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Case Conceptualization Antioch New England Sarah L. Boulac

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Each family, couple, or individual adult or child that walks into my office is unique, made up of distinct dynamics, and deserves an assessment and treatment that is tailored to meet their needs. However, there are certain fundamental concepts and theories that I tend to use as the lenses through which I understand the picture of each client's life. Within this framework, there is room for the individual needs of each client to be met. What is important or works for one person may not have such an influence for others. In the case presented here, I will explain the conceptualization of the assessment and treatment along the many levels that I believe to be important. Assessment includes past and present family, school, and social functioning. Treatment addresses behavioral, systemic, as well as intrapsychic functioning, as developmentally appropriate to the individual. Craig was brought to the agency in September 1999 by his mother, Jane, who was referred by Craig's physician. Craig is an eight year old male who attends second grade at a local public school. Craig lives in a trailer with his biological mother, age 28, father, age 36, eleven year old brother, and seven year old sister. His father is employed as a logger and his mother as a nurse's aid. Jane decided to come to therapy at this time due to some of Craig's uncontrolled behaviors. She reported that in August Craig popped the tire on his father's lawnmower with a knife, shot the window of a friend's house with a BB gun, and threw rocks at his uncle's car's windows. She reported that Craig easily gets angry, has angry outbursts every day, and that his anger has been a problem since Craig was about three years old. Jane was also concerned about Craig's fears and reported that he has "seen" monsters while awake and has also had a nightmare about his sister being electrocuted. Craig had strong fears of being alone and would not shower or brush his teeth without someone being in the room with him.

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Developmental history reveals an unremarkable pregnancy with Craig. Her labor was induced two weeks past her due date and she described it to be a "long, hard labor." When Craig was born, his umbilical cord was wrapped around his neck and he was blue. He reached developmental milestones at appropriate times. Jane reports that when Craig was about two years old, his father, Kyle, had a serious alcohol problem and was verbally abusive. Jane got a temporary restraining order against him; Kyle went to martial counseling and Craig's older brother was also involved in some counseling at that time. Craig was not involved due to his young age. Kyle is currently back at home and Jane reports no further alcohol abuse nor any abuse of the children. Extended family history highlights many additional losses Craig has experienced including the divorce of both sets of grandparents, the death of his grandmother's boyfriend, his best friend recently moving away, and the death of his kitten in July. Craig has two maternal cousins who have been diagnosed with AD/HD and depression as well as a maternal uncle who is taking psychotropic medications. One paternal cousin has also been diagnosed with AD/HD. Craig and his family live within walking distance to Jane's brother, Dave, who seems to be a source of anxiety and fear in the family. Jane reports that Dave is an alcoholic who becomes very mean when he is drunk. Jane reported that he has shot at their dog and has been aggressive toward Kyle. She is afraid for her safety when it becomes dark and Kyle is not home. She has called the police who offer no assistance as she has not witness Dave committing a crime. Currently, Craig is on an active IEP at school for speech and language. He has a noticeable speech problem and sounds "babyish." He is receiving Title 1 services for reading and writing. Craig repeated first grade as he did not do his work at school. So far in second

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grade, he seems to be having some difficulty with math and reading. In October 1997, Craig took the Woodcock Johnson Test of Cognitive Ability and Achievement. The testing did not qualify him for Special Ed services in reading or math. Craig's teacher sees no defiance or uncontrolled outbursts in the classroom though she does note that he has difficulty during transitions, that he can be distractible during work time, and that he is frequently out of his seat. During clinical interviews with Craig, part of my focus centers around the developmental observations described by Stanley Greenspan, M.D. which include observations made on the following levels: physical and neurological development, mood, human relationship capacity, affects and anxiety, use of the environment, thematic development, and personal subjective reaction (1991). This model aids in sorting through and making meaning of observations as well as serves as a cue to keep my eyes open for information to understand where a child is in his/her development of these seven categories. Observations of Craig's physical and neurological development reveal that he is on target with his gross motor development. He is able to participate in and enjoys most activities including bike riding and soccer. Craig's fine motor coordination is somewhat underdeveloped as his writing skills are not as refined as those of his peers and his drawings consist of simple stick-like figures without much detail. His speech is below target range for his age; he frequently uses inappropriate pronouns and does not enunciate his words clearly. Craig prefers to communicate through sound effects and stuffed animals rather than through verbalizations. Observation of Craig's overall mood reveals a cooperative young boy who enters the room with a smile and enjoys games and playing together. During the interviews, Craig often uses the word "bad" to describe how he feels when he is angry, he gets a somber expression on

