This is a case conceptualization of a client referred to a Residential Treatment Facility by Family Court for treatment and evaluation of intellectual, academic, and behavioral performance. The client presents with several issues. In the client interview, the counselor hypothesizes that client has difficulty with anger, aggression, and low frustration tolerance. The client’s current behaviors are affecting his home and educational environments. The client’s early experiences will be explored only as it relates to current behavior and beliefs.
During the therapeutic process, the client and the counselor will explore his inability to respond appropriately when frustrations occur. Exploration would include disputing irrational thoughts and beliefs, and exercising more appropriate positive replacement behaviors. This case conceptualization will create a hypothesis of the client’s aggressive behavior. Using Rational Emotive Behavior Therapy framework, the counselor will explore the client’s issues and create a treatment plan with goals that pertain to the client’s presenting issues. This conceptualization will also include support that will show the benefits the client should gain with application of this theory.
Rational Emotive Behavior Therapy Case Conceptualization of Michael
Michael is a 14-year-old African American male. He has been referred to a Residential Treatment Facility (RTF) for an evaluation of intellectual, academic, and behavioral assessment. While in the treatment facility, Michael must undergo therapy to address his presenting problems. Michael presents himself as a very well dressed and engaged young man. Despite the fact that he is court-ordered to be in a treatment facility for an undetermined length of time, he was cooperative during the interview.
During the interview, the counselor speaks with Michael and his adoptive family about the details of the court documents, the responsibility of the client (Michael) and the facility. The counselor, Michael, and the adoptive parents have completed the intake process and the time was scheduled for his first session.
Biological and Environmental Factors
Michael’s biological parents are reported to have been heavily addicted to drugs and alcohol. His mother reportedly abused multiple prescription drugs and cocaine during her pregnancies. It is also reported that the mother was Schizophrenic. Both parents have lengthy criminal records. Michael did not experience a nurturing environment. At age four, Michael and his younger brother were removed from the biological parents by child protective services. The brothers were placed in separate foster homes. Michael has had four foster care placements in two years prior to going to his adoptive parents. During his placements, it is suspected that Michael experienced neglect and sexual abuse.
His maternal aunt and her husband adopted Michael. They also adopted his younger brother. They have two biological children. Michael did not adjust well to the new environment. He became more aggressive and exhibited hoarding behaviors. By age seven, he had been placed in a psychiatric hospital and other RTFs to receive treatment. Michael and his adoptive parents have sought counseling services through their church and local mental health agencies. Michael had been diagnosed with Reactive Attachment Disorder, ADHD, and ODD. He has poor sleep patterns and is on several medications that have little effect. Michael has self-harmed for attention, but denied suicidal thoughts. Michael has a history of violent and aggressive behaviors in school and home. Michael has very weak and superficial relationships with peers.
Michael’s presenting issues and previous history is suitable for Rational Emotive Behavior (REBT). REBT focuses on environmental and biological factors that affect rational thought and emotional behavior (Murdock, 2009). Michael’s early history will offer insight in evaluating his current behavior, but otherwise have no relevant bearing on Michael’s treatment plan.
Michael often experiences events that cause him to react in a negative manner toward his peers and relatives. The counselor theorizes that Michael’s early exposure to violence, unstable home environment, and inconsistent relationships may have contributed to his inability to rationalize his experiences. These outbursts have increasingly become more violent. One incident resulted in Michael choking another resident at a previous RTF placement. Michael states that he often felt agitated prior to his outburst. Later, he would be confused, sad, and even angrier that he lost control (secondary disturbance).
In session, the counselor listens for the ABCs of the REBT therapy framework. Michael rehearses several events that occur prior to his outbursts and violent attacks (Consequence) (2009), the counselor notes that Michael often feels that “people are trying to get over on him” or “messin’ with him” (Antecedent behavior, irrational thought, faulty thinking) (2009). Michael voiced that people should just leave him alone” (faulty belief) (2009). Michael perceives his peers think he is “stupid” (irrational thought) (2009). When asked why he thinks this, Michael responds, “Maybe I am. I always get the questions wrong in class when the teacher calls on me” (faulty belief) (2009). Michael’s demands: self-demandingness, others demandingness and world demandingness (2009) are not being met, therefore creating a psychological and emotional disturbance for Michael (2010). The counselor also hypothesizes that Michael has low frustration tolerance (LFT) (2010) with peers who he perceives do not treat him fairly or give in to his demands (other demandingness) (2009).
