Adlerian_case_formulation.docx

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MAQE Amr E. Abdelkireem Adler School Spring 2014

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2 MAQE History and Background Information

Identifying Information Mr. A is a 37-year-old, single, heterosexual, Caucasian male who was referred to our agency by Kane County Drug Rehabilitation Court for a substance abuse evaluation. Mr. A defines himself as Italian American man. He notes that he does not believe in God and considers himself to be an atheist. He is the oldest child of two and his sister is 9 years his younger. He states that he grew up with his mother and stepfather and that he does not know anything about his biological father. Mr. A is currently not working and he relates that he is looking for employment; however, he is not willing to work for a minimum wage. He currently lives in his own apartment with his girlfriend who moved to the United States from Italy only five months ago. Mr. A has a history of incarceration and he has been convicted of several crimes. Presentation/Behavioral Observations The client appears to be his stated age. He is a balding man, underweight, and he usually dresses Black Metal T-shirt. Client has several tattoos on his arms, legs, neck, and even on the inside of his ear. He is alert and oriented to all three spheres (e.g., time, place, and person), with no evidence of formal thought disturbance. Eye contact is usually good. His speech is logical, coherent, and relevant. Affect is appropriate to content and mood varies from euthymic to slightly depressed. Suicidal and homicidal ideations are denied at present. Client appears aware of his opioid dependency, however, he lacks insight about the causes and the impact of his dependency on his life. Presenting Problem and Problem History The client was referred to our agency by the Drug Rehabilitation Court (DRC) for

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substance abuse evaluation. Client suffers from opioid and sedative dependency. He was released from prison in 2012 and he is currently on probation. Client is currently unemployed and he states that he is looking for work. Client reports that he has one 18-year-old daughter who also suffers from heroin addiction. He reports that he wishes he would have never went to prison in order to have a better relationship with his daughter. He reports that his daughter refuses to have any relationship with him, and she blames him for her problems. History of Presenting Problem Client reports that he began using cocaine between ages 17 and 18. He states using about ‘once a month’ and to using ‘a few lines’. Client reports his date of last use to be in 2012. He also relates beginning using crack around age 18. Client reports to using once a month and using ‘a couple bags’. He reports he has not used crack for 10 years. Client notes that he began using heroin between the ages of 17 and 18. He reports to using a couple bags per day. He states that 2 weeks prior to the assessment, he had a ‘slip’ and used heroin again after a year and half of sobriety. Client states that besides this slip, the last time he had used heroin was in July 2012. Client reports to beginning his use of PCP around age 14. He notes that he used daily and states he would use ‘a lot’. He reports that he discontinued his use of PCP in 1999. Client states that he was sexually abused from the age of 6 to 12. Psychosocial History Client denies any history of mental health hospitalization. He reports attending counseling while he was in middle school due to having some fights at school. Client denies being on psychiatric medications. He also denies any family members obtaining mental health services. Client denies any other mental health symptoms or issues. He denies any current or history of suicidal and homicidal ideations. Client identifies himself as Italian American. He describes his stepfather to be associated with high status criminal and to be regarded as one. Client states that he

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began stealing at age 12. He reports that his stepfather gave him a sense of approval regarding stealing. Client reports that he was transferred to behavioral disorder school at age 12, where he learned from order children more about the life of crime. Client states that he was sexually abused from the age of 6 to the age of 12 by a family friends’ son, who was 19-year-old when the sexual abuse started. Client relates that he holds some resentment toward his parents because of his sexual abuse experience. Client reports that he did disclose to his parents about the sexual abuse about 5 years ago. He states that they were chocked and that his parents confronted the abuser’s mother, however, there were no legal procedures in this regard. Client reports that he does not believe in God and that he considered himself atheist. Client reports that he has been arrested over 20 times during his life, and his legal charges consist of possession of heroin and residential burglary. Client does not talk much about his relationship with his family, however, he reports that his sister is very successful career woman who works as a lawyer and lives in Las Vegas. He states that as a child he got what he wanted by just asking for it. Client notes that he has a good relationship with his mother, stepfather, and his sister. However, when asked about those relationships he usually engages in story telling avoiding to be specific. Adlerian Case Formulation Life Style Assessment Mr. A, age thirty-seven, is the older of two and his sister, minus nine. Mr. A describes himself as an Italian American, who comes from prestigious criminal family. Mr. A grew up living with his mother and stepfather, and he did not know anything about his biological father. He was the only child for nine years before his sister was born. Mr. A describes his parents as permissive, disengaged, and indulgent who did not enforce any rules, and he learned to make his own decisions at early age. Mr. A states that he started stealing at early age and his stepfather gave him a sense of approval. He sees himself as a convict who does not have much chance in reentering the

