Case Conceptualization

Identifying Information Giuseppe is a 14-year-10 month-old, Latino male in the 8th grade referred for counseling through AB3632 from Hollywood Senior high School under the Los Angeles Unified School District. Giuseppe’s school counselor indicates Giuseppe has difficulty controlling his anger towards peers. She also shares that Giuseppe fights with his peers leading to a suspension from school for three days due to fighting. Giuseppe’s mother reports that at home he is very oppositional especially with his father.

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Giuseppe’s mother has made multiple threats to call the police and have him spend time at Juvenile Hall if the behaviors persist. The counselor and mother, both report that Giuseppe has an attitude problem and frequently argues with them. According to Giuseppe, he believes he cannot control his anger and resorts to hitting. When asked why he is in counseling, Giuseppe responds, “I have an anger problem. ” When asked what an anger problem meant to him he responded, “I will never back own from anyone. ” Fro the initial interview with Giuseppe this behavior is culturally accepted.

He has repeatedly indicated that his father encourages him to defend himself. He has stated that his father has often told him he “…is not raising no punks…” Parents are part of a street gang although they are not actively participating in any gang activity. Giuseppe denies gang involvement. Background Information Parents currently living together as roommates. They have a roommate relationship. Both parents are actively dating and Giuseppe indicates it does not bother him. He is satisfied because he has both parents. Giuseppe and his siblings are the only children to both parents.

Giuseppe reports that he and his brother have grown up with cousins. He describes his home as the “house where everybody goes to. ” Cousins vary in ages from a 21-year-old male to a 12-year-old female; he adds there are at least 4 cousins that frequent the home. Giuseppe’s younger brother, Nathaniel, is 8-years-old, Arkemedes is 11-years-old and his older brother, Equivocal is 16-years-old. Giuseppe reports his family has a history of domestic violence. He states that Equivocal is currently detained at the California Youth Authority detention center, although Giuseppe is not sure why, and the other brother

Arkemedes is in a foster home, in which he also does not know the reason. Giuseppe indicates he and Nathaniel were placed in foster care for one to two years, and again, Giuseppe is not sure why. According to Giuseppe, they returned home to their parents in 2008. According to Giuseppe, he gets into fights with his father because he thinks he favors his younger brother. Giuseppe states that his father punishes him all the time and never punishes Nathaniel. Giuseppe also mentions he always fights with Nathaniel, both physically and verbally, because Nathaniel bothers him and hits him.

Giuseppe believes he gets along “cool” with his mother, and he likes his cousins always being over. In her household, it seems Giuseppe fights with his brother and his father most of the time. Giuseppe’s family appears to have a lower socioeconomic status. Giuseppe indicates his father had recently been out of work because he had been “fired. ” According to his statement, his father’s employer had to cut back on personnel because of the economy. His mother is also unemployed at this time due to a back injury since the summer of 2009. The household unit is now receiving CALWORKS, Food Stamps and social security.

Current Health Status of Client According to Giuseppe, he is currently taking medication for seizures and behavioral problems. He states he takes 250 mg of Depakote to help prevent complex seizures, which began occurring in October 2002. Giuseppe also reports she is taking two 20 mg pills of Concerta for behavioral and anger problems and . 5 mg of Abilify because he hears things. When questioned about hearing things, Giuseppe responds, “I don’t want to talk about that. ” Giuseppe indicates he frequently sprains his ankles, wrists, and fingers due to sports.

He believes he is the healthiest member of his family. According to Giuseppe, there have not been any hospitalizations and is not allergic to any medication. Giuseppe also displays some signs of hyperactivity, such as fidgeting, talking excessively, and schoolteachers’ report restlessness. Additionally, Giuseppe displays some problems with memory skills for difficulty paying attention; he is easily distracted and has disorganized work habits. Psychosocial History Giuseppe reports attending Le Conte Junior High School in Los Angeles prior to the eight grades, where he had received low grades, mainly Fs.

He shares that he was held back a grade in elementary, but he does not remember which grade. He also states he had gotten into many fights while at Le Conte. According to Giuseppe, because of his fights and poor grades, the family moved, and Giuseppe began attending Hollywood Senior High School. Giuseppe currently is receiving A’s and B’s in most of his classes. He also admits tot eh school reports regarding fighting. Giuseppe indicates he has a group of friends at school, and there is never any variation from that group.

The group hangs out throughout school functions and activities. He also shares he is closer to another boy because they do things outside of school. Giuseppe says he does not tell his friends any personal information. Giuseppe admits to arguing frequently with his father. He indicates he thinks his father likes his younger brother more than him. Giuseppe states he feels closer to his mother, who does not take sides, according to Giuseppe. Giuseppe does not appear to have a good-quality relationship with his father; however, his relationship with his mother is stronger.

