Understanding Michael's Behavioral Challenges: A Case Conceptualization

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Abstract

This is a case conceptualization for a client who was referred to a Residential Treatment Facility by Family Court. The referral aims to assess the client's intellectual, academic, and behavioral performance. The client has challenges with anger problems, aggression, and low frustration tolerance which impact their home life and educational environment negatively. During the interview, the counselor speculates that these difficulties may be rooted in the client's early experiences. It is crucial to investigate these experiences solely in connection with their present behavior and beliefs.

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Throughout therapy, the client and counselor collaborate to comprehend the reasons behind the client's difficulty in responding appropriately to frustration. They analyze and question irrational thoughts and beliefs, while also practicing more beneficial and positive behaviors as substitutes. This progression enables the counselor to form a hypothesis regarding the client's aggressive behavior. By utilizing Rational Emotive Behavior Therapy, the counselor delves into the client's concerns and devises a treatment plan that directly tackles their individual obstacles.

The conceptualization further elucidates how this therapy can be advantageous for the client.

Michael's case conceptualization in Rational Emotive Behavior Therapy

Michael, a 14-year-old African American male, has been referred to a Residential Treatment Facility (RTF) for an evaluation of his intellectual, academic, and behavioral assessment. While in the treatment facility, he will receive therapy to address his presenting problems. Despite being court-ordered to stay at the facility for an unknown duration, Michael displayed cooperation during the interview and presented himself as a well-dressed and engaged young man. The counselor discussed the court documents and the responsibilities of both the client (Michael) and the facility with Michael and his adoptive family during the interview.

The intake process has been completed, and a scheduled time has been set for Michael's first therapy session.

Biological and environmental factors

Reports indicate that Michael's biological parents had a severe addiction to drugs and alcohol, with his mother misusing multiple prescription drugs and cocaine while she was pregnant. Additionally, his mother suffered from Schizophrenia. Both of his parents had extensive criminal records, which resulted in an unsupportive upbringing for Michael. When he was four years old, child protective services intervened and took him and his younger brother away from their biological parents. Unfortunately, the brothers were placed in different foster homes. Before being adopted by his current parents, Michael went through four different placements within the foster care system in just two years. There are concerns that he may have experienced neglect and sexual abuse during these transitions.

Michael was adopted by his maternal aunt and her husband, who also adopted his younger brother. They have two biological children. However, Michael struggled to adapt to his new environment and his behavior became more aggressive, displaying hoarding tendencies. By the age of seven, he needed treatment and was placed in psychiatric hospitals and other RTFs. To seek help, Michael and his adoptive parents turned to counseling services from their church and local mental health agencies. Michael's diagnoses include Reactive Attachment Disorder, ADHD, and ODD. He experiences poor sleep patterns and takes multiple medications, though they have a minimal effect. While Michael has engaged in self-harming behaviors for attention, he denies having suicidal thoughts. He has a history of violent and aggressive actions both at school and home. Additionally, Michael's relationships with peers are superficial and lacking in depth.

Case Conceptualization

The presenting issues and previous history of Michael are appropriate for Rational Emotive Behavior Therapy (REBT), which targets environmental and biological factors impacting rational thinking and emotional behavior (Murdock, 2009). Although Michael’s early history will help in understanding his current behavior, it is not directly relevant to his treatment plan.

Michael frequently has negative reactions towards his peers and relatives due to various events he experiences. According to the counselor, this could be attributed to Michael's early exposure to violence, an unstable home environment, and inconsistent relationships, which have hindered his ability to comprehend his experiences. These outbursts have escalated in severity over time. In a previous residential treatment facility (RTF), Michael even physically assaulted another resident by choking them. Prior to his outbursts, Michael often feels tense and on edge. Afterwards, he experiences confusion, sadness, and further anger at himself for losing control (referred to as secondary disturbance).

In session, the counselor is attentive to the ABCs of the REBT therapy framework. Michael shares various events preceding his outbursts and violent attacks (Consequence) (2009), and the counselor observes Michael's tendency to feel that people are trying to take advantage of him or bother him (Antecedent behavior, irrational thought, faulty thinking) (2009). Michael expresses his belief that people should simply leave him alone (faulty belief) (2009). Moreover, Michael incorrectly assumes that his peers consider him "stupid" (irrational thought) (2009). When questioned about this, Michael replies, "Maybe I am. I always get the questions wrong in class when the teacher calls on me" (faulty belief) (2009). As a result of his demands not being fulfilled - including self-demandingness, others demandingness, and world demandingness (2009) - Michael experiences psychological and emotional disturbances (2010). The counselor also suggests that Michael has a low tolerance for frustration (LFT) (2010), particularly in situations where he perceives peers are treating him unjustly or not giving in to his demands (other demandingness) (2009).