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community in a useful way. Mr. A’s inferiority feelings stem from the feelings of inadequacy, weakness, and guilt, which started in his childhood experience of sexual abuse and exacerbated by his heroin dependency. These feelings of inferiority can also be conceptualized as a “result of incongruence between convections in the style of life” (Mosak & Maniacci, 1999, p. 57). Mr. A seems to interact with the world and others in a safeguarding and superior stance. One can observe his safeguarding tendency in his social isolation and substance dependency, and his superior stance in his grandiosity and over-ambition (Clark & Butler, 2012). He seems to be preoccupied with himself by keeping distance from his family. Mr. A holds anger and resentment toward his parents; however, he refuses to express his anger, which reinforces and excuses his distance. Mr. A seems to carry shame and guilt and he appears to use these symptoms to block movement toward life tasks in general. An analysis of early recollection—according to Adlerians—is the most useful and direct method of understanding the client’s fictional goal (Oberst & Stewart, 2003). However, when asked to report about his early recollections, Mr. A said, “All I can remember before the age of 9 or 10 is all sexual abuse.” Mr. A has experienced sexual abuse from the age of 6 throughout the age of 12, which highly affected the development of his lifestyle and social interest (Cash & Snow, 2001). Mr. A seems to hold traditional masculine norms, which include prescriptions for how men should look and act and the kind of attitude men should have (Easton, Coohey, Rhodes, & Moorthy, 2013). These masculine norms exacerbated Mr. A’s feelings of shame and guilt associated with the sexual abuse. Mr. A reports that he was transferred to behavioral disordered school at age 12 as a result of his misbehavior at school. After the transferring to the behavioral disordered school, Mr. A reported that he began to interact with and learn from older children about substance abuse and criminal activities. He began to get in more serious troubles with the legal system and he started to

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use drugs regularly. It appears that Mr. A views himself as different and inadequate. He says, “I am a different kind of addict.” By viewing himself as a different kind of addict and construing his situation as unique, he holds a pessimistic view of himself that prevent him to take action. Hence, he does not need to try or to be involved in narcotic anonymous or recovery in general; there is no use. From Adlerian lens, Mr. A is making excuses to follow his private logic and act as if this private logic is common sense (Mosak & Maniacci, 1999). He excuses and justifies himself with his perception of himself as: “I’m so bad and I will always fail anyway. Why even try?” (Slavik, Carlson, & Sperry, 1995). Life for Mr. A has no meaning; he portrays it as just for enjoyment and having fun, work is for fools. He feels that he cannot count on others, since his own parents failed to protect him as a child. The world for Mr. A is perceived as a jungle where one should strive to get what one needs and wants. People for Mr. A are seen as not worthy of trust but they may be persuaded to provide for him. In order to have a place for Mr. A, he should manipulate others and achieve high prestige. Mr. A has unrealistically high ambition, while he lacks the willingness to work for it. Mr. A appears to be striving for superiority out of self-interest. For example, Mr. A says he needs to find a job, but he also says, “I won’t work for a minimum wage; I get used to making easy money.” Mr. A’s lifestyle allows him to behave in a familiar way to maintain a sense of security, rather than taking risk and try new behaviors (Slavik, 1995). Holism and Interpretation of Symptoms Adlerians pay close attention to understanding of the purpose of the person’s behavior holistically. Unlike Freudians who see present behavior to be influenced by past experiences, Adlerians see present behavior to be influenced by one’s view of the future (Feist & Feist, 2009). For Adler, humans are not pushed by causes but pulled by their self-created goals and dynamic striving (Millar, 2013). Hence, from an Adlerian lens, the therapist will look at Mr. A’s childhood

