Case Study: “Anna”
Internship in Clinical Community Counseling Johns Hopkins University Fall 2008

2 Identifying Information Anna1 is a seven year old Caucasian female of low socioeconomic status. She lives in Pasadena with her paternal aunt and her aunt’s husband, who are Anna’s legal guardians. Also living with them are Anna’s five year old brother, their seven year old female cousin, and Anna’s paternal grandparents. Nature of Referral Anna was brought to counseling by her aunt, who was recommended to bring Anna to therapy by her pediatrician. Anna and her brother were removed from their biological parents’ home in 2004 due to severe neglect. Anna’s aunt also suspects that Anna was a victim of physical abuse by her biological parents. Since being removed from her biological parents’ home, Anna has expressed confusion about her living situation. Her main presenting issue, however, is her low self-esteem, which is focused mostly on her hearing aids and weight. Relevant History Psychiatric. This is Anna’s first time in therapy and she has no prior psychiatric history or substance abuse. Family. Anna has a family history significant for depression, anxiety, ADHD, alcoholism, substance abuse, domestic violence, and suicide. Anna’s biological mother has an 11 year old son from a previous marriage who lived with Anna until she was removed from the home. Anna’s biological parents also have another daughter living with them who is one year old. When Anna lived with her biological parents, she was exposed to domestic violence and drug use. She also witnessed her mother attempt suicide by slitting her wrists. On at least one occasion Anna’s parents were homeless with the children. Anna has been living with her aunt,

1

Name has been changed to protect confidentiality.

3 uncle, cousin, and grandparents since her aunt and uncle gained legal custody of her and her brother in 2004. Anna’s aunt and uncle are caring and supportive. Developmental. Anna was the product of a full term vaginal delivery. Her mother denied using substances during the pregnancy. Anna reached all developmental milestones on time. Anna is below average in social, language, and emotional development and average in physical and intellectual development. Academic. Anna is in second grade, has never been held back, and has a 504 plan. She enjoys school and is a good student. Social. Anna gets along well with other children and has at least one close friend. She is somewhat shy and reserved in large groups and with people she doesn’t know well. Medical. Anna is relatively healthy but does suffer from hearing impairment that requires the use of hearing aids. Past medical procedures include having tubes in her ears and her tonsils and adenoids removed. Anna also suffers from asthma and seasonal allergies. Mental Status Exam Anna is a casually dressed and cooperative seven year old who appears her stated age. She is alert and oriented to person, place, and time and makes good eye contact. Anna’s memory is intact and her attention and concentration are good. Her speech is normal in rate, rhythm, volume, and tone and her stream of thought is linear and logical. Anna reports her mood as happy and affect is congruent. She denies any current suicidal ideation or homicidal ideation and displays no evidence of delusions, hallucinations, obsessions, compulsions, or phobias. Anna’s insight and judgment are fair for her age and she seems to have control over her impulses. Anna has some trouble sleeping and tends to overeat. Her motor activity and energy level are normal.

4 Diagnosis Axis I: 300.00 Anxiety Disorder, NOS 995.52 Neglect of a Child Axis II: 799.90 Deferred Axis III: Hearing impairment, asthma, allergies Axis IV: Primary support group problem Axis V: 55 Critique of Therapy In reviewing my time with Anna, it seems as if cultural and diversity issues have not been an issue for us. This is likely a result of the fact that in many ways our cultures are similar: we both grew up in the same region and we share the same gender, race, and ethnicity. Religion has not come into play in our sessions. The only cultural differences that have been apparent to me are age, hearing ability, and socioeconomic status, none of which seem to have had an impact on our relationship. I can see how Anna may have been less embarrassed about her disability if I also had hearing aids, but I do not think that this difference has caused any problems for us. I think that the similarities Anna and I share have made each of us more comfortable working with each other. I believe that we bonded faster than I have with other clients, and I attribute this to the fact that we didn’t have to work through a lot of differences first. The most significant limit to my ability to understand and empathize with Anna is her lack of expressivity about her feelings and experiences. Anna tends to close off conversations about emotionally heavy issues, such as her parents and her self-image. Additionally, as a seven year old she has limited insight into her problems. For these reasons I feel as if I have had to make a lot of assumptions about Anna’s subjective experience, which has limited my ability to fully understand what she is going through. I also have not had a lot of training in trauma work, so I feel somewhat limited in understanding how Anna’s experiences with her parents may be shaping her current state.

