This paper presents critical evaluations of three child and adolescent counseling case studies drawn from Golden's (2002) casebook. The first critique examines the treatment of a young boy following his father's death, questioning the appropriateness of antidepressant medication, premature pathologizing of normal grief, and the eventual bipolar diagnosis. The second critique evaluates family therapy with an adolescent girl, addressing the misuse of adjustment disorder diagnosis and the therapist's skill in facilitating family communication. The third critique analyzes a suicide assessment, identifying flaws in the therapist's listening and confirmation bias, while acknowledging appropriate handling of suicidal ideation and safety planning.
In 1989–1990, antidepressant medications were not approved for use in nine- and ten-year-olds, yet this child was placed on antidepressants immediately after his father's death. Predictably, he experienced worsening mood swings and was eventually diagnosed with bipolar disorder — with no apparent consideration of the well-documented fact that mania is a fairly common side effect of antidepressant medications.
The second concern involves placing a troubled young man from an unstable home immediately into grief therapy following his father's death. There is no more obvious way to communicate to a nine-year-old that he is "sick" — that there is something wrong with the way he feels. One must ask: did no nine-year-old ever survive such a loss without professional intervention? What did children who experienced tragedies do before professional counselors existed? The implicit assumption that they all grew up as maladjusted adults is unsupported and troubling.
Third, the author of the original case claims that grief is indistinguishable from major depression. This is a significant clinical error. Although depressed mood is often part of the grieving process, the two conditions are diagnostically distinct — which is precisely why one is classified as bereavement and the other as depression. The therapist would have benefited from consulting the DSM (in this case, the DSM-III-R) before working with clients in a mental health setting. The subsequent decision to hospitalize the child compounds these concerns considerably.
A closer look at the description of the child's home life before any diagnosis was rendered is instructive. His home was described as "chaotic due to his father's alcoholism and bipolar disorder" (Golden, 2002, p. 143). One is left to wonder how much of his difficulties were family-related and premorbid — a realization that appears to have occurred to everyone involved only after approximately two years of misguided treatment.
Given the child's father's death and all his existing premorbid issues, the decision to immediately place him in formal treatment raises serious questions. Where was the concern prior to this crisis? Other potential complicating conditions, such as ADHD, do not appear to have been considered at all. Perhaps the mother could have provided greater attention and nurturing to her son after the father's death rather than referring him to a series of clinicians. A greater degree of understanding, love, and care both before and after the loss might well have been more therapeutic than the interventions employed. Ultimately, the positive outcome in this case owes more to the child's own resilience than to the clinical decisions made on his behalf.
The first concern in this case is the assignment of an adjustment disorder diagnosis at a point when the therapist herself acknowledges that the client is experiencing fairly normal adolescent changes and feelings. According to the DSM-IV-TR, adjustment disorders are characterized by marked distress in excess of what would be expected given the nature of the stressor (American Psychiatric Association, 2000). The more accurate clinical picture here appears to be a relational issue — a V code — rather than a diagnosable disorder. Insurance companies typically do not reimburse for V codes, which may explain the diagnostic choice, but the real problem remains relational in nature.
From the case study, the mother would benefit from individual therapy in addition to the family sessions. She appears to be projecting her own unresolved issues onto her daughter, which drives much of the distrust and controlling behavior she directs toward the adolescent. Addressing this dynamic would require delicate clinical maneuvering — perhaps initially framing individual sessions for the parents as an extension of the couples' work focused on helping them better support their daughter. Given that many insurance companies are also hesitant to compensate for marital issues, this approach would need to be handled skillfully. The therapist does appear to recognize these dynamics, and addressing them with the mother could meaningfully reduce future relational problems.
"Therapist strengths in communication and contingency planning"
"Therapist confirmation bias and poor active listening"
"Safety contract limitations and risk level conclusions"
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