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sexual abuse holistically in term of his lifestyle. The therapist would not perceive Mr. A’s substance dependency and criminal behavior as a result of his childhood history of sexual abuse (Slavik et al., 1995). Adler (as cited in Millar, 2013; Slavik et al) stated, “It is not the child’s experiences which dictate his actions; it is the conclusions which he draws from his experiences” (p. 203). Hence, the therapist may look at Mr. A’s misguided action in term of purposive behavior. For example, Mr. A seems to be what Adler called a getting type. When Mr. A fails to get from others, he may use his symptoms (i.e., being a victim) to manipulate others to serve his needs. In other words, the problem is not the childhood sexual abuse; the problem is his interpretation of his abuse and of life in general. The therapist is focusing on and exploring current lifestyle, not past history (Slavik et al). Mr. A seems to use more than his symptoms as sideshows to distract his attention away from meeting the tasks of life (Mosak & Maniacci, 1999). Making excuses and seeking distance are other sideshows in which Mr. A displays. Mr. A views his felony as a barrier for employment, he says, “No one will hire a convict felon.” Mr. A is standing still in his movement by acting as if he is still an adolescent who parties too much, avoids taking responsibility, and not meeting the tasks of life in general. He also creates sideshows by engaging in mob storytelling to avoid exposing his authentic self. Life Tasks and Social Interest Adlerians identify the individual’s level of social interest in six life tasks. 

Work Task: Mr. A does not have a long history of employment. He has worked as a painter but not for a steady period of time. Currently, he is looking for employment but looking for the perfect easy job. Mr. A got used to making easy money by dealing drugs and engaging in other criminal activities. Hence, he is having difficulties accepting working hard for less money. He states that he used to work with his uncle at his bond shop and that he wants to

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Social Life: Mr. A was affiliated with gang activities from the age of 12 till the age of 34. He has not been cooperating with the community in a useful way and he lacks a sense of belonging due to his alienation and isolation. He distances himself from others by moving backward and standing still due to his feelings of inadequacy and inferiority.

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The Sexual Task: Mr. A has never been married; however, he describes himself to be a sex addict who cannot have enough sex. He is currently in a relationship with an Italian woman who migrated recently to the United States four months ago. Being a sex addict and choosing an Italian woman to be his partner are congruent with Mr. A’s style of life. Being a sex addict could be conceptualized as a way to overcompensate for his inferiority complex (i.e., childhood sexual abuse), and choosing an Italian partner perhaps out of masculine protest perception. That is, Mr. A overvaluing masculinity and perceives it to be superior. Thus, he chooses a woman from the farms of Italy (as he noted) who probably also perceives men to be superior over women.

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The Self Task: Mr. A sees himself as inferior to others and he act and wants to be perceived as someone else. He thinks others will not like or accept him if they knew his real self. Mr. A is not sure of his identity; however, he acts out of his self-ideal that is being Italian gangster.

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The Spiritual Task: Mr. A considers himself an atheist. He does not believe in afterlife or of the existence of heaven and hell. Mr. A avoids discussing spirituality in general, which is a challenge to his treatment. Regardless of his belief or lack of it, he needs to have a meaning for his life in order to overcome his addiction and to have a better quality of life.

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The parenting and Family Task: Mr. A has an 18-year-old daughter who refuses to have a relationship with him and sees him as the reason for her problems and for her heroin

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9 addiction. Mr. A states that he has a good relationship with his mother and stepfather; however, he holds resentment toward them for failing to protect him as a child. Mr. A reported that when he relapsed he called his stepfather and told him about the relapse incident. The therapist perceives this act as a way of making his parents feeling bad for him and put the blame on them for his failure. It could be that Mr. A unconsciously wanting to show his parents what a terrible human being they have created by being neglectful and not protecting him. It could also be that Mr. A wants to get attention from his family and having everyone worrying about him.

