The client is a sixteen-year-old African American female who is pregnant with her second child. The client attends junior high school. The client lives with her mother, age unknown, who is unemployed.
Peak View Behavioral Health is located in Colorado Springs, Colorado. Peak View Behavioral Health is a “psychiatric hospital dedicated to providing quality care to promote growth and structure for clients and families” (Peak View Behavioral Health, 2012). Peak View Behavioral Health treats adults ages eighteen and older and, in January 2013, will begin to serve children ages four to seventeen. The hospital’s services include acute psychiatric care, partial hospitalization, intensive outpatient services, substance abuse, twenty-four hour assessment and Electroconvulsive Therapy.
C. Reason for Referral
The client was referred to Each One Teach One, an alternative school, by her prior public school principal. The client is pregnant with her second child and has been suspended from the public school. Adolescent pregnancy, intended or not, can have negative consequences. Common consequences of adolescent pregnancy include dropping out of high school, living in poverty, relying on public welfare, and experiencing higher levels of psychological distress, as compared to their same age peers (Stoiber, 2005). The consequences of the client’s pregnancies are reflected by her situation. She has been referred to an alternative school and experiences psychological stress which impacts her relationships. The principal was aware of the client’s first pregnancy, although no previous interventions were attempted. The principal suspects the client is having difficulty in her home life, although she will not disclose to the principal how she became pregnant twice.
Client is not happy about the suspension from public school. Client does not understand why she is being suspended because she feels as though she has not done anything wrong. Although she is upset about the suspension from her public school, she does seem interested in the referral to the alternative school as evidenced by her accepting the referral and attending Each One Teach One. One of the highlighted strengths in the lives of African Americans is their strong educational or achievement orientation (Boyd-Franklin, 2006). Although the client is experiencing a negative social and economic environment, she appears to be motivated to better herself. The client’s mother does not support the referral for client to attend the alternative school. The client’s mother encourages the client not to attend school and “get on the Welfare.”
D. Client’s Description and Functioning
Client is of average height and pregnant. Client attends school well groomed, e.g, hair brushed, teeth brushed, showered, and wears clothes that are clean and well-fitted. Although the client is pregnant, she is able to walk to school and walk up and down the stairs to her apartment without difficulty. Client took necessary testing precautions to be tested for Human Immunodeficiency Virus (HIV) after learning her father passed away from Acquired Immunodeficiency Syndrome (AIDS). Consequently, client tested positive for Human Immunodeficiency Virus (HIV).
Client does not speak grammatically correct English as evidenced by client stating sentences such as “I is learning,” “I does my work,” and “what this one is?” Although client reports she sits in the back of the classroom, does not open a book and does not participate, client’s math teacher reports client does well in math. Client has difficulty reading. The client’s mother reports client as “stupid” and “not ever amounting to anything.” Client identifies one of her strengths as cooking. Client reports auditory and visual hallucinations in the form of vampires telling her “you are one of us.” Client fantasizes about being white, living rich and famous, and being “saved” from her current situation.
E. Physical and Economic Environment
The client’s mother is unemployed and receives welfare of an unknown monthly amount. Client’s mother has custody of client’s first child in order to receive aide on that child. Client attended public school until suspended and will be attending Each One Teach One. In the evenings, client cooks and cleans for the household. Client describes her mother’s day as a “beached whale lying on the couch.” Client states her mother “eats, watch T.V., eats, watch T.V.”
The client and mother live in a two bedroom apartment, rent unknown, in Harlem. Client describes the neighborhood as the “ghetto” and consumed with “crack heads.” The client’s apartment building is sprayed with graffiti. Americans visualize the ghetto as “where the black people live” representing a poor, susceptible to crime, drug-infected and violent part of the city (Anderson, 2012). The client defines her neighborhood as the ghetto due to drug activity and crime.