Michael rehearsed that in the classroom the teacher never listens to him. She always tries to embarrass him in front of the class. Michael often stated that the teacher frequently called on him to prove he was “dumb” (awfulizing) (2009). Michael perceived the classroom environment was unfair and intolerable and hated going to school (maladaptive thought) (2009) because all the teachers hate him. Michael felt that he should be left alone, especially when he was not “bothering” anyone (world demandingness) (2009). The result was to defend himself through acting out, aggression, or defiance. Michael believed that he needed to be aggressive to prove his peers, teachers, and family members wrong, which led to further frustration. Michael explained that behavior made him feel like he was not “good enough” for people (self-demandingness) (2009).
The counselor hypothesized that Michael is relying on irrational thinking to draw irrational conclusions (2009) which lead to irrational behavior. Michael’s negative thinking and behaviors influenced his home life. Michael describes that he upsets his adoptive mother when he fights (antecedent) (2009) and that he will never be able to make her happy (irrational thinking) (2009). Michael believes this makes him a bad person on the inside (faulty belief) (2009). This belief makes him angry and irritated (secondary disturbance) (2009), which causes him to become violent toward his younger siblings (consequence) (2009).
Treatment Goals and Plan
Michael’s goals toward survival and happiness (2009) are thwarted by his irrational thoughts and absolutions (Harrington, 2007) that life should be easy and painless (2007). Michael becomes frustrated with events at school and home frequently when he does not get what he wants. The counselor understands that frustration with particular events in itself is not the cause of the violent outburst, but is the result of wrong views of the event (2007). Michael has an additional belief: his reality must conform to his wishes. When this fails to occur, intolaration results (faulty belief). Hence, this creates the violent outburst (consequence). In other words, frustration intolerance arises, because the wish for a different reality collided with the demand for it (Harrington, 2011).
Michael’s therapeutic goals will include teaching him the three unconditionals of acceptance (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 have each have our 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 also be taught to do a behavioral assessment (2009) of his thoughts and beliefs during the course of his treatment. This will include the use of a journal (between session homework) (2009) to track antecedent events, his emotional state prior to the event (calm, engaged) and immediately following (irritated, angry, and sad), and his beliefs toward the given circumstance.
The counselor will actively model appropriate behaviors when frustrating moments occur in counseling. The counselor will use exaggerated behavior (2009) to demonstrate Michael’s behavior (sudden outbursts/aggression) when frustrating events occur. It is the hope of the counselor that Michael will see that his behavior can be considered extreme. Michael may even see some humor in the extremity of his outbursts in minor occurrences. The counselor will be direct with Michael in modeling (2009), an “it’s-not-about-you/me” stance in session. Michael will be consistently confronted during sessions with questions that will challenge him to consider when this attitude begins to surface (Shanahan, et. al. 2010). The counselor will model humor (2009) when appropriate to demonstrate when Michael’s irrational thoughts grow beyond reason.
The use of coping skills can dispute irrational thoughts (self-talk, humor, relaxation techniques) (Harrington, 2011) and create a self-monitoring tool for Michael between sessions. The counselor will actively dispute irrational thoughts during the session using philosophical interpretation—demonstrating this is interrupting his goal to be happy, empirical evidence—asking for evidence that supports his belief or offering evidence that counteracts his belief, logic, and functional—helping him evaluate “always and never” statement (2009) relationships between the perceived disturbance and the reality of the unconditional. Behavior strategies can also be implemented.
Michael should learn behavior (violence and outbursts) management through: 1. Reward (engaging in a pleasurable activity after enduring an uncomfortable/frustrating circumstance), and penalty (restriction of pleasurable activity) (2009). 2. The use of imagery of frustrating or uncomfortable situations, and unhealthy negative emotions (and behaviors) to reframe and rehearse rational beliefs and responses (Harrington, 2011).
The counselor will use multiple resources (music, TV, and movies) and actual events for scenarios (Harrington, 2011). 3. Coping mechanisms (2011) will also be implemented when frustration arises. This will include relaxation techniques (2009) and removing Michael from the frustrating situation until he is able to respond appropriately. Eventually, Michael should be able to endure an uncomfortable circumstance (2011) without having to leave to regain composure. In summation, throughout the course of Michael’s sessions, he should be able to recognize irrational thoughts and dispute them immediately. Even when challenged with frustration, Michael should be able to evaluate the reality (reframing) (2009) of the circumstance and respond appropriately.