Treatment Prognosis, and Planning There are four phases of Adlerian psychotherapy, which are: establishing the therapeutic relationship, assessing and understanding the life style, encouraging self-understanding and insight, and reorientation and reeducation (Oberst & Stewart, 2005). From an Adlerian perspective, the most important goal of the treatment of the adult who has experienced childhood sexual abuse is to encourage his or her sense of belonging, to find meaning in life, and to restore faith in human kind (Slavik, Carlson, & Sperry, 1993). When the person feels a sense of belonging as an equal, he or she will probably use social interest and will find ways to contribute usefully to the common welfare of others (Millar, 2013). There is a positive relationship between the sense of belonging and social interest; the more sense of belonging one feels, the more social interest he or she will develop and the minimal feelings of inferiority he or she will display (Mosak & Maniacci, 1999). In the case of Mr. A, the treatment focus is on overcoming his discouragement, pessimism, and over-ambition striving, which is the result of his perception of his childhood sexual abuse (Slavik et al.). Mr. A’s prognosis is good since he is involved in the treatment process and open to insight and self-understanding.

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10 Phase 1: Establishing the Therapeutic Relationship: from the beginning of the therapy

process, the therapist works collaboratively with Mr. A by listening attentively, showing empathy and caring, and by developing a relationship based on mutual respect between equals. Giving the history of Mr. A’s child sexual abuse, it is crucial not to move toward processing this experience until establishing the proper trusting relationship. In addition, the therapist needs to help Mr. A see his assets and strengths, not just focusing on his deficits and problems. Adlerians emphasize focusing on strengths and warn against processing the traumatic experience (i.e., childhood sexual abuse) before the safety is established (Millar, 2013; Slavik et al., 1993). The therapist should not treat the sexual abuse experience as a crisis (Slavik, et al.). Creating an egalitarian relationship between the therapist and Mr. A is also a focus of the first phase of Adlerian psychotherapy. The therapist should not pamper Mr. A or treats him as fragile. The therapist should show faith in Mr. A’s capacity to meet the tasks of life. In this first phase of therapy, it is also important for the therapist and Mr. A to agree on and align the goals of treatment in order for the therapeutic relationship to be beneficial (Oberst & Stewart, 2005). Given that Mr. A is mandated by the court system to attend therapy, it will be necessary to align the court system’s goals with the treatment goals. Phase 2: Assessing and Understanding the Life Style: During this phase, Adlerians proceed by gathering data that reveal client’s attitude, behavior, and ways of coping with life demands (Oberst & Stewart, 2005). In Mr. A’s case, the therapist assesses his family constellation, birth order, early childhood history and recollections. Mr. A comes from Italian heritage and he wants to be seen as a tough Italian gangster as a way of overcompensating. Mr. A strives for superiority motivated by his exaggerated feelings of inferiority. These feelings of inferiority or inferiority complex are derived from his perception of childhood sexual abuse. While assessing Mr. A’s lifestyle, the therapist should not tackle early traumatic memories before the client is stable enough

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to do so (Millar, 2013). The therapist should be cautious while encouraging the client to recall his sexual abuse memories. Phase 3: Encouraging Self-Understanding and Insight: in this phase, the therapist will work with Mr. A to remove feelings of guilt and to minimize giving excuses. Mr. A needs to see himself as a survivor not a victim, and in turn, he will respond to life in a more responsible way. Mr. A also will start setting realistic goals, seek realistic jobs, and begin to focus on his assets and strengths. The therapist in this phase should confront Mr. A with his safeguarding tendencies and discrepancy between his speech and behavior. For example, Mr. A says, “I cannot control my drug use” and “I am different than other addicts.” Mr. A focuses on the differences between himself and other addicts not on the similarities. Mr. A justifies not going to an inpatient program by his need of taking care of his girlfriend; however, he does not have a job and does not bring any money home, while still using drugs. The therapist confronts Mr. A by pointing out to all of these discrepancies and urging him to take action or he is going to lose everything. Phase 4: Reorientation and Reeducation: at this stage, the therapist will start working with Mr. A on committing to changing his style of life and fulfilling the life tasks in a healthier way. There is a metaphor used by recovering alcoholics and addicts regarding change, which is, “The only thing the newcomer—or the individual who is seeking recovery—needs to change is everything.” Mr. A admitted to this writer that he needs help to stay sober and that he needs to go to inpatient treatment. He added, “ I cannot live like this anymore.” Form a 12-step fellowship perspective, Mr. A admitting defeat and being powerless, which is the first part of the first step. Although Mr. A is still at the very beginning of the recovery process, admitting defeat is a crucial gain in the therapy process. Hopefully, after Mr. A finishes the inpatient treatment the therapist will work with him to maintain recovery. The therapist will be focusing on helping Mr. A change his maladaptive way of relating to other human beings by understanding the importance of