5 My leading strength in working with Anna has been my ability to build rapport with her. I think this has been influenced by our similarities and also her likeable and agreeable attitude. I also try to make Anna feel comfortable by being silly, such as wearing a giraffe hat in session, and she seems to respond well to this. Planning is another area I have excelled in during my counseling with Anna. I have come up with activities that have accurately targeted the issues Anna has struggled with. I think my biggest weakness has been a lack in facilitation of self-esteem building. When I listen back over my sessions I notice times when I should have praised Anna’s effort or helped her feel proud of herself. I also struggle with knowing when I should wait for Anna to bring up issues, specifically ones that are emotionally laden, and when I should directly ask about them. I have had some trouble figuring out how to approach the trauma Anna experienced as I have not have a lot of training in that area. Another weakness is that I sometimes push an activity that I think will be helpful when Anna isn’t ready. For example, I had her spend a session coming up with five things she likes about herself when it was clear that this made her uncomfortable. Theoretical Formulation Anna’s case is well suited for conceptualization using the theories of Alfred Adler and his followers. The Adlerian approach to therapy uses the framework of Individual Psychology, which ascertains that people should be understood holistically and human behavior is purposeful. This perspective is based on the growth model as opposed to the medical model, so according to this theory Anna should not be labeled with diagnoses but rather be viewed as discouraged in her attempts to understand and carry out life. As mentioned previously, Adlerian theory considers personality holistically in the context of the environment. Thus it is important to focus on the impact of Anna’s family system on her

6 thoughts, feelings, and behaviors. Anna is the middle child in her family and according to Adler this could result in her feeling left out and unfairly treated. Anna’s aunt reports that Anna describes these types of feelings whenever she doesn’t receive the same type of praise or rewards as her brother and cousin. Adler also theorized that the middle child may become the peacemaker in times of family conflict. We see this in Anna as she attempts to protect her biological parents by rationalizing and downplaying their negative behavior. In Adlerian theory, perception is greater than reality. This becomes evident in Anna’s case in her beliefs about her parents. Her perception is that they can do no wrong, so she says that they are “better now” and she wants to live with them again at the end of this school year. She seems to put no weight on the reality of what her parents have done and the impact it has had on her life. The Adlerian perspective is that people are motivated by social relatedness. Adler’s theory also stresses the importance of community feeling, which is achieved by finding a place in the family and society to fulfill basic needs. The theory postulates that anxiety is a result of those basic needs not being met. Anna experiences a lot of anxiety related to her family situation and her self-image, so this is likely influenced by the lack of security she felt with her biological parents and the lack of acceptance and worthiness she perceives as a result of not living with them. Adlerians believe that people’s personalities dictate how they react to stressful situations. Nira Kefir, an Adlerian psychologist, classified these types of reactions into four personality priorities; Anna’s priority is aiming to please. Anna is unable to make even minor decisions in therapy sessions, and she constantly seeks approval of her work. Her aunt says that at home Anna regularly needs assurance that she is doing the right thing. This aspect of Anna’s

7 personality was likely shaped by her feelings of rejection regarding her biological parents; Anna aims to please out of fear of being unwanted. Before leaving the topic of systemic influences, it is important to note one key Adlerian concept. This theory proposes that it is not the environment and experiences that cause behavior, but rather a person’s interpretation of their system that has the most impact. According to Adlerian theory, Anna chooses to see her parents as harmless and feel that her hearing disability is something to be ashamed of. Anna’s beliefs about her past and herself play a huge role in shaping her feelings and behavior. Adlerians believe that thoughts cause feelings and feelings cause behavior. Adler referred to a person’s core beliefs as their “private logic,” and felt that private logic guides perception and striving in a pattern that becomes a lifestyle. Anna’s lifestyle is characterized by negative thoughts about herself and fear of being unloved, which results in shy and careful behavior. Anna makes these basic mistakes in her private logic: overgeneralizations, impossible goals, misperceptions of life, and minimization of self-worth. Anna’s main overgeneralization is in thinking that everyone thinks her hearing aids look stupid. She says that she covers her ears with her hair because everyone makes fun of her hearing aids, but when asked who has made fun of her she can only recall one specific girl. This basic mistake is causing Anna to feel extremely self conscious about her hearing aids, which is leading to some behavior issues. Anna validates her beliefs by hiding her hearing aids and never giving anyone the chance to notice the bright pink design on them and possibly acknowledge that they aren’t stupid. A main tenet of Adlerian theory is that all behavior is purposeful and goal directed. Anna makes the mistake of setting the impossible goal of perfection. She tries so hard to make sure

8 her drawings are perfect and is very hard on herself when she misspells words. It seems as if she has set an internal standard that is unattainable, which only sets her up for more feelings of failure. It appears that Anna misperceives many things in life. Her most significant misperceptions are related to her parents and her living situation. Anna operates under the belief that her parents are good, but in reality that may not be the case. Anna’s aunt has expressed that the parents still have not completely cleaned up their act in the eyes of the court. It is also possible that part of the reason Anna is so ashamed of her hearing aids could be that she feels her disability is to blame for her removal from her parents. This is likely because Anna and her younger brother, both of which have hearing disabilities, were removed from the home while their older half-brother and newborn sister, both of whom have no disabilities, still live with their parents. Anna’s final significant mistaken belief is her overwhelming feeling of inferiority. Adlerians propose that everyone has feelings of inferiority which result from recognizing helplessness at a young age. The theory suggests that these feelings are healthy in that they fuel the striving aspect of one’s lifestyle. In Anna’s case, however, she takes those feelings to an extreme by supposing that she is worthless. In an exercise to build self-esteem, Anna was asked to list five things she likes about herself. She could only come up with four and then spent the next week agonizing over the fifth. Overall, Anna has experienced many unpleasant things in her life and has been born with a disability. According to Adlerian theory, however, Anna’s biggest problems are her faulty assumptions and misperceptions about her experiences and herself.