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May/June 2008

Therapist’s Notebook
Social Work Today
Vol. 8 No. 3 P. 34

Social Work Today presents a case vignette with input from three social workers—a case presenter and two discussants who offer their insights on the case history, background, and the initial phase of treatment.

Editor’s Note: Cases are fictitious. Any resemblance to actual clients is coincidental.

Case of Carlo
By Camielle Call, LCSW

Carlo, 14, is the oldest of three children, with an 11-year-old brother and a 9-year-old sister. He has been living with just his mother and siblings since the age of 8 when his father was sent to prison. And although Carlo says his father is now a free man, there has been no contact. His mother works hard as an assistant librarian and has been able to make ends meet, however minimally. Carlo says he loves his mother but that he is a burden to her.

Carlo is a gang member. He uses alcohol occasionally but prefers cigarettes and smokes pot when he can find it. He does not use any other substances on a regular basis. He has left home numerous times to live on the streets with his gang brothers, returning home when he needs food or money. Due to several misdemeanor charges, Carlo is currently in the custody of youth corrections with a probation officer tracking him. Although he dropped out of school at the age of 11, he is required to attend since being in the custody of the state.

Recently, Carlo was placed in therapeutic foster care, living with foster parents and three other foster children, all adolescents. This foster care placement is approximately two hours driving time from his home; it was necessary to remove Carlo from his hometown in order to access the consistent services that are so critical for him and avoid the negative influence of his gang brothers.

Two years ago, Carlo was hospitalized for several weeks after being shot in the back of the head during a gang turf battle. Surviving with a serious concussion, Carlo was unconscious only briefly, regaining consciousness in the ambulance. His injury did not harm essential parts of his brain, and he is able to function much as he did prior to the shooting. When he pulls off his hat and parts his hair at the base of his skull to reveal the scar, he tells the story of being shot in a monotone voice as if he has repeated it a hundred times.

“I dunno, it just happened. We gotta protect ourselves, ya know. It ain’t right to let them in our space. They take an’ we gotta fight back. Don’t matter if the cops are around or not. Don’t matter if there’s laws. They ain’t laws of the streets. An’ it don’t matter if you don’t like it. I just got messed up that one night an’ was trapped. I busted over the fence an’ tripped an’ then I guess that’s when the shot came. I don’t ‘member much after that. But it’s all OK now. Just a scar.”

Carlo responds appropriately to questions, although his responses are slightly delayed. He is a fair historian, has a fair to good remote memory, and is able to track the conversation. During each therapy session, Carlo simply comes in, responds with little if any affect, agrees to return, and leaves. The clinician engages Carlo with therapeutic games such as “Feelings Jenga” and card games. Playing games is one of the rare times when Carlo becomes somewhat animated. He reports that he rarely feels what he would term “happy,” contrasting his description of “always having fun” with his friends. He does not attend the required group therapy, instead hanging out at the downtown “wall” with those few friends he says he enjoys being around.

Carlo has multiple issues, some of which are a traumatic brain injury, low self-esteem, depressive symptoms, family of origin issues, and lack of adequate education. His mother tries to be supportive but also wants to protect her other two children from the ravages of gang life. Carlo has not yet had a psychiatric evaluation, nor has he had psychological testing.

Working with the juvenile probation officer, Carlo, and his mother, the clinician’s treatment plan reflects the following problem, goal, and objectives that are addressed in the most recent session:

Problem: Long-term issues with poor self-worth, evidenced by demeaning self-statements and depressive symptomology.

Goal: Carlo will improve his lifelong self-esteem issues.

a: Develop open communication in the therapeutic setting to assist Carlo in improved self-esteem and decreased depressive symptoms.

b: Articulate at least two positive affirmations each day.

The most recent therapy session includes a clear attempt at pushing the clinician away emotionally and a vague threat of bodily harm. While the session begins in a typical fashion, without prompting, Carlo asks the first question of the session: “Are you afraid of me?” And the following conversation ensues:

Clinician: No.

Carlo: Why not?

Clinician: No reason. Just not afraid.

Carlo: Yes you are. I can tell. Everyone’s afraid of me.

Clinician: (shaking head) No, I’m really not afraid of you, Carlo. Is that what you tell yourself? That everyone is afraid of you?

Carlo: It’s true. Besides, you’re afraid of dying.

Clinician: Nope. Not afraid of dying either. Is that a positive statement? That everyone is afraid of you?

Carlo: (sneering) I get respect cuz they’re afraid of me. And everyone’s afraid of dying.

Clinician: Are you afraid of dying?

There is a long pause, which the clinician uses to study Carlo and his body language. Looking at his hands and slumping slightly in his chair, he responds.

Carlo: Everyone’s afraid of dying. Can we play a game or something? This sucks.

Clinician: Sure, we can play. Tell me something. You’ve beat death once; are you still afraid of it?

Carlo: You’d be afraid of me if I had a gun to your head.

The clinician pauses and reaches to the side table for the Jenga game on which she has drawn expressive faces representing emotions. When the clinician looks up, Carlo’s body language adjusts to make himself look bigger as he lounges back in the chair.