The counselor concluded that REBT is appropriate to use in this counseling scenario. REBT addresses thoughts and beliefs of an individual. These thoughts and beliefs create the behavior response. When an individual has irrational thoughts motivated by faulty beliefs, it is typically followed by a negative response. The counselor’s goal is to teach the client to evaluate irrational thoughts and faulty beliefs concerning the antecedent event in order to create a more appropriate consequence (response). Michael’s core faulty beliefs are found in the three unconditionals. Michael feels he is entitled (Fives, et al. 2010) to fair treatment and getting his way.
Michael believed that when this entitlement was not fulfilled, it was appropriate to respond with aggression (2010). This response (consequence) created a cyclical event: antecedent event (fight/defiance)—irrational thought (my teacher is trying to embarrass me or he’s trying to intimidate me) — faulty belief (that teacher should leave me alone/ I will not be intimidated). After the fight/defiance, Michael often feels guilty, sad, or more frustrated (secondary disturbance) because he is a failure and cannot get it right (which disappoints his adoptive mother).
As a result, Michael experiences more frustration and anger. Using REBT, the counselor hopes to effectively teach Michael to dispute his negative/irrational thoughts and faulty beliefs. Therefore, this will reduce frustration intolerance and create a more appropriate consequence to the antecedent event. REBT is logical, workable, and teaches the client realistic skills to cope with life’s circumstances (Minor, 2007). In cases like Michael’s, REBT is effective with including the family in the framework of the therapy (Bernard and DiGiuseppe, 2006). Michael’s adoptive parents will be taught to identify his (and even their own) irrational thoughts and faulty beliefs and the behavioral relationship. This equips them with knowledge needed to address the behavior.
Most importantly, it helps with the long-term success of the child client in identification and appropriate response of frustrating circumstances (Fives, et al., 2010). REBT does not focus on the person, but the behaviors the person demonstrates (Levinson, 2006). This approach will be beneficial to Michael because his faulty thinking and irrational thoughts have been attached to his personhood. He perceives himself as “bad” and “inadequate” (Jones, et al, 2011). REBT should teach Michael it is not he or “the event, but the thoughts about the event” (Ellis) that cause his issues. This should encourage Michael to evaluate his thought and belief patterns frequently.
REBT utilizes psychology, examining how thoughts cause emotional disturbance. Philosophically, REBT suggests that life views influence emotions. Lastly, REBT incorporates education that should provide Michael with the necessary tools to manage his thoughts, beliefs, and responses to frustrating events (Banks and Zionts, 2008).
This will be an on-going process for Michael. Michael will experience success and failure throughout the application of REBT. The counselor will be diligent in explaining this reality to Michael. The counselor will reiterate this is a part of the three unconditionals. Michael will experience the reward of recognizing the ABCDE’s of REBT. Michael should understand the final stage of REBT is effectively (the “E”) (2010) disputing (the “D”) irrational thoughts toward the event, therefore, causing an appropriate response. Michael will learn when he is not successful, he can accept it and the consequences without becoming aggressive.
Banks, T., & Zionts, P. (2009). REBT Used with Children and Adolescents
who have Emotional and Behavioral Disorders in Educational Settings: A Review of the Literature. Journal of Rational Emotive Cognitive-Behavior Therapy , 51-65. Bernard, M. E., & Diguiseppe, R. (2006). REBT assesstment and treatment with children. Rational Emotive Behaviors approaches to childhood disorders, theory, and practice , 85-113. Fives, C. J., Kong, G., Fuller, J. R., & DiGuiseppe, R. (2010). Anger, Aggression, and Irrational Beliefs in Adolescents. Cognitive Theory Research , 199-208. Harrington, ,. N. (2007). Frustration intolerance as a multidimentional concept. Journal of Rational-Emotive & Cognitive-Behavior Therapy , 191-211. Levinson, M. (2006). Anger management and violence prevention: A holistic solution. et Cetera 187-199. Minor, J. (2007). Why I use REBT in my private practice and personal life. et Cetera , 320-323. Murdock, N. (2009). Theories of Counseling and Psychotherapy. Upper Saddle River, NJ: Pearson. Shanahan, S., Jones, J., & Thomas-Peter, B. (2010). Are you looking at me, or am I? Anger, aggression, shame and self-worth in violent individuals. Journal of Rational Emotive Cognitive Behavior Therapy , 77-91.