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connecting with others, particularly, recovering addicts in the rooms of Alcoholic or Narcotic Anonymous. It will be essential for Mr. A to replace old ways of thinking and to develop healthy behaviors and new habits to fill the void that addiction will leave. The key point is for Mr. A to develop and enhance his social interest and sense of belonging and significance. According to Adler (as cited in Slavik, 1995), social interest is a guiding line that can replace other guiding lines. Hence, Mr. A—with the help of the therapist—can release himself from the chains of addiction and find his inner freedom. Existential Case Formulation Mr. A is a man of above average intelligence, however, he appears to lack meaning for his living and feels alienated from society expectations. Mr. A views himself to be different and he lacks a sense of identity. Hence, it seems appropriate to apply the existential therapy to understand Mr. A’s world. Existential therapists strive to enter the private world of the client rather than focus on the manner in which the patient has deviated from the norms (Fisher, 2005). Mr. A exhibits what Jean-Paul Sartre calls “bad faith,” by avoiding taking personal responsibility (Pitchford, 2009). He said, “I am an addict and there is nothing could be done about it. I am going to keep living this way.” Existentialism emphasizes individual potential and growth. It is essential for the individual to take responsibility of his or her life and to be free to choose. Existentialists see individuals struggling with four main concerns in the pursuit of an authentic life, freedom, isolation, meaningless, and death (Yalom, as cited in Pitchford, 2009). Individuals who experienced childhood sexual abuse, as Mr. A, face these concerns in an unusually pervasive manner. He probably lived in a world characterized by isolation and fear, while his parents failed to protect him. Mr. A’s sense of freedom was impaired by lies, and his search for meaning was lost while he is trying to be someone else.

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13 From an existential view, Mr. A has the capacity to expand his self-awareness and to

make an optimal decision for his future. The concept of freedom is at the heart of existential therapy (Pitchford, 2009). Mr. A is a classic example of a person who is longing for freedom while trying to escape from it. During the counseling sessions, Mr. A wanted to go back to prison, rather than facing his addiction and take action toward recovery. Mr. A, with the help of the therapist, needs to feel free to design his own future. He does not need to be victimized by his past childhood experience. Mr. A needs to face his anxiety, rather than hiding behind his fear of life by his heroin dependency. The therapist, from existential therapeutic stance, works with Mr. A on accepting his own responsibility and directing his own life. Mr. A needs to realize that he is free to be who he is and to choose to participate in a meaningful life. The therapist, after creating an authentic and trusting relationship with Mr. A, will confront him he is trying to escape from his freedom and responsibility by being addicted to heroin. The therapist will provoke Mr. A’s anxiety and invite him to take risk by opening up and uncover his authentic self. Mr. A needs to look at himself to find his own identity rather than seeking confirmation through others. Yalom (1980) noted that existentialism perceives a person “as a consciousness who participates in the construction of reality” (p. 23). Mr. A’s inability to participate fully in his internal and external world drives much of his behavior. Thus, existential work can help the survivor acknowledge and embrace his autonomy by allowing him to reconnect with his inner self and begin to trust his perceptions of the world. Several of Yalom’s eleven therapeutic factors could be applied to this case. Mr. A needs to gain hope as a starting point in his recovery. Yalom considered the instillation of hope to be a central aspect of all forms of therapy. Yalom specifically noted that the presence of recovered alcoholics in the fellowship of AA directly inspires hope in newcomers and