Giuseppe reports receiving counseling for the past three to four years for his anger problems and concerns about her family. Giuseppe states he remembers being angry a lot in sixth grade, which was around the time he was placed back in his parents’ care. He believes that was when his problems started with fighting. In summation, Giuseppe currently is still getting into fights at school and home. He argues frequently with his brother and parents. Giuseppe indicates he has friends at school and she gets into fights at school with other students. Academically, Giuseppe says is getting A’s and B’s now.

Giuseppe’s specific areas of difficulty are in his peer and sibling relationships, which are characterized by fighting, bullying, defiance, taunting, and teasing. He is also acting in ways that are quite obviously attention seeking, such as acting out in-group counseling sessions, and he has poor coping responses to anger-provoking situations. Behavioral Observations During counseling sessions, several observations were made about Giuseppe, including his appearance. He has a clean and well-kept appearance throughout all sessions. Giuseppe is of average height in comparison with most boys his age and is a little overweight for his height.

At every session, he wears baggy jeans with a baggy shirt. He has a shaved head. He has indicated that he or a family member shaves his head. Giuseppe’s motor activity is hyperactive at times. He displays hyperactive movements, by continuously moving around on the chair or talks excessively. His manner during the sessions is pleasant and likeable. However, he appears to have trouble establishing eye contact continuously. He often slouches in his chair, which is typical for his age. He does not appear to be resistant to the counselor at any time, and rapport is easily established.

Giuseppe’s speech is faster than most people’s speech but the volume is within normal limits. His speech also is within normal limits for clarity and articulation. Giuseppe’s intellectual functions appear to be within normal limits. However, at times, he gets off-topic and frequently goes off on a tangent. His thought process appears to be within normal limits. Giuseppe does not display many emotional reactions. Many of his emotions appear to be different to his statements. For example, when discussing how he had been mad at his brother, he was smiling and chuckling.

Although, this is not consistent, like when he was mad at a fellow student and was serious as he was telling the events that lead to the altercation. Giuseppe’s perception of his problem areas is accurate. He recognizes that he has a hard time controlling his anger, and he recognizes that his family has a history of problems. However, he does not appear to recognize anything beneath the anger. At one point, he became aware that his anger at school protected him from other students. His motivation and investment in the counseling process is low. Giuseppe knows the appropriate actions to take when he is angry.

For example walking away or telling an adult. However, he does not appear to have a strong motivation to do the appropriate thing when provoked. Giuseppe does not appear to want to change the ways in which he handles problems. Case Formulation Diagnostic Impressions The counselor’s multi-axial DSM-IV-TR diagnostic impression was as follows: Axis I:309. 3Acute Adjustment Disorder w/ Disturbance of Conduct Axis II:301. 7 Antisocial Personality Disorder Axis III:345. 0Epilepsy Axis IV:61. 20 Parent-Child Relational Problem Axis V:GAF = 61 Literature Review The major task for adolescents is for them to become their own person (Lebelle, 2005).

According to Goldstein and Glick (1987), the period of adolescence “comprises a developmental process in which youth move from the dependency and immaturity of childhood toward the physical, psychological, and social maturity of adulthood” (p. 280). There are other developmental changes that occur during this period that can make it difficult for youth to become there own person. For children in early adolescence, ages 11 to 14, changes occur in every aspect of their lives (Lebelle, 2005). For example, boys experience growth spurts and sexual development, voice changes, and increased body odor.

Early adolescence also involves learning to combine logical and abstract thinking, handling the changing self-image, and having frequent mood swings (Lebelle, 2005). This implies that establishing peer friendships is a focus of priority during this critical time. It also suggestive that receiving love and proper support at home is as important as peer recognition. If adolescents do not receive appropriate nurturing, encouragement, and guidance from their family and peers, they can be impulsive and lack the “ability to appropriately control and deal with their anger” (Goldstein & Glick, 1987, p. 80). Anger can derive at any age during any given situation. Physiological symptoms can occur when a person is angry, such as increased adrenaline flow, increased heart rate, tensed muscles, clenched hands, and flushed faces (Sisco, 1991). These signs of anger usually warn people when they are feeling in a state of threatened safety. Acts of anger in which adolescents engage can include fighting, disruptiveness, quarrelsomeness, defiance of authority, and high levels of attention-seeking behaviors (Tamaki, 1994).