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his face when talking about these feelings, and does not want to stay long on the topic. His overall mood is receptive and curious while careful at the same time. Craig's capacity for human relationships appears to be on target. He has a best buddy with whom he spends some time, although the buddy has recently moved away. Craig also has several friends in his class that he plays with during recesses. His relatedness to me seems appropriate and he is able to organize patterns of relating to others by following rules in the classroom and during our time together. Craig separates easily from both mother and teacher (when we meet at school), and does not appear clingy with either adults or peers. Craig's affects include both positive and negative feelings during the interview. When talking about angry or mad feelings, Craig's body language and facial expressions are congruent. Craig also laughs and smiles during our interviews, especially during games and play with stuffed animals. Initially, Craig did not appear to display feelings such as worried, scared, or anxious in his play, body language, or verbalizations. However, it was noted in his intake interview that he does often have fears of the dark, of being alone, and fears of the monsters he reports to have seen. It was also reported by Jane that Craig has a fear of his uncle. Craig seems to move through his environment with confidence. He walks through the halls of his school with his head held high and with briskness to his step. Once in our room, he initially sat quickly and without much motion in one space, while using his eyes to take in the room. As our sessions progressed, he has gained in comfort and is now more animated, uses more of the space, and does not sit in the same spot for the entire meeting. Thematic expression of Craig's play includes issues of power, aggression, competition, teasing, and more recently, scaring. His play is somewhat disorganized in that it is not a continuous expression; rather it is constricted and does not have a noticeable beginning, middle,

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and end to the plot. After only one or two minutes of playing with the stuffed animals as they fight and tease each other, Craig stops the play and seems as though he does not know how or where to proceed, then either changes to a new game or begins the series over again. Play with a box of zoo animals consisted of repeated fighting between two groups with his group increasing in power with every round as they acquired guns, hand grenades, and other weapons. Interviews with Craig, Jane, and his teacher as well as a psychiatric evaluation have led to the following DSM-IV (American Psychiatric Association, 1994) diagnostics: Axis I: Axis II: Axis III: Axis IV: Axis V: 314.01 AD/HD Combined type 300.0 Anxiety Disorder NOS V71.09 No diagnosis None Difficulty in social relationships and primary support group (family) 65

My thinking about this case includes more than a DSM-IV diagnosis. The agency where I work requires that a diagnosis be given after the intake interview. While assigning a diagnosis is an important step in the assessment process, a complete picture is difficult to gain within one hour and the diagnosis assigned after this period may not be an accurate reflection of what is actually occurring within the child and/or family. During a community lecture held in November, 1998 at Antioch University by Shawn Shea, M.D., I learned what he called "the hand rule." When a clinician things they have an idea regarding what is behind someone's symptoms, it is advisable to come up with five more possible explanations. I think this is valuable because we can never be sure our first explanation is necessarily the most accurate. It is important to recognize that there can be a variety of differing causes and, possibly, treatments. Therefore, I will explain a number of hypotheses regarding Craig's case. One hypothesis is that he became bored with first grade, which he had to repeat due to his academic difficulties, and lased out in extreme behaviors the summer before entering second