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enhances their self-efficacy (1995). Mr. A sees himself as a hopeless heroin addict who does not have meaning for his existence. He thinks this is the way his life is meant to be and he is condemned living life of dependency. The therapist makes a point of sharing with Mr. A about other recovering heroin addicts who have been in recovery for many years and who are leading successful meaningful lives. According to Yalom (1995), The therapeutic factor of universality (and all other factors) plays a role in individual therapy as well. Mr. A has feelings of uniqueness and of being different from others. He thinks that he alone has frightening experiences. To Yalom (1995), the “disconfirmation of a patient’s feelings of uniqueness is a powerful source of relief” (p. 6). One of the most powerful slogan at AA is, “You are not alone anymore.” Thus, Mr. A will benefit drastically from being with others, sharing with them, and most importantly, listen to their experience, strength, and hope. The third factor of Yalom’s therapeutic approach, which is imparting information, is a didactic and psycho-educational that is essential to this case. Given that Mr. A is suffering from heroin dependency, explaining and clarifying the disease concept of addiction could serve as a turning point in his self-perception. That is viewing his addiction as a disease rather than moral deficiency will remove all the guilt and shame associated with his addiction. This implies that Mr. A is not responsible for his addiction; nonetheless, he is responsible for his recovery. The existentialist therapist will emphasize this responsibility as a key therapeutic point. Imparting information may also be given through successful stories of other recovering addicts as the case of AA and NA. Mr. A will benefit more by listening to others’ stories while making his own conclusions. Altruism is a therapeutic concept that cannot be overemphasized; it is substantial for almost all therapeutic orientations. Victor Frankl noted that life meaning materializes when the individual

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forgets oneself and become absorbed in something outside of oneself (2006). Mr. A needs to appreciate the concept of altruism and to understand how he can benefit himself by helping others, by accepting help from others, and by sharing his experience. He needs to find interest and purpose in something outside himself. The Corrective Recapitulation of the Primary Family Group is another important factor in the case of Mr. A, given his traumatic childhood experience. Given Mr. A’s childhood experience, he probably uses denial, repression, and regression as a defense mechanism. However, dissociation is often the most used and effective defense by childhood sexual abuse survival. This dissociation The therapist and Mr. A should revisit and process the early childhood sexual abuse experience in a therapeutic manner, while encouraging openness and vulnerability. However, the therapist must exercise caution and patience as he seeks to cultivate and encourage these qualities. Development of Socializing Techniques, Imitative behavior, and Interpersonal Learning are related factors. Diagnostic Impressions Axis I: 304.00 Opioid Dependency. V61.20 Parent-Child Relational Problem V61.21 Sexual Abuse 995.53 Axis II: 799.9 Diagnosis Deferred Axis III: None Reported Axis IV: Legal Issues, Occupational Problem, And Problem with Primary Support Axis V: GAF = 57 (Assessment) GAF = 65 (Current) Treatment Plan Goals

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16 1. Accept the fact of chemical dependence as a disease and begin to actively participate in a recovery program. 2. Establish and maintain total abstinence while increasing knowledge of the disease and the process of recovery. Learn sobriety skills. 3. Accept personal responsibility for recovery. 4. Gain and Maintain employment. 5. Develop Social Interest and a sense of belonging to help with reducing isolation. The last goal is essential to Adlerians, existentialists, and to the 12-step fellowship. It is

expressed in Bill Wilson’s writing that the goal of AA is to restore the alcoholic’s sense of belonging to the family of man, from a position of self-centeredness, of “self-will run riot” (Alcoholic Anonymous, 2001, p. 62). Objectives  Reconnecting with the social group from which the client has become estranged by virtue of the disease of addiction.  Attend Alcoholic Anonymous (AA) or Narcotic Anonymous (NA) at least three times a week.  Reducing the degree of egocentricity and denial. “Hyper-vigilance”  Correcting the faulty picture of the world.  Gaining an insight of the problem from an Adlerian term. For Adlerian there is no insight unless there is an action component. Therapeutic Interventions 

Assist the client in making plan to develop new sober relationships.

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Developing a new social support system.

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Challenging client’s life style and mistaken belief.

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Discuss with the client the impact of the meetings on oneself.

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Complete the first step and process it with this writer.

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Verbalize an understanding of the addiction as a disease (this will help in removing the misguided guilt and shame that accompanies most addicted client)

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Require the client to name some people that he can trust and connect with them.

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Facilitate the client’s understanding of his personality, social, and family factors, including childhood experiences that led to the development of chemical dependency and serve as a risk factor for relapse.