These behaviors can result in aggression that usually causes conflicts with peers. To eliminate the aggressive behaviors it is important to begin with examining the home. Children spend most of their time with their parents who will reinforce the aggressive behaviors; therefore, an intervention plan will need to focus on the interactions between the child and parent. When parents are inconsistently punishing aggressive behaviors or not punishing their children at all for behaving aggressively, children will learn that the aggressive behavior will get them what they want (Mounts, 1997).

An anger control program that focuses on cognitive-behavioral techniques is Rational Emotive Behavioral Therapy (REBT) (Goldstein & Glick, 1987). This cognitive aspect focuses on self-control, cognitive restructuring, and arousal reduction. The behavioral aspect focuses on problem solving techniques, behavior modification, and social skills. REBT programs base their interventions on actively and deliberately teaching desirable behaviors, strengthening interpersonal skills, accurately perceiving situations, and decelerating anger arousal which should reduce aggressive behavior (Tamaki, 1994).

Aggressive children have shown to be unable to recognize feelings of fear and sadness in certain situations, instead labeling the arousal they feel as anger (Garrison & Stolberg, 1983). Modeling and role-playing will be a key feature in the treatment plan by the therapist. Through modeling, as the therapist, I can speak my thoughts on a situation, offer a solution, and provide possible consequences for each solution. Role-playing involves letting the aggressive child practice interpersonal, social, and cognitive skills as well as increasing his/her empathy skills (Kendall, 1993).

The treatment approach for REBT is divided into cognitive methods, emotive methods, and behavioral methods (Corey, 2001, p. 304). Cognitive methods involve making clients aware of statements they are telling themselves and then teaching the clients how to handle those statements so that they do not believe them (Corey, 2001, p. 305). In this case, I can challenge, Giuseppe on an irrational belief, and teach him how to change his particular perception. REBT utilizes behavioral techniques in which carrying out assignments in real-life is extremely important. Reinforcement, and self-management, is part of the behavioral techniques.

As the therapist, I will encourage Giuseppe to carry out activities in order to put his insights into actual actions. An example would be having Giuseppe perform a desired behavior and then receive a reward in order to reinforce his behavior; this may elicit the increase of the desired behaviors. Case Conceptualization In the case of Giuseppe, he in his adolescence stage of life. In this stage, developing friendships is vital. Giuseppe has admitted to only having four friends in his school, and he appears to get into fights and have difficulties with the majority of his classmates.

Goldstein and Glick (1987) concluded that if adolescents do not develop appropriate and nurturing relationships with their peers, they would not be able to appropriately control and handle their anger. One of Giuseppe’s main goals for counseling is to learn how to control his anger; this is a key factor in developing friendships. Rational Emotive Behavior Therapy (REBT) is based on the assumption that people have a potential for both rational and irrational thinking (Corey, 2001, p. 299). Giuseppe’s beliefs about being unlovable and needing to be on guard are irrational.

According to Kendall, Ronan, and Epps (1991), aggressive children can have cognitive distortions, which involve dysfunctional thinking processes. Some of Giuseppe’s distortions include thinking he is not loveable and is unable to make many friends. He also has the notion that he cannot modify his aggressive actions for fear of his peers bullying him. Giuseppe is afraid to lower his guard and trust that peers want to befriend him versus hurting him. Giuseppe also needs to know he is a loveable individual. I think a way to modify this irrational belief is by beginning to help him lower his guard and see himself in a positive way.

When parents are inconsistently punishing aggressive behaviors or not punishing their children at all for behaving aggressively, children will learn that the aggressive behavior will get them what they want (Mounts, 1997). This is also the case for Giuseppe. It appears that he does not get a lot of support or attention at home until he acts aggressively. When he acts out or gets into a fight with his brother, Giuseppe then gets attention from his parents. As Giuseppe describes a typical day at home, he mentions that he does not spend time with his parents only in the event of reprimanding.

This clearly shows that his parents are reinforcing the aggressive behaviors. Giuseppe seems unable to recognize or verbalize the feelings beneath his anger. Role-playing will be useful in showing him how he reacts to a given situation and possible alternative ways to change his inappropriate feelings to appropriate ones. Intervention It is fair to assume that based on Giuseppe’s needs utilizing a Rational Emotive Behavioral Therapy (REBT) approach would best benefit him. His counseling may need to focus on changing his behaviors including the irrational beliefs about himself.

Additionally, Giuseppe needs to learn how to recognize the feelings underlying his anger. I think it is important to begin by disputing Giuseppe’s belief about being unlovable and being afraid of being hurt if he were to let his defenses down. Role-playing can facilitate the recognition of irrational beliefs by Giuseppe. When the beliefs are identified, the beliefs can be challenged, and this point I can help Giuseppe replace the beliefs with healthier ones. For example, Giuseppe’s feelings of distrust and defensiveness are replaced by trust and acceptance. It is imperative that Giuseppe is assigned homework.

