¶ … Henderson A Cognitive Behavioral Study of Steven Henderson: Case Conceptualization and Treatment Plan

Theories of Counseling

Coun510_D04

This is a case conceptualization of a 26-year-old man who experienced sexual abuse as a child and the haunting memories of the abuse have led to difficulties in his personal, social, and educational functioning as an adult. The client is experiencing anxiety, depression, problems with motivation, an inability to confide in those close to him, and difficulties in developing educational and occupational goals for himself. He complained of very low self-esteem and believes that his inability to deal with his past sexual abuse has led to these issues. The case conceptualization explores the proposed treatment of this individual's issues using a cognitive behavioral approach. Empirical evidence for the use of cognitive behavioral treatment for trauma victims is discussed. The specific issues that the individual is experiencing as a result of the abuse are identified, a cognitive behavioral treatment approach designed for this individual using exposure and thought restructuring is described to deal with these issues, and expectations for the outcome of this case are offered.

A Cognitive Behavioral Study of Steve Henderson: Case Conceptualization and Treatment Plan

Steve Henderson is a 26-year-old economics student at the University of Michigan who has been plagued for many years by feelings of guilt, sadness, and anxiety that he relates to a history of sexual abuse he suffered at the hands of an adult worker on his father's plantation beginning when he was six years old. At the time of this case conceptualization it is not known how long this abuse lasted, but Mr. Henderson has indicated that it was ongoing for some unspecified length of time.

Presenting Concerns

Mr. Henderson is the oldest child in a sibship of three (one younger brother and one younger sister). He has never confided in his family about his childhood experiences of abuse. He reports that his father was an alcoholic and he could not confide in him due to his father's alcoholism. Mr. Henderson has experienced feelings of low self-esteem, depression, guilt, poor motivation, and confusion regarding his childhood traumatic sexual abuse. He still has significant anxiety regarding his experiences and cannot confide in others. He is unsure as to where his life should go and in what direction he should head even though he is an honor student. Mr. Henderson seeks treatment in order to be able to more effectively deal with this past abuse, increase his feelings of self-worth, to be able to identify and relate with others, and get on with his life.

Case Conceptualization

In a sport like archery or target shooting is virtually impossible to reach the goal of hitting the target, let alone the bull's-eye, unless one can actually see the target. Likewise, it is difficult to treat an individual in counseling without a diagnosis. A solid diagnosis is like having a target in that it allows the clinician to map out an effective treatment program for the individual. Without a solid diagnosis a counselor can fall into the trap of treating symptoms instead of a syndrome. Symptom management is part of the treatment but is much more effective when the management of symptoms is conceptualized as a syndrome or diagnosis of symptoms that hang together (Resick & Miller, 2009). Mr. Henderson has experienced a significant trauma early in his development and it is with this trauma that the counselor should begin to conceptualize his case.

Conceptualizing Mr. Henderson as a Person with Possible PTSD.

This is a complex case consisting of a number of potential diagnostic considerations. The most obvious consideration would be a diagnosis of Posttraumatic Stress Disorder (PTSD). Given Mr. Henderson's history and presenting symptoms this is also the most useful diagnostic consideration. The symptoms of the case are not well-defined at this point there are several things that one would need to consider before diagnosing Mr. Henderson with PTSD. The major facets of the clinical presentation of PTSD include four broad criteria: (a) the witnessing or experience of a stressful event; (b) painful re-experiences of the event (dreams, recollections, flashbacks, etc.); (c) patterns of avoidance and emotional numbing; and (d) nearly constant hyperarousal (American Psychiatric Association [APA], 2000). One of the defining features of clinically significant PTSD is the intrusive re-experiences of the trauma or traumatic event. These re-experiences are more than just memories; they are often experienced as distressing and invasive because the person has no control over...

The intrusive re-experiences also illicit strong negative reactions that were associated with the initial trauma (Horowitz, 2001). It would be important to determine if Mr. Henderson is indeed experiencing these symptoms and would meet diagnostic criteria for PTSD. It is estimated that well over 50% of children who are sexually abused will meet the criteria for a PTSD diagnosis and upwards of 80% of these children continue to experience PTSD-like symptoms into adulthood even if they do not meet diagnostic criteria (Merikangas et al., 2010; Sadock & Sadock, 2007). Therefore, the effects of Mr. Henderson's trauma can be treated in a similar manner to the treatment for PTSD clients even if he does not meet diagnostic criteria. However, if he has PTSD the specific flashback experiences would also be a focus of the treatment.
PTSD is a disorder typically conceptualized in terms of both classical conditioning and operant conditioning mechanisms working in unison (Keane et al., 1985). There are also some identified family variables and personality variables that seem to be risk factors for PTSD (Koenen, Stellman, Stellman, & Sommer, 2003; Nugent, Tyrka, Carpenter, & Price, 2011; Yehuda et al., 2010). In addition, family therapy has been shown to be useful in treating PTSD patients (Cloitre, 2009). In this case it would be best to discuss how Mr. Henderson wishes to include or not include his family and the therapeutic process. The therapist would need to fully explain the benefits and disadvantages of including them in the treatment. Family therapy has been demonstrated to be effective in treated PTSD and the effects of trauma in individuals and it would be important to offer Mr. Henderson this option even if he does not wish to involve his family in his counseling. Given his history not confiding in his father the current case conceptualization will be constructed under the assumption that he does want to pursue family counseling initially, but this option will be left open for him.

Currently Mr. Henderson is isolated, avoidant, and perhaps has issues with hyperarousal especially regarding relationships with others. At the current time is unclear if he is experiencing any type of flashback or recurrent dream regarding his experiences. However, Mr. Henderson does exhibit some symptoms of PTSD. Therefore, it would be useful to conceptualize the current case as one of PTSD -- like symptoms related to the experience of early sexual abuse. These presenting symptoms include the aforementioned symptoms as well as issues with self-esteem, depressive symptoms, anxiety regarding his past and in developing relationships, amotivation, and issues with trust. The symptoms of depression and anxiety are most likely associated symptoms of his trauma-related issues. It has long been understood that anxiety and depression are symptoms associated with nearly every psychiatric disorder (Hoch, 1972); therefore, these symptoms can be treated in concert with an overall treatment plan aimed at helping Mr. Henderson deal with his trauma, his dysfunctional thoughts, and low self-esteem associated with the past trauma, and adjustment.

There is also the issue of Mr. Henderson's relationship with his father who Mr. Henderson reports is/was an alcoholic. Other than that (his father is an alcoholic and he did not feel safe confiding in him) Mr. Henderson does not supply much information about his relationship with his father; however, there may be some type of an abusive past relationship with his father as well. This is something that will have to be teased out as his treatment continues. In addition, Mr. Henderson has stated that he believed that he could not confide in his father due to his father's alcoholism. Substance dependence alone is not a reason for a child to feel unsafe in confiding in his father (in fact a six-year-old son would most likely NOT label his father as an alcoholic). Moreover, why did he feel unsafe in confiding in his mother? There are probably several other complicated issues regarding Mr. Henderson's relationship with his parents that would need to be explored and uncovered in therapy.

Other issues of concern for Mr. Henderson are his use of alcohol or drugs, if there is any, his ability to develop intimate relationships with others, and of course his own self-image. It is important for Mr. Henderson to understand that he will never totally forget his past traumatic experiences but he can change the way he views himself and the way he thinks about these past experiences in the future. The event cannot be erased from his memory/personality but he can learn how to forgive, understand his reaction to these experiences, and learn how to view these reactions in…