Clinician: No, Carlo, I wouldn’t be afraid of you if you had a gun to my head. I know you would not hurt me.

Carlo: How do you know that?

Clinician: You’ve been coming here—what, six weeks now? And you’ve told me your stories and talked about your gang family, as well as your mom and your brother and sister. You obviously care about other people. And even though you had a gun shot at your head, you wouldn’t shoot anybody.

The session continues, and Carlo eases his desire to intimidate. They begin the game, and Carlo’s demeanor relaxes. After six weeks of twice-weekly therapy, he has developed a rather unique bond with the female clinician. Well into the game, Carlo’s stance has softened significantly. He looks up at the clinician again, this time with a bit of hope.

Carlo: So you like me, then?

Clinician: Of course I like you. You have so much good to offer.
(There is a pause in conversation while the game ensues.) Carlo successfully pulls out a Jenga block and tries to sound out the word listed next to the caricaturelike face on the block—“con ... con-fi ... con-fi-dent. Confident.” And the clinician responds: “Excellent! Tell me about a time that you felt confident, Carlo, when you felt proud of yourself for something you did well.” Carlo rolls the block between his hands, looking at the floor. Gradually, his appearance takes on a more certain attitude as he begins to tell the story of helping his mother care for his younger sister shortly after her birth.

— Camielle Call, LCSW, maintains a consultation and contract supervision practice in Sitka, AK.

Discussion No. 1
By Donna Ulteig, LCSW

I liked Carlo from the beginning of this case narrative. For all of his pseudomaturity and macho intimidation, I picture him as a kid with a tough exterior who is probably scared and may even be hungry for a bit of nurturing. His therapist gives him this in the conversation about whether she is afraid of him. She denies being afraid of him because he “obviously cares about other people,” and he softens with the knowledge that he is liked. Even with his chaotic history, this 14-year-old retains his capacity for attachment.

When I work with my toughest clients, I do a case formulation using an Interpersonal Reconstructive Therapy (IRT) perspective, which was developed by Lorna Benjamin, PhD, who is now at the University of Utah. She approaches a case by looking at what kinds of relational patterns may have been learned, how they were learned, and why they persist even when these patterns are dysfunctional. Benjamin maintains that “every psychopathology is a gift of love.” In other words, patterns that were learned growing up from important early figures persist as a way to try to (fruitlessly) connect with and receive love from that person. IRT requires more detailed work with the client to discover pattern histories or triggers, why the patterns are there, and what purpose they serve in the present.

Carlo is the oldest of three with a responsible, hard-working mother and a father who was incarcerated when Carlo was 8. There has been no contact with his father since then. Missing is information about his father’s crime, Carlo’s opinion of his father, and his relationship with his father prior to the imprisonment.

Other than Carlo feeling that he is a burden to his mother, we do not know the details about his relationship with her. He uses this feeling as a reason for being out of the home. We do not know if Carlo’s mother tells him that he is a burden or if Carlo senses his mother’s fatigue and stress and believes he is a reason for her distress. If Carlo is like most oldest sons in a family with a woman as the head of the household, he is likely to see his role as being the “man of the house,” a role that is impossible for him to fill. Is his perception of himself as a burden related to this self-expectation which is a set-up for failure?

And where does Carlo go when he leaves home? He is on the street, living with a gang, with attachments to his gang brothers so strong that youth corrections placed him two hours away where he won’t have contact with them. It is true that he has learned some “adult” behaviors with this peer group—smoking, and some alcohol and marijuana use—and that he has been involved in a street shooting resulting in a head injury. Most gang members in this situation would have posttraumatic stress disorder (PTSD) from multiple traumas, and this seems to be true of Carlo, who suffered a head wound and a serious concussion, which he minimizes. I understand that minimizing the abuse and trauma that is part of gang life is a common phenomenon and shared traumas and abuse can bond a gang and create loyalty. Carlo asks his therapist if she would be afraid of him if he put a gun to her head. It’s interesting that he subjects her to the pretend trauma that he actually experienced.

I see Carlo as a teen who has identity issues (what teen doesn’t), behavioral problems, academic issues (struggling to read in the game with his therapist), and probable depression and/or PTSD. I notice the emotional numbing, poor self-worth, lack of animation, self-demeaning statements, and limited ability to experience pleasure. Does he have residual brain damage from the head trauma two years prior? In addition to psychotherapy, he should have a neurological and a psychiatric evaluation and psychological testing.

It is not clear from this presentation if it is a goal to return Carlo to his family, but perhaps it is too soon to determine whether he could handle his old environment at some future time. However, we know that his mother and siblings are important to him (his example of a time that he felt confident in helping his mother care for his younger sister) and that contact with them is likely to be helpful. Regular visitation and, at some point, family therapy (in-home if he returns there) are recommended for him.