F. Current Social Functioning
1. Family Situation. The client and mother live in apartment together. The client’s mother has custody of the client’s first born child and claims that child for welfare purposes, although the child actually lives with client’s grandmother. The client’s father previously lived in the home with client and mother prior to moving out. Client’s relationship with her mother is volatile. The client’s mother reported she “should have aborted her.” Client cooks for her mother, cleans the home, and runs errands for her mother when needed. Client fantasizes of wanting to be on the cover of a magazine or in a music video.
Client has current and past history of sexual and physical abuse. Client was raped by her father. The client’s first child, and the second child she is pregnant with, are products of rape by the client’s father. The client’s mother is aware of the rape of the client by her father but blames the client for “taking my man.” The client’s mother also blames the client for client’s father moving out of the house. The client’s mother also admitted to sexually abusing client, stating “who was going to please me.” Client has also experienced physical abuse at the hands of her mother. The client’s mother has slapped her and thrown a frying pan towards her head. The client’s mother is verbally abusive calling client names such as “bitch,” “whore,” “good for nothing” and “stupid.”
2. Current Sexual/Emotional Relationship. Client reports never having a boyfriend but wishes she had a “light skin boyfriend with nice hair.”
3. Occupational/School Situation. Client has been suspended from public school and referred to Each One Teach One, an alternative school, due to her second pregnancy. Client enjoys math and does well in math, as reported by her math teacher. Client has difficulty reading and tested at a second grade reading level. Client has difficulty with her peers as evidenced by client’s physical aggression towards peers, i.e., slapping, punching, and cursing at her peers. Client has obedient relationships towards teachers and principal as evidenced by following directions without defiance.
4. Other Social Relationships and Social Roles and Satisfaction. Client reports never having a boyfriend and does not have any friends. Client takes pride in being a mother but is not able to be a mother to her first child due to her own mother not allowing her child to live in their home because of the child’s developmental disability. Client has expressed wanting to get her child back. Client does not currently attend a church but fantasizes of participating in the church choir. For generations, African Americans have used spirituality and religion as a crucial instrument for survival (Boyd-Franklin, 2006). One role of the African American church is to act as a refuge, as a sanctuary in an often times unfriendly world (Boyd-Franklin, 2010). Although client does not currently attend church, in her fantasies, she finds the church as a safe place from her negative and hostile environment.
5. Medical/Psychological. Client is pregnant with her second child. Client’s first pregnancy resulted in a female with developmental disabilities. At time of client’s referral to Each One Teach One, client had not yet seen a doctor for her second pregnancy. Client found out from her mother her father passed away from AIDS and client tested positive for HIV. Client’s mother refuses to be tested for HIV because she believes she has not contracted the disease because she and client’s father did not engage in anal sex.
6. Legal Issues. Client does not have any legal issues at this time.
G. Personal and Family History relevant to current focus
Client was born in November 1971 in Harlem. Mother reported client would sleep in the bed with her and the client’s father. Client was bottle fed as a baby, as client’s father would drink the breast milk from client’s mother’s breast. The client’s mother reported client was three years old at the time of her first sexual abuse by her father. Client has experienced sexual abuse by her father and mother, and physical and verbal abuse from her mother. Individuals who are of lower economic status are more likely to experience traumatic events, and African Americans are more likely to be of lower socioeconomic status (Gapen et al., 2011). Client’s mother reports there is no alcohol or substance use in the home.
The client’s intellectual functioning is at a moderate level as evidenced by grammatically incorrect language and a second grade reading level. In terms of the client’s psychological functioning, her ego functions are moderately compromised. The ego’s ability to unify and combine mental processes is called ego functions (Berzoff, Flanagan, & Hertz, 2011). Reality testing is the ego’s ability to recognize and agree with physical and social reality. The most important aspect of this function is the ability to tell the difference between internal reality and external reality (Berzoff, Flanagan, & Hertz, 2011). The client’s function of reality testing is compromised at times, as evidenced by auditory and visual hallucinations and retreats to her “fantasy world.” The client’s ego function of controlling impulses is also compromised, as evidenced by aggressiveness towards peers.
