sociocultural values that he has likely internalized are those that say that men should be masculine, that gays are “girlie”, that girls are weaker, and that aggression is the way to get what you want. Thus, we can see these values being exhibited by Chris’ behavior: he bullies girls at school as a way of showcasing his aggressive masculinity, and to reaffirm his heterosexuality in the face of his father’s recent admission.
Preliminary Multiaxial DSM Diagnosis
Axis I: 309.3 – Adjustment Disorder with disturbance of conduct, acute
Chris is exhibiting problematic behavior since the revelation of his father’s sexual orientation, which serves as the identifiable stressor (Criterion A) (American Psychiatric Association [APA], 2000). His emotional and behavioral reactions to this stressor are in excess of what would normally be expected (Criterion B1), and he is experiencing significant impairment in his social and academic functioning (Criterion B2), as evidenced by his treatment of female students that has resulted in multiple suspensions. His behavior, because it can be traced to a specific stressor, does not meet the criteria for another specific Axis I disorder (Criterion C), and the symptoms do not represent bereavement (Criterion D).
Axis II: V71.09 – None present
Axis III: None
Axis IV: Problems with primary support group – Father is largely absent, and has recently disclosed homosexual orientation; Educational problems – Discord with fellow students
Axis V: GAF = 55 (current)
Objectives of Treatment
One of the clearest objectives of treatment is to reduce Chris’ aggressive behavior at school and the resulting disciplinary suspensions. Two other, related, goals will be to help Chris deal with his father’s recent disclosure regarding his sexual orientation; and to help him learn how to handle peer-related pressure to “prove” his masculinity. Finally, treatment should help improve Chris’ relationships with both of his parents.
Counselors who work with children and adolescents are also often called on (or feel led) to become advocates for their clients, helping to change the conditions that have led to their presenting problems (Lewis, Cheek, & Hendricks, 2000). One of the things the clinician could do in this case is offer to do workshops, in-services, and other educational training with school staff to help them learn how to deal with the lesbian, gay, and bisexual students in their school, and with the students who have a homosexual member in their family. This may lead to a reduction of peer-related issues, if the teachers are more aware of what to watch for and how to handle problems as they arise, rather than simply resorting to harsh disciplinary measures for extreme behavior.
The clinician, in this case, should be competent in providing services to child and adolescent clients. The clinician should be familiar with the homosexual coming-out process and how that can affect family members. Additionally, the clinician should be well-versed in applying both Rational Emotive Behavioral Therapy (REBT) and Solution Focused Therapy (SFT).
Location of Treatment
A private practice office is probably the most appropriate location for this treatment, due to the sensitive nature of the topic, and because Chris and his parents need more attention than can typically be obtained in brief school counseling sessions.
Interventions to be Used
The therapist in this case would use a combination of REBT interventions and techniques borrowed from (SFT). Using REBT, the therapist will help Chris to identify and challenge the irrational thoughts and beliefs he has about gay men, in general, and about his father, in particular(Vernon, 2003). Chris will be encouraged to practice thought-stopping, and later, he will be taught how to reframe those irrational thoughts and beliefs into ones that are more rational. Chris will also need to learn and practice various coping strategies, in order to withstand any teasing he suffers from his peers. The therapist can teach Chris some self-awareness exercises to practice naming emotions and can engage both Chris and the family in role-play exercises to help them learn new ways to express emotions, needs, and boundaries.
The therapist can employ some interventions specific to Solution Focused Therapy, such as the miracle question and the exceptions question (Lewis, 2003). The miracle question asks the client to imagine that one night, while everyone is sleeping, a miracle occurs wherein the problem is solved. The client is then asked to describe what they observe that is different that would prove that the problem was indeed solved. The exceptions question asks the client to remember a time when the issue wasn’t a problem, or when they were able to successfully deal with the problem (Lewis, 2003). Asking the SFT miracle question can help Chris and his family determine goals and desired outcomes for therapy, by getting them to visualize what their lives would be like if the problems they’re currently experiencing spontaneously evaporated mindset (Nichols & Schwartz, 2008). The therapist would also ask the exceptions question from SFT to help the family identify successful past interactions (Patterson, Williams, Grauf-Grounds, & Chamow, 1998). Finally, in the role of advocate, the therapist would engage in interventions with Chris’ teachers and school counselor (with client permission) to teach them how to help children who are dealing with similar coming-out issues in their families.