The homework is making a list of all what he perceives as problems, examine his beliefs, and try to dispute his irrational beliefs. This can also be an activity to do with Giuseppe during the counseling sessions. Reinforcing Giuseppe’s aggressive behaviors at home is unacceptable. Giuseppe’s parents need to know the concept of reinforcement. I will schedule sessions for both Giuseppe and parents, together to discuss the possibility of decreasing their reinforcing behaviors. I will want to teach them that when Giuseppe is not being aggressive, they should pay attention to him and reinforce the appropriate behavior.

Positive reinforcements can include watching a movie together. The same goes for showing appropriate attention when he is exhibiting the non-desired behaviors. Continuous communication between the parents and I will need to be present. This is useful to document progress or a need to change techniques. Specific Intervention Goals Based on the REBT approach, Giuseppe’s short-term and long-term goals and interventions focus on behavioral and cognitive techniques. Giuseppe has three long-term goals. First goal is gain the ability to compete, cooperate, and resolve conflict appropriately with peers and his younger brother.

The second goal is to form respectful, trusting peer and sibling relationships. The final long-term goal is to attain the core belief that he is lovable and capable. Short-term objectives formulated to assist Giuseppe in reaching her long-term goals. The first objective is to decrease the frequency and intensity of aggressive actions towards peers, and the second objective is to increase the quantity of time he spends with peers and his younger brother without being aggressive. These two objectives are best met in behavioral methods. Two other short-term objectives are developed that will be implemented through cognitive methods.

One objective is to identify positive traits and talents about himself to increase his self-esteem, and the second objective is to develop the ability to verbalize and identify his feelings. Giuseppe and I are going build his level of trust through active listening and acceptance to help increase his ability to identify and express his feelings. Another intervention is to instruct Giuseppe’s parents to ignore his aggressive acts, except when he is in danger to himself or others; this includes praising all of his non-aggressive behaviors.

This intervention incorporates the concept of reinforcement. A third intervention is to investigate the origins for anger in his rejection experiences with his family and peers, and a fourth intervention is to increase Giuseppe’s awareness of his feelings. Summary Although specific goals and interventions are developed for Giuseppe, his mother does not follow through in keeping appointments despite my attempt to offer alternative meeting places for example the family’s home. The counseling process has been very difficult and challenging to implement the treatment plans.

Giuseppe’s father and teacher indicated that Giuseppe is problematic behavior have not decreased during the weeks he has been attending counseling. In fact, Giuseppe’s father stated that his behavior has gotten worse. Giuseppe’s mother has left a message suggesting termination because she states, “counseling is not working and it takes up to much time… ” Numerous messages have been left to discuss the mothers request and possibly anticipate length of treatment to ensure her participation.

Giuseppe’s faulty cognitions and problematic behaviors have been ingrained in his life for many years; short-term therapy most likely will not be successful. Giuseppe is inconsistent in attending sessions and his prognosis is now poor. References Corey, G. (2001). Theory and practice of counseling and psychotherapy. Cognitive Behavioral Therapy (pp. 294-339). Stamford, CT: Brooks/Cole Thomson Learning. Garrison, S. T. , & Stolberg, A. L. (1983). Modification of anger in children by affective imagery training. Journal of Abnormal Child Psychology, 11, 115-130.

Goldstein, A. P. , & Glick, B. (1987). Aggression replacement training: A comprehensive intervention for aggressive youth. Champaign, IL: Research Press Kendall, P. C. (1993). Cognitive-behavioral therapies with youth: Guiding theory, current status, and emerging developments. Journal of Consulting and Clinical Psychology, 61 (2), 235-247. Kendall, P. C. , Ronan, K. R. , & Epps, J. (1991). Aggression in children/adolescents: Cognitive-behavioral treatment perspective. In D. J. Pepler & K. H. Rubin (Eds. ), The development and treatment of childhood aggression (pp. 41-360). Hillsdale, NJ: Erlbaum. Lebelle. N. (2005). Focus Adolescent Services. Retrieved on February 27, 2010 from http://www. focusas. com/Adolescence. htm Mounts, N. S. (1997). Aggression and peer-rejected children. Human Development and Family Life Bulletin, 3(2), 1-4 Sisco, B. (1991). Anger: How to handle it during recovery. Minneapolis: Johnson Institute. Tamaki, S. (1994). Adolescent Anger Control. Retrieved on 6/2/2010 from http://www. saskschoolboards. ca/old/ResearchAndDevelopment/ResearchReports/StudentsDiverseNeeds/94-06. htm