The ego’s attempt to maintain an accurate level of positive self-worth in the face of stressful or aggravating circumstances is self-esteem regulation (Berzoff, Flanagan, & Herzt, 2011). The client’s self-esteem could be defined as low due to physical, sexual, and verbal abuse. The client’s low self-esteem can be seen through her fantasies of wanting to be someone else, e.g White, famous. Defense mechanisms guard the self from danger, actual or perceived (Berzoff, Flanagan, & Hertz, 2011). In terms of defense mechanisms, the client’s defense mechanisms could be classified as immature. The client’s immature defense of dissociation, where a painful memory is detached from the feeling, is evidenced by the client’s fantasies of herself leading a different life (Berzoff, Flanagan, & Hertz, 2011).
B. Emotional Functioning
Between nine and twelve months of age children begin to develop Internal Working Models to characterize emotions and expectations resulting from interactions and communication between infant and caregiver (Riggs, 2010). Consistent with the notion emotional abuse negatively impacts Internal Working Models and the ability to regulate affect, research suggests emotional abuse places children at risk for poor self-concept and disorders of emotional regulation and impulse control (Riggs, 2010). In regards to the client’s emotional functioning, her limited range of emotional expression and poor impulse control are demonstrated by her use of aggression and anger towards peers. The client’s negative coping responses can be seen through her fantasies, as she cannot verbally express how she is feeling.
According to attachment theory, insecure attachment styles are used because they are adaptive in relation to the behavioral responses of their attachment figure (Riggs, 2010). One type of insecure attachment pattern is disorganized attachment. Disorganized attachment can be connected to child abuse, lack of resolution to trauma or loss by parent, and maternal frightening behavior and psychopathology (Riggs, 2010). The client’s attachment pattern can be classified as disorganized due to her experience of sexual abuse, by her mother and father, and physical abuse, by her mother. The client’s disorganized attachment can also be attributed to her mother’s lack of support in regards to her sexual abuse by her father, i.e., blaming the client for the abuse. Evidence of client’s insecure attachment in early childhood can also be seen, currently, through client’s dismissiveness, i.e., that she takes care of her mother despite the abuse, low self-concept (Berzoff, Flanagan, & Hertz, 2011).
C. Social/Behavioral Functioning
Attachment insecurity, due to emotionally abusive parenting, adds to poor social functioning. In early attachment relationships, children begin to develop the skills needed to build future social relationships, such as self-awareness, empathy, negotiation, and conflict resolution. The security of attachment influences many areas of interpersonal relationships, including effectiveness in peer groups, reciprocity in relationships, empathy, problem solving, conflict resolution, and establishing close and intimate relationships with peers (Riggs, 2010). The client’s social isolation, as evidenced by her lack of peer group, demonstrates the client’s insecure attachment with caregivers. The client’s lack of distrust in peers and adults is displayed through client’s aggressive behaviors.
D. Environmental Issues and Constraints Affecting the Situation
The client lives in a neighborhood in which she would consider the “ghetto.” Client lives with her mother, although the relationship is unstable. Children with a very insecure attachment to their mothers are more likely than other children to live in high-risk families and environments (Kwako, Knoll, Putnam, & Trickett, 2010). The client has experienced sexual, physical, and verbal abuse from her caregivers. African American families experience higher rates of poverty than families of other races. Living in poverty increases the risk of exposure to trauma and trauma is found more often in African American populations (Graves, Kaslow, & Frabutt, 2010). The client’s turbulent home environment, unsafe neighborhood, and lack of social supports and resources exacerbates client’s distrust in others, social isolation, and negative self-concept.
E. Motivation and Commitment to Services
The client’s mother does not support client attending school and would rather client take welfare services. Despite the client’s mother’s lack of support, the client is motivated to attend school to continue her education and be a positive mother for her children.
