Working with Teenagers on School Performance

Working with Teenagers on School Performance

Nicole Higginbotham

Working with Teenagers on School Performance

Younger clients can be difficult to work with, especially when they are court-ordered to go to therapy. There are issues with resistance, and sometimes, these clients have problems understanding their emotions and opening up to a stranger about their daily struggles. Teenagers that struggle with their educational goals can be stereotyped into specific groups and given attention for common struggles instead of the specific treatment that they may need for their own individual performance. During my internship, I was given the chance to work with a few teenagers that were having issues with their school performance and help them understand their struggles and find solutions to help them better help themselves. I will attempt to analyze the clinical reasoning used.

Case Summary

A 16-year-old, Caucasian male presented with multiple stressors, signs, and symptoms. He was recently brought into the court system on truancy charges that his guardian claimed were due to the lack of transportation that she had at the time. His affect was sad, and he seemed to have a guarded attitude. The client was cooperative as he relayed that his mother had been having issues getting a job and had, had to get her license back in order to get a car to take him and his brother to school. He reported that the conditions in the household were stable, except for a few altercations that he had with his stepfather in the past.

The client continued to tell me about his history of being bullied and an abusive relationship that he had with his ex-girlfriend. He stated that he had been bullied all through elementary school and middle school and had finally found solace in high school. However, the client also stated that he had been engaged with a female that emotionally abused him and held him back from his efforts to progress. The client stated that he began feeling depressed to the point where he was having complications getting motivated to do household chores and school work. He stated that at that point, he often thought of death and different ways that he could die and couldn’t get the images out of his head. The client stated that he began to watch his grades go downhill at this point, and the fact that his mother couldn’t always provide transportation for him to get to school didn’t help him.

He states a need for help with his depression and reports that he has difficult controlling his anger at times. He states that he wants to be able to learn to cope with the things that bother him and craves a sense of balance. His diagnosis includes 300.40 Dysthymic Disorder on Axis I. There was no diagnosis found for Axis II or Axis III, and he had physical abuse of a child and academic problems on Axis IV. His GAF was 75 with no past GAF to compare it to.

Related Professional Knowledge

The article that I found was about how depression affected the functional abilities of juveniles. The article is called, “Cognitive and Social Cognitive Development of Depressed Children and Adolescents”, and it discusses how a student’s school performance can be endangered by depressive disorders. “Actual school performance seems to be more consistently affected by depression than cognitive and intellectual abilities; in addition, depressed youth appear to be less socially adept than nondepressed peers, although depression does not consistently impair social cognitive abilities” (Kovacs & Goldston, 1990).  I found this interesting, because I feel that my client is one of these juveniles suffering academically due to depression.

Insights about the Case

Most of the clinical assessments performed at this internship site are completed by the psychologists. However, the interns are responsible for the Pre-treatment Assessments (PTA) and the Mental Status Exams (MSE) for their clients. The PTA helps us gather a lot of background information that can play into a client’s way of thinking and show us the cultural environment in which he or she grew up in. This assessment begins by asking questions about a client’s family history and support system. There are also questions in the first part about a client’s social and multicultural background. The second part of this assessment focuses on a client’s past therapy treatment and medical history. There is also a section on personal substance abuse and whether or not there is a history of substance abuse in the client’s family. The last section focuses on the activities that the client enjoys, whether he or she is having suicidal or homicidal ideations, and the diagnosis that the therapist thinks is appropriate. The MSE follows the PTA, giving the therapist’s interpretation of the client’s mood and behaviors during the session. This helps the therapist pay attention to the non-verbal language that may be going on during the session.

In the case of my client, a PTA and MSE were administered. There were no further psychological evaluations, partially because the client’s guardian didn’t have insurance and would have had to pay out of pocket. The PTA and MSE did tell me a lot about the client’s upbringing and current living conditions. I also learned a lot about the family structure and beliefs.

Overcoming Initial Impressions about Diagnosis

Based on the client’s history, signs, and symptoms, I diagnosed him with dysthymic disorder. The client had stated that he had felt this way for at least a year, and according to the DSM-IV, this is one of the main necessities for adolescents. Also, he had stated that during that time, he had ongoing feelings of hopelessness, poor concentration, and difficulty making decisions. The client claimed that one of the things that he needed to work on was his low energy and lack of motivation to get things done. He stated that he experienced insomnia frequently, and most of the time, it would take him a couple of hours to fall asleep.