Michael frequently expressed his frustration with the teacher in the classroom, believing that she never listened to him and always tried to embarrass him in front of the class. He often mentioned how the teacher would call on him frequently, solely to prove that he was "dumb." This perception of an unfair and intolerable classroom environment caused Michael to hate going to school, as he believed that all the teachers hated him. He felt that he should be left alone, especially when he wasn't bothering anyone. These thoughts led him to defend himself through acts of aggression or defiance. Michael believed that being aggressive was necessary to prove his critics wrong, which only served to increase his frustration. Moreover, this behavior made him feel inadequate and not "good enough" for others.

The counselor proposed that Michael's irrational thinking and subsequent irrational behavior (2009) affected his home life. According to Michael, his fights with his adoptive mother upset her (antecedent) (2009), leading him to believe that he will never be able to make her happy (irrational thinking) (2009). This belief, in turn, makes him perceive himself as a bad person internally (faulty belief) (2009). As a result, he experiences anger and irritation (secondary disturbance) (2009), leading him to exhibit violent behavior towards his younger siblings (consequence) (2009).

Treatment Goals and Plan

In 2009, Michael's goals for survival and happiness are hindered by his irrational thoughts and absolutions (Harrington, 2007) that life should be easy and painless (2007). Michael often becomes frustrated with events at school and home when he doesn't get what he wants. The counselor recognizes that this frustration alone is not the cause of his violent outbursts, but rather the result of distorted perceptions of these events (2007). Additionally, Michael firmly believes that his reality must align with his desires, and when this doesn't happen, he becomes intolerant (faulty belief). Consequently, this leads to the occurrence of violent outbursts (consequence). To put it differently, frustration intolerance stems from the clash between the desire for a different reality and the demand for it (Harrington, 2011).

Michael’s therapeutic goals will include teaching him the three unconditionals of acceptance according to Barry (2009):
1. Unconditional self-acceptance - I am not a bad person. I can make good choices, even if it does not always turn out right.
2. Unconditional acceptance of others - Everyone does not have to like my ideas or me, they can each have their own opinion. People will not always treat me the way I want to be treated. This does not mean they want to harm me or do not care for me.
3. Unconditional life acceptance - Life is not fair. I can take the good with the bad. I can choose to enjoy the moment. I cannot control every circumstance, but I can control my reaction and thoughts toward it.

Michael will receive instruction on how to conduct a behavioral assessment (2009) of his thoughts and beliefs while undergoing treatment. As part of this process, he will be asked to keep a journal (assigned as homework between sessions) (2009) in which he can record antecedent events, as well as his emotional state before (calm, engaged) and after (irritated, angry, and sad) these events occur. The journal will also serve as a platform for documenting his beliefs about specific situations.

The counselor will actively demonstrate appropriate behaviors during frustrating moments in counseling. Exaggerated behavior will be used to show Michael's sudden outbursts and aggression when faced with frustrating events. The counselor hopes that Michael will realize the extreme nature of his behavior and may even find some humor in the excessive outbursts during minor incidents. In session, the counselor will directly model an "it's-not-about-you/me" perspective to Michael. Through consistent questioning, the counselor will challenge Michael to consider when this attitude begins to manifest. When appropriate, the counselor will use humor to showcase when Michael's irrational thoughts become unreasonable.

The use of coping skills, such as self-talk, humor, and relaxation techniques (Harrington, 2011), can help dispute irrational thoughts. These skills can also create a self-monitoring tool for Michael to use between counseling sessions. During the sessions, the counselor will actively challenge Michael's irrational thoughts using philosophical interpretation. This involves demonstrating how these thoughts are preventing him from achieving happiness. The counselor will also use empirical evidence by asking for proof that supports Michael's beliefs or offering evidence that contradicts them. Additionally, logic and functional evaluation will be used to help Michael assess the relationship between his perceived disturbances and the reality of the unconditional (2009). Behavior strategies may also be employed.