F. Worker’s Understanding of Client’s Presenting Situation/Problem
The client is a sixteen year old, African-American teenage mother of two. The client has experienced severe childhood sexual trauma by her mother and father. The client’s two pregnancies are results of sexual abuse from the client’s father. The client lacks emotional support from her mother and is often ridiculed by her mother in terms of her appearance, intellectual functioning and overall being. Emotional abuse in the attachment relationship significantly increases the likelihood of developing insecure attachment, which is proven to be linked to low empathy and reciprocity, hostility or aggression and impulsivity, exploitation or ridicule by peers, social withdrawal or exclusion from group activities, and general patterns of un-relatedness and isolation (Riggs, 2010).
The client lacks any type of social support from peers and, often times, interactions with peers result in aggressive confrontation. Client’s distrust in peers and adults is evidenced by lack of nurturing relationships. Up to this point, client has not accessed community resources. Previous experience with racism frequently prevents African Americans from accessing assistance and/or services from organizations which historically have safeguarded Caucasians (Graves, Kaslow, & Frabutt, 2010). Client’s mother is distrusting of community institutions which may lead to client’s inability to access support.
According to attachment theory, a child forms representational models, i.e., internal working models, of attachment figures, of the self, and of self-in-relation to others based on their relationship with primary caregivers. When a child’s caregiver responds in a sensitive, loving, and consistent manner, a working model of “other” as loving, reliable, and supportive is internalized. On the other hand, experiencing emotional abuse and neglect may instill damaging beliefs about the self, e.g., “I am stupid,” “I am not worthy of attention,” which may result in maladaptive models of self, other, and self in-relation to others. Instead of developing a working model of the self as worthy of love and attention, negative models of the self as worthless, incompetent, or powerless may result (Wright, Crawford, & Castillo, 2009). Due to the client’s mother’s unstable and inconsistent caregiving patterns, client has developed a low concept of self, as evidenced by the client’s feelings of unworthiness to have or accept any type of relationships.
Although the client has experienced severe childhood trauma, insecure attachments with caregivers, and family and community instability, the client appears to be moderately resilient. Resilience refers to patterns of positive adaptation during or following major adversity or risk (Lopez & Snyder, 2011). Faced with two pregnancies, unsupportive and abusive caregivers, and lack of social support, the client continues to be motivated to pursue her education, regain custody of her first child, and become a caring and loving mother to her children.
III. Evidenced Based Practice Search
This author began the search using the Google Scholar search engine with the term ‘psychodynamic treatment for female African American adolescents of sexual abuse.’ This search yielded articles related to interventions for substance abuse. The same search term was used again but the term intervention was exchanged for the term treatment. This search yielded articles on cognitive behavioral interventions. This author then moved to using the search engine PsyhInfo. Terms including psychodynamic treatment, psychodynamic intervention, African American, adolescent and sexual abuse were again interchanged to aide in the search. This author then added the term ‘sexual abuse survivor’ to the search. This search began to yield interventions related to psychodynamic interventions. This author began finding articles related to psychodynamic groups as a psychodynamic intervention.
Continuing to use the PsychInfo search engine, this author then used search terms psychodynamic groups, adolescents, sexual abuse survivor and African American. This author was able to yield articles related to psychodynamic groups. This author then moved to using the University of Southern California Library to continue the search. This author again used the terms psychodynamic groups, adolescents, sexual abuse survivor and African American to yield further articles in regards to psychodynamic groups. This author was able to accumulate six articles in regards to psychodynamic group intervention. Overall, this author found it extremely difficult to find, in the literature, psychodynamic interventions specific to African American adolescents who have experienced sexual abuse.