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grade. He remained with the same teacher and in the same classroom for two years. This setting was very familiar to him and probably quite safe as well. Perhaps his inattentiveness last year could be due to the fact that it was all a repeat for him and he was bored with it. As summer came and went, Craig was faced with entering second grade with a new teacher and new routines. Perhaps this unfamiliarity was frightening for him and he dealt with this fear by becoming angry. When someone feels angry, sometimes they feel more in control and less vulnerable than when they feel scared. Another hypothesis is that Craig has some cognitive difficulties and that these interfere with his ability to pay attention and focus. The root of these difficulties could have a neurological or biological component. When he does not understand something at school, he drifts off into his fantasy and misses much of the instruction. Perhaps his anger outburst at ho me reflect his difficulty and frustration that he feels toward his school where he is better able to contain them due to the structured and social atmosphere. This leads to another hypothesis regarding Craig's behavior. Perhaps the family environment is not suited to his personality. There may be a mismatch in the fit between the parents and the child. Jane reported that her method of disciplining Craig's brother does not work when applied to Craig and that they are very different temperamentally. Craig seems to need more structure and external boundaries than his parents have had to give to his siblings. For example, when Craig was sent to his room, he would not quietly cooperate but would resist and tear up his room when he was alone in contrast with his brother for whom this was an effective method of discipline. What is the nature of their different personalities and the mismatch in fit? This brings up the nature versus nurture dilemma. It is quite possible that he is biologically wired differently than his brother and sister. It is also possible that the abuse

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endured by the family had differing effects on each of the children due to their different developmental stages. My final hypothesis is that the verbal abuse Craig endured by his father was quite traumatic for him. This is supported by Jane's report that symptoms began when he was three years old, just after the abuse. Initially, Craig appeared reluctant or unable to express anxious, scared, or sad feelings but would go into rage or anger easily. That his play contains themes of teasing and aggression leads me to believe that he is attempting to gain mastery over what occurred to him while he was young and is trying to integrate this into his developing self. According to James, traumatic experiences can lead to an enduring emotional condition she calls "traumagenic states" (1989). She delineates nine traumagenic states, two of which relate with some of Craig's history and symptoms. The state of powerlessness occurs when children maintain the feeling of powerlessness they felt during their abuse. Craig may have held onto his feelings of powerlessness and may currently be attempting to overcome these feelings by being very aggressive and threatening to potential abusers. He is putting up a strong front to keep his more vulnerable feelings safe. This state could also account for his nightmares and fears of being alone or without protection. His strong fears reflect the sense of powerlessness he has regarding his personal safety. The destructiveness state also seems to incorporate many of the elements of Craig's clinical picture, perhaps more so than powerlessness. James says these children behave in ways that actually encourage dislike or punishment from others and that their lack of impulse control can result in "frightening displays of their own rage." (1989, p. 32). The following symptoms of the destructiveness state parallel Craig's behavior: "Mastery: Behavior is attempt to understand and cope with experiences," Craig's repetition of aggressive play themes and his continued

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attraction to upsetting, scary, and violent television and movies seems like an attempt to gain control over these feelings. "Identification with the aggressor: Child associates emotionally with aggressor and imitates destructive acts," Craig's behavior could be an outward expression of some of the aggression he experienced as an attempt to identify with and feel close to his aggressor. "Punishment: Believes he deserves punishment and acts in ways which cause him to be hurt, by himself or by others," Craig would frequently engage in behaviors which resulted in being punished and/or yelled at by his parents (James, 1989, p. 33). These behaviors each point to a child who has been hurt in the past and is stuck in that place while he attempts to incorporate the abuse, remain close with his abuser, and continue along the natural developmental path we all must traverse as we grow up. My approach to treatment as followed Wachtel's cyclical psychodynamic theory which integrates psychodynamic and behaviorist systems in order to: block symptoms, explore unconscious conflicts that made the behavior necessary, and to investigate the family influences that surround the behavior of concern (1994). Our initial goal was to decrease Craig's symptoms, the destructive outbursts. These impulses initially seemed to be out of his control. My role in this area has been to help Craig see them as something within his control. By helping Craig define his strong feelings and be able to see them as separate from himself, he will be more likely to control his impulses. We started with angry feelings since those seemed most comfortable to Craig. As his level of trust and relaxation with me has increased, he has been more willing to explore fear and other scary feelings. To accomplish this goal of controlling his impulses, Craig has drawn pictures of himself when he is feeling angry or "bad," and scared along with when he has felt a variety of other emotions. Craig has described his anger to me in terms of what animal it is like, he has talked about times when he has controlled an impulse and