Initially, I was going to diagnose him with an adjustment disorder due to the fact that his mother had experienced a drastic economic change, which affected both him and his brother. However, the client stated that he had been experiencing these symptoms since before this change. Explaining this diagnosis to the client was easy, but his mother didn’t take it as well. She seemed to have the attitude that labeling her child with a mental disorder would make him more of an outcast. She wasn’t as accepting of the therapy as the client was, but she insisted on sitting in on the therapy.

Etiological Hypothesis

I believe that the client’s history played a large part in the development of the presenting problems. For example, the client’s physical abuse issues with his stepfather made him feel less connected to the male role model in his house and protective of his mother and brother. This provoked him to establish a leadership role for his family. His mother’s divorce from his biological father also may have incorporated into these issues. The economic issues that presented themselves made it more difficult for him to make it to school, which caused another issue. On top of these issues, the client has been dating since he was very young and has a tendency to get emotionally intimate with his female partners, creating a great distress when he is rejected in this capacity. The client also has a history of emotional abuse from his previous relationship, which left him with grave self-esteem issues.

It seems that these situational stressors have caused a great deal of harm. The client is highly stressed about his family’s well-being to the point that he is the one that listens to his mother’s problems and gives her advice. He doesn’t yet have the capability to drive or work, so he has felt trapped for the last year or so, trying to push forward, even in difficult circumstances. This has left him little time to reflect on himself and his own needs, which also seems to create him stress. He looks for the approval of others when he has to make a difficult decision, and he still hasn’t learned how to formulate his own personality.

Treatment Plan Preparation

In order to formulate a treatment plan, one must gather all of the facts about the client, looking at the information closely in order to bring out the main problem the client is having. The client has input in this process as well as the therapist will ask him and her about his or her therapy goals and what he or she wants to accomplish. Treatment plan objectives, always measurable and specific, must also be written on the treatment plan. This process will be much easier if the client is cooperative with the goals chosen. Also, insurance agencies may have to look at the treatment plan to determine if the client is getting a positive level of treatment.

Culture and Personality Factors

The client that I am working with is from a strong African American background. He lives in a wealthy area of the city, and he speaks very articulately. His mother seems very traditional, and the family is very close. I feel that it is very important to gage the client’s cultural background and beliefs in order for him or her to cooperate with therapy. I also think that this is a way for the therapist to bond with the client without offending his or her principals and learn how the client processes things. Though his personality is very different from his mother and brother, the cultural ties are the same.

Transference and Counter-transference

During the first couple of sessions, I didn’t feel like there were any transference issues. The sessions were very professional, even when the client opened up about his history and his issues. As the sessions went on, the client stated that he was the oldest in his family, which brought on some counter-transference issues due to the fact that I am also the oldest in my family. The respect for this position hindered my ability to be objective, so I had to deal with that situation in order to move further into the counseling process.

Cases Supervision

Supervision meetings occur once a week though we are able to walk in our supervisor’s office and consult about cases if necessary. At this point in my internship, I am not very close with my supervisor, as most of my training has been done by other therapists or interns that she supervises. I have consulted briefly with my supervisor on cases, but it seems that since the other interns are two internships ahead of me, there is a lot that she assumes I already know. I am trying to work with her in order to establish a positive professional relationship. However, I feel that will take more time.

Insights on Learning and Growth

This case has taught me a lot and showed me better ways to handle situations with clients. I feel that I learned how to incorporate different learning theories when explaining different concepts to clients. I have also learned how to work with a variety of age groups, genders, and cultural backgrounds. I learned about dealing with resistance and how not to work harder than the client. I learned how to be a better listener and accept the choices that the client makes, even if they wouldn’t be the ones that I would make in my own personal life. I feel that all of these things will help me become a better therapist and help my clients in the future.

References

Kovacs, M., & Goldston, D. (1991). Cognitive and Social Cognitive Development of Depressed Children and Adolescents.Journal of the American Academy of Child & Adolescent Psychiatry30(3), 388-392. Retrieved July 28, 2013, from http://www.jaacap.com/article/S0890-8567(09)64555-X/abstract

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