Emphasis of treatment
Directive, cognitive-behavioral, person-centered, individual and family, short-term, growth-oriented, entailing homework
Weekly 50 minute sessions, for 6-10 weeks
None at this time
The family will be encouraged to become members of PFLAG (Parents, Friends and Friends of Lesbians and Gays) for support and resources. Even if the family does not live in an area that supports a PFLAG Chapter, there is good deal of information available at the organization’s website (PFLAG, 2006). This organization was started by one woman who chose to publicly support her gay son, and it has since grown to over 200,000 members with chapters in over 500 communities across the United States. By helping the family connect to this and similar organizations, they can see that they are not alone in dealing with the challenges that come with having a gay family member.
Because Chris’ disorder is related to a specific stressor, there is a high likelihood he will eventually learn to cope with his father’s revelation, and the family will become stronger as a result of this process.
Utilizing REBT with Chris will empower him to find ways in the future of handling his difficulties, since it equips him with a fairly easy-to-understand set of steps for identifying problematic thoughts and challenging the irrational beliefs underlying those thoughts. Using SFT with Chris and his family is a positive approach, one that conveys the client the belief that they are their own experts and that they have the resources within themselves to solve their own problems. SFT changes the perspective from one that focuses on the problems themselves, to one that actively looks for and celebrates solutions, leading to a healthier, more positive outlook. Between these two approaches, both Chris and his family will be given tools to help them overcome future difficulties, which will contribute to everyone’s self-esteem and sense of self-efficacy.
Treatment Outcome Measures
A scaling question, similar to those used in SFT (in which an individual is asked to rate, on a scale of 1 to 10, with 1 being worst and 10 being best, their perception of the severity of the problem [Lewis, 2003]) will be used at the beginning and end of treatment to measure the family’s evaluation of the severity of the problems, and how close to the stated treatment goals they’ve come (family change). A reduction in school disciplinary measures of Chris will also be used to objectively assess whether treatment is effective (behavioral change). Reports from teachers that in-school interventions, such as support groups and workshops, are having a measurable effect on behavioral problems throughout the school population (social change).
Legal & Ethical Issues
The legal and ethical issue of confidentiality would be a big concern in this case. Client confidentiality, in general, refers to the responsibility of the therapist to avoid disclosing information about the client to any third parties without client consent (Prout & Prout, 2007). Chris is having a hard time in school, keeping his father’s sexual orientation a secret, while also attempting to demonstrate his own hyper-masculinization to protect his self-image. So, it would be very important to assure him that whatever he shares in the therapy room is private, excepting anything that would physically harm himself or others.
Informed consent means that the clients have been given complete, clear information regarding intervention approaches, and that the clients are competent to understand the information, as well as cognitively mature enough to voluntarily consent to the approach (Prout & Prout, 2007). In the case of Chris, his parents or legal guardians would need to give consent, since they are legally responsible for him, but his consent would also be important, in order to gain his cooperation in the treatment plan. A strong therapeutic relationship would need to be established with Chris, and the therapist would need to clearly explain how and why therapy might actually help him.
It will also be important to identify the “client” in this case: is it Chris alone, or his parents, or the family as a whole? Regardless of who is the identified client, the rules and expectations of counseling need to be understood by everyone involved. Since the recommended treatment plan includes both individual and family counseling, Chris would be the identified client during individual counseling sessions, while the family is the client during family therapy sessions. It is advisable that the individual sessions and the family sessions be conducted by two different clinicians, in order to prevent a conflict of interest developing for the clinician regarding Chris and his parents. Ideally, these two professionals would have their clients’ permission to share information and collaborate on treatment (American Counseling Association [ACA], 2005, § A.3). Thus, release of information or consent forms would need to obtained from the parents so that this collaboration can happen ethically (Prout & Prout, 2007).
Professional competence is yet another ethical issue that needs to be taken into account. According to the ACA Code of Ethics (2005), “Counselors practice only within the boundaries of their competence, based on their education, training, supervised experience, state and national professional credentials, and appropriate professional experience. Counselors gain knowledge, personal awareness, sensitivity, and skills pertinent to working with a diverse client population” (§ C.2.a). This means that, in the case of Chris and his family, the counselor needs to be competent not only working with children and adolescents, they must also be able to work effectively with families, and be knowledgeable about the special issues associated with homosexuality and how the coming-out process can affect families.
Especially in this case, it is additionally important to attend to multicultural issues and negative bias. Counselors are bound to not discriminate on several demographic factors, including sexual orientation (ACA, 2005, § C.5). It is essential that counselors are aware of their own internalized homophobia and heterosexism (Kort, 2008), and that they refrain from imposing any heterosexist values on these clients (ACA, 2005, § A.4.b).
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