Therapist Name Case Name/ Reason for Referral Essay

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Therapist Name:

Case Name/#:

Reason for Referral:

The client is a 15-year-old male who has issues with anger management. The client is also a gang member and given his age and background he is considered to be at risk for a number of antisocial behaviors.

Presenting Problems:

Clinical concerns: Anger management/acting out.

Clinical concerns: Interpersonal isolation/relationship issues.

Clinical concerns: Underage cigarette smoking.

Client is a high potential risk for substance abuse.

Clinical concerns: Client is at a high potential risk for depressive symptoms.

Contextual considerations:

The client has been in counseling with another counselor for four months before being transferred to this counselor's caseload. According to the reports from his previous counselor this client had made very little progress and was uncooperative.

He was uncooperative during the initial assessments and did not wish to discuss his feelings or acknowledge that he has difficulties with managing his anger. He tends to rationalize his outbreaks and does not see himself as responsible for them, but instead places the blame on other people for his outbursts of anger and aggressiveness. These outbursts can occur whenever someone disagrees with him or he does not get exactly what he wants. He uses anger and aggressiveness as a form of intimidation to coerce others to either give him what he wants or to leave him alone (which is often what he wants). Thus, his outbursts of anger are reinforced on a contingent basis because he can justify leaving or he can intimidate others into giving him what he wants or getting them to leave. In this manner it allows for him to feel superior to anyone that he can intimidate or he can remove himself from. This leads to him being quite self-centered and self absorbed and only concerned with his needs.

We can hypothesize that the client's anger actually represents a number of affective states including his frustration with his life and with personal relationships as well as anxiety and frustration that he attempts to gain mastery over by "acting out" via the use of sarcasm, aggressive behaviors, and cigarette smoking (McWilliams, 1994).

III. Relevant Background Information

The client is the oldest child in a sibship of two with one younger brother. The family lives in a four room flat in Bukit Batok. Both parents work collecting old newspapers, soft drink or aluminum cans, and other things that can be sold to companies that collect materials for recycling purposes. They both leave very early in the morning before the children go to school and come home very late, but the mother does cook dinner. The parents have very little interaction with both of the boys and their interactions primarily consists of punishing the boys for reported transgressions at school, behavioral issues at home, and poor grades. Outside of being punished by his parents the client appears to have very little parental supervision and does not appear to view his parents as positive role models that he would like to emulate, although he does state that he wants to help support them someday. The client looks up to higher-level gang members, musicians, and elite sport sports athletes as his role models.

The client has exhibited issues with anger management since upper Primary school, and is reportedly doing below-average level work in school. He joined a gang at the age of 13 years old for protection purposes as gangs are common in his environment. He was arrested in 2012 being apprehended at a gang settlement talk and sentenced to six months in a corrective boy's home. He has no other offenses.

The client denies the use of drugs as he is fearful he will be caught by the police and this will be a "death sentence" for him. He smokes regularly in an effort to relieve "boredom" but has resisted the attempts of his peers to get involved in alcohol or drugs.

IV. Contact Details:

Client was seen for eight sessions.

V. Formulation:

First and foremost, while there are obvious anger management issues currently there is not enough information to apply any other solid diagnoses in this case. We can get a sense of depressive symptoms, a need for acceptance, his frustration and acting out, and his potential for substance abuse. However, we need to keep in mind that there are features of depression and anxiety in nearly every psychiatric disorder and in all instances of dissatisfaction with one's circumstances (Hoch, 1972). It is tempting to diagnose a mood disorder when in fact the moodiness may represent part of a larger issue; therefore, just diagnosing the patient with "depression" will not reach the core issues here, aside from the fact that we do not have enough information to satisfy the diagnostic criteria for depression (American Psychiatric Association [APA], 2000).

The patient does display very early features of a potential characterological disorder, but again, there is not enough information to satisfy the diagnostic criteria for a personality disorder, he is too young for such a diagnosis, and there is no indication of an Oppositional Defiant Disorder at this time (APA, 2000). There also appear to be long-standing issues regarding this patient's personal relationships. These may reflect feelings of inferiority, concerns of self-worth, the need to gain acceptance, and may be rooted in an unconscious wish to be accepted and perhaps nurtured.

Individuals who experience difficulty controlling their anger often experience problems with perceived pressures from other people, their life situation, and difficulty understanding and predicting how people relate to them. Their everyday negative thoughts, negative beliefs, and difficulties with interpersonal relationships are all intertwined with these issues because tension related distressing creases the likelihood of an anger outburst or aggressiveness.

For most people there is a continuum between being irritable and anger that is fueled by beliefs that one's life is unfair or that other people have violated one's standards of behavior. Often difficulties with anger management in young people can surface when the person is repeatedly criticized or humiliated to the point where they do not feel worthwhile. Such wounds to the young person's self-esteem are triggered when they believe that they have to defend themselves against negative feelings by engaging in aggressive behaviors to protect their own self-esteem.

Of course there are times when someone really is threatened and responds with aggression or anger, but becomes problematic when one responds with anger to a broad range of circumstances or uses inappropriate anger to defend oneself. Anger of any type is composed of: (1) the method a person uses to interpret their experience; (2) the process a person uses to recognize, to express, and to control their anger; and (3) communications that occur in interpersonal relationships (either communication errors or genuine communications; Sukhodolsky & Schahill, 2012).

VI. Goals for Counseling and Rationale for Treatment Plan

The therapy of choice for this client would cognitive behavioral therapy (CBT). There are a number of empirical studies that have demonstrated that CBT is an effective therapeutic technique for anger management. For example Beck and Fernandez (1998) reviewed 50 studies on CBT and anger with many of the studies targeting violent offenders and found that those involved in a CBT treatment program had better outcomes in reducing their anger levels than 76% of the control groups in the studies. Boxer and Goldstein (2012) reported that CBT techniques are extremely effective in anger management issues with juveniles and even with gang members.

The approach with anger management techniques using CBT is slightly different with adolescents than with adults, and this is especially true with an adolescent involved in gang activity (Boxer & Goldstein, 2012; Sukhodolsky & Schahill, 2012). Most often in cases of adolescents with anger management issues they do not refer themselves for treatment and do not readily recognize that the problem might lie with their perceptions of the world as much as the problem is a manifestation of the way others treat them. Therefore, the approach in this case should be cautious. Making sure that a very strong working alliance is developed with the client before any real therapeutic interventions are tempted is crucial (Hill, 2005). Thus, the initial stages of therapy would totally be devoted to talking with the client, trying to get him to talk, and emphasizing with them as much as possible. As rapport is developed the formalized stages of the CBT would be worked into the sessions.

The first step of counseling following rapport building would be to discuss recognizing the onset of anger and the conditions that lead to outbursts with the client. Because the client is self-centered and protective he will initially be directed to try and see how others "get him angry" in an attempt to get him to recognize the types of situations that lead to his anger outbursts. Generally these will involve threats to his self-esteem and is important to discuss both sides (what the person in this situation does to him and what he is feeling; Sukhodolsky & Schahill, 2012).

The next step would be to explain to the client…[continue]

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