IV. Intervention Plan
In the first years of childhood, the family is responsible for the care and development of the child. In healthy families, children learn they can depend of their environment to provide emotional security and physical safety. Children then gain behaviors which allow them to nurture their own emotional and physical health free from parents or caregivers. Poor health also can develop early in life. Children who live in families with characteristics such as family conflict, i.e., frequent episodes of anger or aggression, and lack of nurturing, i.e., relationships which are cold, unsupportive, and neglectful, can have negative consequences on mental and physical health (Repetti, Taylor, & Seeman, 2002). Unfortunately, due to client’s exposure to an abusive and un-nurturing environment, she has developed poor mental health, as seen by her moderate level of defense mechanisms, poor self-concept and lack of support.
Due to the client’s insecure attachment with caregivers, which has led to lack of support and untrusting nature to others, the intervention employed will be psychodynamic group psychotherapy. Because of client’s young age, client will be more suitable for time limited psychodynamic group psychotherapy, which occurs between twelve and thirty sessions (Wise, 2009). The format used for psychodynamic group psychotherapy is verbal. The basis of the group should be to feel and talk, rather than act. Because it is a psychodynamic therapy, the therapist should wait for the group interactions to occur freely and then comment when appropriate (Wise, 2009). During the process of psychodynamic group psychotherapy, the therapist will attempt not to set agendas but follow the suggestions of the group. The belief is the group process will eventually lead to the most emotionally charged subjects if allowed to proceed without interruption. The therapist in the psychodynamic group psychotherapy session will attend to the group and individual members based on how the session begins (Rutan, 1992).
The implementation of the psychodynamic group psychotherapy intervention is community based, therefore the client will need to access community organizations to utilize the treatment intervention. As previously noted, the client has not accessed community resources thus far. Another hurdle the client will have to overcome in order to maximize optimum results from the psychodynamic group psychotherapy intervention is a proper match to therapist leading the group and participation. Because client is untrusting of other others it may be difficult to engage client in group psychotherapy process. A therapist who creates an environment of acceptance, understanding and trust, and provides empathy and responsiveness will have a better chance of keeping and engaging challenging members (Gans & Counselman, 2010).
The goal of psychodynamic group psychotherapy is to make aware parts of the unconscious which result in negative distortions in present day perceptions (Rutan, 1992). Furthermore, goals of treatment are to assist in overcoming resistance to experiencing, expressing and understanding emotion. The psychodynamic group psychotherapy model allows for resolving the tension between suppression of emotions and explosiveness. The group format also allows for members to work together to manage and contain feelings (Wise, 2009). This aspect of psychodynamic group psychotherapy will be beneficial to client, as she has difficulty expressing her emotions, as evidenced by aggression towards peers. Although the client will gain emotional regulation skills through the psychodynamic group psychotherapy intervention, this will not be her main treatment goal.
Psychodynamic group psychotherapy is also another way for individuals to interact within a system of relationships. This is beneficial due to most presenting problems having a relational context. Allowing individuals to interact and then reflect gives the individual the opportunity to use the group as a place to observe and change patterns (Wise, 2009). The client has expressed a desire to have safe, nurturing and loving relationships with others, but due to low self-concept does not feel worthy of such relationships. The client’s goal for psychodynamic group psychotherapy will be to increase number of quality relationships from zero to at least two by the conclusion of the group sessions. The client’s relationships will be measured by her own self-report, as well as therapist observations of her interactions and relationships with fellow members of the group and development of social skills.
The catalyst for change in psychodynamic group psychotherapy includes change by imitation, i.e, learning by observing others, identification, i.e., unconsciously taking on traits or characteristics of others, and internalization. The therapeutic process develops using confrontation, explanation, interpretation and working through (Wise, 2009). Additionally, other therapeutic aspects which are addressed include support, self-revelation, learning, and self-understanding, with interpersonal learning as the utmost important (Wise, 2009). Because the client has developed negative internal working models, due to insecure attachment with caregivers, i.e. mother and father, the interactions with others in the group setting may begin to assist client in developing higher self-concept and more nurturing relationships.