It is also unclear if there is collaboration between his therapist and the county social services/youth corrections workers. An integrated case management approach would be in Carlo’s best interest, with perhaps some regular team meetings to reevaluate his needs and treatment plan as he progresses. Given his probable PTSD, involving Carlo in activities that help him create a new, healthy peer group seems essential. Bessel van der Kolk, MD, the medical director of the Trauma Center of the Justice Resource Institute and a prominent trauma expert, would involve him in music, drama, and activities that require body movement (dance, working out, sports, etc.) to resolve the trauma stored in a part of the brain that does not respond to talk therapy. I would endorse that as a plan and also obtain a Big Brother and an academic tutor for Carlo.

As for his psychotherapy, we know that he is being seen twice weekly and after six weeks, he has a “unique bond” with his female therapist, who appears to be using a cognitive-behavioral/solution-focused approach. An IRT approach would also use these strategies and, in addition, would help Carlo develop insight that would allow him to make better choices in the future. The patterns to explore are identification, same or opposite; recapitulation, same or opposite; and introjection. They are all accompanied by a wish, most often unconscious, for love, approval, and acceptance.

For example, if Carlo had an identification/same father pattern, he may be adopting behaviors similar to his father (or gang members in the present) in an effort to be loved by him/them, especially since his dad is absent. (“Look how much I love you. I am even like you. Please notice and love me in return.”) His caretaker parts may be identifying with his mother, who has tried to provide some stability, if not nurturing.

If Carlo had a pattern of recapitulation/same, his tendency would be to re-create the environment in the present that he lived with growing up, with all of its chaos and possible abuse. Who knows what it was like with Dad? This recapitulation/same pattern makes sense for many gang members who have this kind of background. A final example is one of introject/same, in which Carlo would be treating himself the way that he was treated. Assuming that he was treated in a hostile, critical, rejecting manner, Carlo would then relate to himself with careless disregard, self-indictment, and blame.

Talking about and understanding how behavioral patterns were learned, why they were adopted (survival), and what purpose the patterns serve in the present can be a powerful and emotional therapeutic experience. Perhaps Carlo could then be sad and afraid, rather than being dissociative or in denial with his false bravado. I wish this for Carlo.

— Donna Ulteig, LCSW, works at Psychiatric Services, SC, in Madison, WI.

Discussion No. 2
By Mila Ruiz Tecala, MSW, ACSW, LICSW, DCSW

The clinician should be commended for working with Carlo. Using street lingo to describe Carlo, he is “one tough nut to crack.” Carlo’s life experiences easily explain how he ended up in the youth corrections system. Abandoned by his father at the age of 8, his involvement with a gang may have met his need to belong and given the illusion of being strong and in control. Additionally, surviving a serious head injury may have fostered his lack of fear of death, his feelings of being invincible, and his involvement in self-destructive activities. When he is much healthier, his close encounter with death will need to be addressed. That comment was likely an attempt at connecting with his therapist, which was a good sign.

The clinician’s goal—”Carlo will improve his lifelong self-esteem issues”—is an excellent one. But if I were treating Carlo, I would start with what it means to him to have a father in jail and then be abandoned by him. Abandonment is a major source of low self-esteem. Perhaps Carlo is assuming that “I am not good enough to be loved by my father.”

Joining a gang gives Carlo a sense of belonging and permission to use violence to exert control. Unconsciously, his involvement with crime may be an attempt to follow his father’s footsteps. If he mimics his father, Carlo may think his father will love him and come back. Carlo is trying in all the wrong ways to get his father’s attention, and one could look at his actions as a desperate attempt to reach out to his father. The question and answer part of the session is Carlo’s attempt at testing his therapist. In her calm manner, she passed the test with flying colors.

I also would explore Carlo’s feelings toward his mother and siblings. Mom is just trying to survive. It seems clear to her that she has lost Carlo to the gang and is just trying to save what she can. But how does Carlo interpret that? As someone with low self-esteem, Carlo could view her indifference as a reinforcement of abandonment. If Carlo gains insight into his mother’s and siblings’ actions, he may learn to relate to them in a nonthreatening way. His need to have people fear him conceals his insecurities. He would rather push people away than be rejected. Carlo still has some attachment (strained though it may be) to his mother since he goes home now and then when he needs money.

Carlo should be referred for a psychiatric evaluation and psychological testing. It would give the therapist a blueprint for where to focus in therapy. Both will help in developing a specific treatment plan.

I would also explore why Carlo has avoided group therapy. At his age, group therapy is a valuable adjunct to individual therapy. It would be a great place to learn social skills and get a sense of positive belonging.

With Carlo’s permission, I would see Mom in order to gather more information about Carlo’s childhood development and, when Carlo is ready, he should be seen in family therapy with his mother and perhaps his siblings to rebuild the relationships. But this not possible until Carlo has improved personally and gained insight about his problems.

Carlo has a long journey ahead of him with lots of twists and turns before he arrives at what will hopefully be a healthy destination.

— Mila Ruiz Tecala, MSW, ACSW, LICSW, DCSW, is an expert on loss, bereavement, and thanatology. She founded the Center for Loss and Grief in Washington, DC.