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has felt positive about the experience, and has tape recorded his own made up stories about anger and fear with the help of some stuffed animals. Further we have explored what it looks like and feels like to feel other emotions like happy and sad in order to help Craig develop a vocabulary about his feelings and to increase his ability to control his impulses. A simultaneous focus with the goal of symptom reduction has been parent counseling with Jane. We have processed some of Craig's disruptive behaviors and strategized new ways of dealing with them and preventing them with clearer and firmer limits. We have also talked about what words to use with Craig when he is upset that help him identify and organize how he is feeling. Jane has changed her interactions with each of her children and has encouraged Kyle to do so as well. The behaviors that brought Jane and Craig into therapy have drastically reduced. Jane reports being quite pleased with the changes she sees in Craig who also reports being better able to control his impulses. The next step is to go beyond symptom relief and look at the processes that encouraged this behavior initially. To work toward this goal, Craig and I have engaged in therapy which has centered around play, as it is the most natural means of communication for a child. As Bettelheim states, "Play is anchored in the present, but it also takes up and tries to solve problems of the past, and is often future-directed, as well" (1987, p. 96). Craig's play expresses not only what is going on with him currently, but also what he is attempting to understand of his past as he moves along the path of development. In this way we deal with components of his intrapsychic self. Within the safety of the therapeutic setting, Craig is able to repeat in his play the aggression, power, and dominance themes he experienced in his past (and perhaps the present) in effort to gain mastery with an adult who can remain calm and not be overwhelmed by these situations.

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My role has been assisting Craig develop a vocabulary and language around these themes by offering narrative comments regarding the actions and feelings he is incorporating. I also offer alternatives to the repetitive play in order to show Craig his options and help increase his feelings of power and choice offer the situations. When children who feel powerless learn that they have choices and can take action for themselves, they can regain a sense of power and mastery (James, 1989). Craig's aggression is likely a defense against feelings of vulnerability. He mirrors the description of the "overly aggressive youngster" described by Wachtel who utilizes aggression to mask a sense of insecurity (1994, p. 146). This insecurity is also made evident through his themes of competition and power in his play. In addition to exploring what intrapsychic conflicts are at work that result in Craig's symptoms, it is also important to focus on the family dynamics that encourage their emergence in the first place. My sessions with Jane are turning from behavioral and parenting support to an examination of what dynamics are in place that encourage masking vulnerable feelings with aggressive ones as well as other that may not yet be clearly developed. It is continually important to develop ways to show Craig that he is an important and valued member of the family for who he is and to create safety in letting go of some of his aggression. Craig has come far with the support of his family. The precipitating problem is becoming more manageable and the stress on the family is decreasing. The next step in treatment is to continue play therapies with Craig and to aid in his growing feelings of empowerment and importance while working with Jane to unravel the subtle family dynamics that have encouraged and sustained this pattern.

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References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author Bettelheim, B. (1987). The importance of play. The Atlantic, March, 92-100. Greenspan, S.I., & Greenspan, N.T. (1991). The clinical interview of the child (2nd ed.). Washington, DC: American Psychiatric Press, Inc. James, B. (1989). Treating traumatized children: New insights and creative interventions. New York: The Free Press. Wachtel, E.F. (1994). Treating troubled children and their families. New York: The Guilford Press.

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