Course of Treatment The therapist is currently using Adlerian counseling and the 12-step program in this case. Although the client appears to have trust issues, the first phase in therapy (i.e., establishing a therapeutic relationship) was developed successfully. The therapist worked with the client on establishing egalitarian relationship in which the client feels comfortable to share feelings and cognitions. The goals of treatment were aligned with the client and the drug court expectations, which are to stay sober, to attend at least three AA/NA meetings per week, and to find a steady job. The therapist has been focusing on the client’s strengths while confronting him when needed. The therapist has been encouraging the client to look at himself and face his problems, to see the discrepancy in his speech and behavior. The therapist also encourages the client to expand his social interaction in a healthy way. For example, contacting family members and old friends who are not using drugs, and to go to NA/AA meetings and share his feelings and thoughts. Unfortunately, client has relapsed during our counseling sessions. He called and acknowledged this therapist regarding his relapse. He said, “I need to get admitted to inpatient treatment; I cannot keep doing this.” The therapist knew that the client needs to be away for a while from his environment, so he can develop a clearer mental state and commit to recovery and

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counseling in a deeper level. However, the therapist did not want to force any opinion on the client and waited for the client to be ready. Fortunately, Mr. A is ready now and hopefully, he will find his right path. Interventions and Involvement  12-Step Program  The client goes to three Narcotic Anonymous meetings weekly as required by court, however, he states that he does not get involved in the discussion and that he does not contact other recovering addicts.  The client states that he is an atheist and that he struggles with spirituality and the concept of the higher power or God. Hence, he has difficulties accepting some aspects of the 12-step program.  Adlerian Counseling  Inferiority and Social Interest. Since the client has difficulties with the spirituality of the 12-step program, it is beneficial to integrate Adlerian therapy with the 12step.  Focusing on client’s strengths (e.g., being intelligent, rational, aware of own problems.)  Style of life.  Early recollections.  Birth order and family constellation.  The Question.  Confrontination:  Spitting in the soup: this technique was used more than once with Mr. A. The therapist understands client’s lifestyle and how he belongs and finds significance.

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19 For example, client relapsed and called his stepfather just to let him know. Client was seeking attention from his family. The therapist asked the client, “How did it feel to have everyone worried about you? It must feel good.” Involvement 

The client shows up on time and he appears involved in the counseling process. He is open to discussion and to this writer’s suggestions.

Transference and Countertransference 

Client always tries to get closer to the therapist in a personal level, by asking questions about the therapist’s own life and asking to have the session at the library. The therapist strives to be objective while remaining a person. Thus, the therapist might be sensitive to being perceived as aloof professional. The therapist’s need to be liked could be a form of countertransference in this case.

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The therapist feels reluctant to ask the client more about his sexual abuse.

Expectations of the Rest of Treatment 

This writer is very optimistic regarding this client’s progress in counseling; however, client needs to gain hope and to trust the process. Social interest is a key in this client’s case.

Ethical and Legal Concerns a. Several ACA codes of ethics may be relevant to this case. They are as follows: 1. A.4.b. Personal Values—“Counselors are aware of their own values, attitudes, beliefs, and behaviors and avoid imposing values that are inconsistent with counseling goals. Counselors respect the diversity of clients, trainees, and research participants.” Mr. A identifies himself as an atheist while this therapist is a spiritual and believes in the

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20 importance of spirituality in the individual’s life, however, this therapist does not impose his belief on the client.

2. B.1.d. Explanation of Limitations—“At initiation and throughout the counseling process, counselors inform clients of the limitations of confidentiality and seek to identify foreseeable situations in which confidentiality must be breached.” The therapist initially and during the counseling process explains to Mr. A about the limitations of confidentiality. 3. B.2.d. Minimal Disclosure—“To the extent possible, clients are informed before confidential information is disclosed and are involved in the disclosure decision-making process. When circumstances require the disclosure of confidential information, only essential information is revealed.” Given that Mr. A is mandated by court to attend counseling, Mr. A’s probation officer asks about Mr. A’s progress in therapy and treatment goals. However, the therapist discusses with the client the kind of information in which the probation officer will receive. The therapist initially obtained the client’s consent to accept these limits of confidentiality before entering the counseling relationship. The therapist discloses confidential information to the extent that is legally possible. 4. B.3.b. Treatment Team—“When client treatment involves a continued review or participation by a treatment team, the client will be informed of the team’s existence and composition, information being shared, and the purposes of sharing such information.” Mr. A’s treatment was assessed for the second time after two months from the initial admission for continued stay. The therapist has informed Mr. A regarding the process of the assessment. Meanwhile this therapist was asked by the treatment team to discuss the client’s case progress and struggle in therapy for educational purpose. This therapist has

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21 not share any information and will discuss this possibility with his supervisor and with the client.