Michael should learn behavior management techniques such as reward and penalty. This involves engaging in a pleasurable activity after enduring an uncomfortable or frustrating circumstance, or having a restriction of pleasurable activity. Additionally, he can use imagery of frustrating or uncomfortable situations and unhealthy negative emotions to reframe and rehearse rational beliefs and responses.

The counselor will utilize various resources such as music, TV, and movies, as well as real-life events for scenarios (Harrington, 2011). 3. When faced with frustration, coping mechanisms (2011) will also be employed. These techniques will include relaxation techniques (2009) and removing Michael from the frustrating situation until he can respond appropriately. Ultimately, the goal is for Michael to be able to tolerate an uncomfortable situation (2011) without needing to leave in order to regain composure. In summary, throughout his sessions, Michael should be able to identify irrational thoughts and dispute them immediately. Even when faced with frustration, Michael should be able to assess the reality of the situation (reframing) (2009) and respond appropriately.

Conclusion

The counselor concluded that REBT is suitable for this counseling scenario. REBT focuses on an individual's thoughts and beliefs, which influence their behavior. Irrational thoughts and faulty beliefs often lead to negative responses. The counselor aims to help the client assess these irrational thoughts and faulty beliefs related to the initial event, allowing for a more appropriate response. In Michael's case, his core faulty beliefs are present in the three unconditionals. He believes he deserves fair treatment and always getting his way (Fives, et al. 2010).

According to Michael (2010), he believed that aggression was an appropriate response when his entitlement was not fulfilled. This aggressive response then led to a cyclical event consisting of an antecedent event (fight/defiance), irrational thoughts (such as his teacher trying to embarrass or intimidate him), and a faulty belief (that the teacher should leave him alone or he cannot be intimidated). After the fight/defiance, Michael often experiences feelings of guilt, sadness, or heightened frustration (known as secondary disturbance) because he sees himself as a failure and disappoints his adoptive mother.

The counselor aims to teach Michael to challenge and change his negative thoughts and beliefs using REBT. This will help him manage his frustration and anger better. REBT is a logical and practical approach that equips clients with realistic coping skills for life's challenges. Including the family in therapy, as in Michael's case, allows them to identify and address irrational thoughts and beliefs, contributing to a more effective outcome.

Most importantly, REBT helps the child client in identifying and appropriately responding to frustrating circumstances for long-term success (Fives, et al., 2010). Instead of focusing on the person, REBT focuses on the behaviors exhibited by the person (Levinson, 2006). This approach will benefit Michael because his faulty thinking and irrational thoughts have become attached to his sense of self. He sees himself as “bad” and “inadequate” (Jones, et al., 2011). REBT will teach Michael that it is not he or the event itself, but rather his thoughts about the event that cause his issues. This will motivate Michael to regularly evaluate his thought and belief patterns.

REBT incorporates psychological concepts to analyze the link between thoughts and emotional disturbance. Additionally, it emphasizes the influence of life perspectives on emotions. Moreover, REBT advocates for educational interventions that equip individuals like Michael with the skills to effectively handle their thoughts, beliefs, and reactions to frustrating situations (Banks and Zionts, 2008).

This will be an ongoing process for Michael. He will experience both success and failure while applying REBT. The counselor will diligently explain to him that this is a reality and a part of the three unconditionals. The counselor will reinforce that Michael will experience the reward of recognizing the ABCDE's of REBT. Michael should understand that effectively disputing irrational thoughts toward the event is the final stage of REBT, referred to as the "E", which results in an appropriate response (2010). He will learn that when he is not successful, he can accept it and its consequences without becoming aggressive.

References

The literature review "REBT Used with Children and Adolescents who have Emotional and Behavioral Disorders in Educational Settings" by Banks and Zionts (2009) explores the application of REBT in educational settings. Bernard and Diguiseppe (2006) discuss the assessment and treatment of children using REBT in their work "REBT Assessment and Treatment with Children". Fives, Kong, Fuller, and DiGuiseppe (2010) study the relationship between anger, aggression, and irrational beliefs in adolescents. Harrington (2007) examines frustration intolerance as a multidimensional concept. Levinson (2006) presents a holistic solution to anger management and violence prevention. Minor (2007) discusses the use of REBT in personal life and private practice. Murdock (2009) provides an overview of theories of counseling and psychotherapy. Shanahan, Jones, and Thomas-Peter (2010) investigate anger, aggression, shame, and self-worth in violent individuals.