V. Discussion, Analysis and Rationale for Interventions Chosen
Psychodynamic group psychotherapy was chosen as the intervention for the client due to her experience of sexual abuse by caregivers. Time limited, as well as ongoing psychodynamic group psychotherapy has been effective in treating women with a history of sexual abuse, due to the opportunity for the individual to reduce the feelings of isolation, guilt, and shame. An individual is able to effectively work through feelings when the individual is able to share their experience in a therapeutic environment comprised of compassion and acceptance. The psychodynamic group psychotherapy process provides an individual with the ability to incorporate a new object experience without devaluation or ridicule, while at the same time abandoning previous attachments which were associated with the original event and emotion (Nusbaum, 2000).
When an individual is abused, the person tends to identify with the unloving, aggressive, and immoral characteristics of the superego rather than the gentle, loving and protective characteristics. The individual may interpret the caregivers failure to nurture and protect adequately as a sign they are unworthy and unlovable (Nusbaum, 2010). Evidence of these characteristics can be seen in the client’s low self-concept and feelings of unworthiness to have any type of relationship. Within the psychodynamic group psychotherapy process, the group can demonstrate appropriate levels of protectiveness, love and concern to its members. Negative feelings often experienced by individuals with sexual abuse can often be eased through disclosure of the traumatic experience. The group can then provide corrective superego functions by not allowing its members to blame themselves for the experience, which may have been unavoidable and not their fault (Nusbaum, 2000).
Psychodynamic group psychotherapy also deepens the alliance between group members and facilitates the development of relationships which can be observed and analyzed in the context of interpersonal fears and roadblocks. Furthermore, in psychodynamic group psychotherapy individuals can identify interpersonal conflicts and work through primary defense structures which are run by fears of trusting. Additionally, because abuse and neglect tend to occur in dysfunctional families, by successfully working through emotional conflict the psychodynamic group offers the opportunity for interpersonal learning and development of social skills, which are usually not modeled in dysfunctional homes (Nusbaum, 2000).
This author is unable to implement the psychodynamic group psychotherapy intervention with the client but can visualize how the intervention would unfold with the client. In the first sessions this author would attempt to create a trusting, nurturing and safe environment where client would feel she could engage in the group process and share personal experience. According to psychodynamic theory, personality is formed developmentally. In this model each stage of development builds on the previous stage and each stage affects the following one. It is important to note in the therapeutic process, defects in earlier developmental stages can be corrected if that stage can be recalled, relieved and be affectively re-experienced and corrected in the here and now (Rutan, 1992). It will be pivotal for the client’s treatment for her to share feelings, emotions and past experiences in order facilitate positive transformation.
This author would predict the client would be difficult to engage initially due to her mistrust in others and feelings of unworthiness. After consistent nurturing, accepting, trusting and safe experiences in the psychodynamic group, this author would see the client begin to engage in the group process. Once the client begins to share personal experiences, feelings and emotions this author would utilize a specific intervention, the here and now. The here and now technique would allow this author to use the client’s past experience to understand and explain occasions when she unconsciously repeats the past or misperceives the present based on what she has learned in the past (Rutan, 1992). This technique would allow self-learning and self-understanding in regards to how her past abuse and neglect as affected her current relationships.
This author expects transference will likely surface in the therapeutic process with the client. Transference can be defined as the misrepresentation of present object relationships on the basis of early object relationships (Rutan, 1992). Transference will be beneficial in the therapeutic process with the client. It will allow for this author to gather information and explore the nature of early relationships based on the characteristics the client transfers on to this author (Rutan, 1992).
Through the psychodynamic group psychotherapy process the client’s main goal will to be to form quality, nurturing and trusting relationships. Relationships are important in forming personality, causing psychopathology, and curing psychiatric symptoms. As individuals develop in the psychodynamic group they are forming important relationships and, while doing so, every part of their character is emerging. Individuals reveal their defense mechanisms and transferences while, in turn, receiving feedback from the therapist and other members. There may not be any other therapeutic process where so much data is available to an individual about themselves as in psychodynamic group psychotherapy (Rutan, 1992).