5. B.6.b. Permission to Record—“Counselors obtain permission from clients prior to recording sessions through electronic or other means.” The therapist has obtained a written document from the client prior to recording the session. b. Relevant Legal Considerations: Mr. A—as mentioned above—comes from Italian heritage and he describes his family as a high status criminal family. He seems proud of his heritage and he engages in story telling about members of his family that involve criminal act. Given the limits to confidentiality and the lack of consistent definition of privileged communication (Corey, Corey, & Callanan, 2011), the therapist had to explain to Mr. A that there are certain circumstances where confidentiality cannot be maintained. Hence, Mr. A is advised to be cautious about the information he reveals. Diversity/Multicultural Mr. A is Caucasian male who comes from Italian heritage, however, whereas the therapist is Middle-Eastern Egyptian male. Although there are similarities between those cultures, there are differences as well. The therapist has biases about atheism; however, he is aware of his biases and does not let it affect the therapeutic process. The therapist is aware of his own negative and positive attitude toward the client’s culture. He is also aware of the stereotypical assumptions, cultural biases, and mistaken beliefs that could be at play. For example, therapist understands client’s struggle with the environment and with addiction. He appreciates the nature of addiction and does not hold judgmental view regarding client’s motivation. The therapist is also aware of the faulty assumption, which holds that will power is sufficient to maintain sobriety. In this regard, the therapist works first on understanding the client’s worldview before inviting him to decide on change that is congruent with his own

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22

beliefs. Hence, the therapist does not impose spirituality on the client and encourages the client to find belonging and significance through social embeddedness. The therapist appreciates the importance of having a higher power as a key element in addiction treatment, however, accepting and defining this higher power is left up to Mr. A to decide.

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23 References

Clark, A. J., & Butler, C. M. (2012). Degree of activity: Relationship to early recollections and safeguarding tendencies. Journal of Individual Psychology, 68(2), 136-147. Easton, S. D., Coohey, C., Rhodes, A., & Moorthy, M. V (2013). Posttraumatic growth among men with histories of child sexual abuse. Child Maltreat, 18, 211-220, doi:10.1177/1077559513503037 Henning, J. A. (2013). Working with survivors of traumatic life events: A response to Millar on the Adlerian approach. Journal of Individual Psychology, 69(3), 262-276. Millar, A. (2013). Trauma therapy: An Adlerian perspective. Journal of Individual Psychology, 69(3), 245-261. Pitchford, P. D. (2009). The Existentialism of Rollo May: An influence on trauma treatment. Journal of Humanistic Psychology, 49, 441-461. doi:10.1177/0022167808327679 Rosen Saltzman, M., Matic, M., & Marsden, E. (2013). Adlerian art therapy with sexual abuse and assault survivors. Journal of Individual Psychology, 69(3), 223-244. Slavik, S. (1995). Presenting social interest to different life-styles. Journal of Individual Psycholoy, 51(2), 166-177. Slavik, S., Carlson, J., & Sperry, L. (1995). Extreme life-styles of adults who have experienced.. Individual Psychology: The Journal of Adlerian Theory, Research & Practice, 51(4), 358374. Slavik, S., Carlson, J., & Sperry, L. (1993). An Adlerian treatment of adults with a history of childhood sexual abuse. Individual Psychology: The Journal of Adlerian Theory, Research & Practice, 49(2), 111-131. Walitzer, K., Dermen, K., & Barrick, C. (2009). Facilitating involvement in Alcoholics

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24 Anonymous during out-patient treatment: a randomized clinical trial. Addiction (Abingdon, England), 104(3), 391-401. doi:10.1111/j.1360-0443.2008.02467.x