Case of Anthony: Presenting Issues
Who are you (Anthony)?
You are an eight-year-old, European-American cisgender boy who has been brought in for treatment by your stepmother and biological father. Your father remarried six months ago. When you came for visitation three months ago, your stepmother noticed that your leg had a festering sore. At the hospital, the physician stated that your leg was highly infected and that if treatment had been delayed a few more days, amputation might have been necessary. The physician called Children and Youth Services (CYS), who investigated and determined that your biological mother had seriously neglected you. Your stepmother encouraged your father to assume custody, and you moved in with them. You have been living with them for the last two months. You are meeting with the school counselor to figure out how to get back on track in school.
How do you behave in the interview?
You are dressed in clean clothes, and you frequently look down at your pants or the sleeves of your shirt to check to see if they are still looking good. You might stand up periodically to smooth the back of your pants and then sit back down. You are doing this to prevent wrinkles.
If the interviewer notices how much attention you are paying to your clothes and asks you about it, say that these are brand new school clothes and your stepmom warned you not to ruin them like you did your last new outfit. You are very talkative and engage easily in extensive conversations with the interviewer. You are very curious about the interviewer and the place you are being interviewed and may interrupt the conversation repeatedly in order to ask questions about these things. For example, you may ask where the interviewer got his or her cool shoes or why the interviewer decided to buy one of the pictures that is on the wall or the type of chair in the room.
If asked about why you are here, you sink into the chair, sigh, and look very sad. You may tear up or begin to cry quietly. If asked what is wrong, you say that your stepmother hates you. When asked why, you change the subject or ask if the interviewer hates you also. You may try to get the interviewer to discuss his or her own life. If the interviewer gets very firm with you and insists that you answer a question, you cringe, apologize, and get very quiet. If the interviewer is firm but supportive, you say that your stepmom wants you to come here because she thinks you are a compulsive liar who is selfish and destroys everything you touch. If asked about your father’s opinion, you say that he seems to think you are okay, but your stepmother is the boss. If you are asked why your stepmother calls you a liar, selfish and so forth, you work hard to change the subject. You are indirectly uncooperative. You never refuse to answer a question, but you always manage, somehow, to get off track onto another subject. You apologize several times if you think you have angered or disappointed the interviewer, and you look down into your lap.
You don’t understand mental status questions unless the interviewer asks them in a very concrete manner. For example, you are confused by things such as, “Have you ever had any unusual experiences?” You understand things like, “How do you feel when your stepmother yells at you?” If you understand the interviewer’s questions, you admit to feeling fearful, sad, and angry at certain times. You don’t express any desire to hurt yourself or others. You don’t have any concentration problems or other signs of a thought disorder except you are easily distractible. For example, if you are in the middle of answering something and the interviewer looks up at a clock or picture, you stop talking for a moment and then ask the interviewer a question about the clock or the picture.
- Why are you being seen by the counselor?
You were referred by your CYS caseworker after your stepmother complained to this individual about your behavior. She described you to the caseworker as lazy, a pathological liar, and destructive. You know this because your stepmother made you stand by the phone while she made the call. Your stepmother told you that the CYS caseworker thinks your behavior is due to your prior history of neglect. Your stepmother is giving you a few more months to shape up or she is kicking you out. You cried about this while your dad was home, and he put his arms around you and gave you a big hug. At the same time, he said that your stepmother knew best and you had to learn to do what she said. Your stepmother has told you many times that she blames your biological mother for your problems, but now that you are in a good home, you should be able to shape up. You give this information to the interviewer but only after initially trying to avoid doing so by changing the subject.
If the interviewer asks you specifically what is going wrong at home, you admit that you never remember to change out of your school clothes before going out to play. You get home at 3:30 but your stepmother doesn’t get home from work until 5:30. You are supposed to go to your room, change clothes, then go into the kitchen and get your snack out of the refrigerator. Your stepmother leaves it for you in a special container. When you are done eating the snack, you are supposed to put your dirty dishes into the sink and then start in on your homework.
Once your homework is done, you are allowed outside. Rather than following this schedule, you always go out to play in your school clothes and get them all ripped and dirty because you play too rough. Then, you eat your snack, but you get food all over the floor and never remember to put your dirty stuff in the sink. You never do your homework unless she stands over you and makes you. If asked how you are punished, you admit, after initial attempts to avoid doing so, that your stepmother has sent you to your room without dinner, taken away your TV privileges, and refused to let you go out to play. When she does this, you get really mad and start breaking anything you can get your hands on. You get very sad when you give this information and ask repeatedly if the interviewer hates you now. You have never received any mental health services before. If asked what you expect to happen from coming to the interview, say your stepmother expects you to be punished by the interviewer if you act up. You are also supposed to come home with ideas from the interviewer on good ways to punish you when you don’t behave at home. Your stepmother is frustrated that nothing she does makes you behave; she wants ideas that will work.
How do you feel?
You may have trouble responding to feeling questions because you aren’t used to thinking about your feelings. You are used to being active and doing stuff. If asked if you are ever happy, for example, you might not know what to say. However, if asked about what you do after good stuff happens, like your dad playing with you, you are able to say you smile and laugh and jump a lot. Then, if asked how you feel when you jump and smile and laugh, you say you feel happy. If asked if you are ever anxious, you do not know what anxious means. If the interviewer says something like, “Do you ever worry about stuff at home?” you say you worry about making mistakes whenever your stepmother is around. She seems to notice every mistake you make. If asked for a specific example, you say that you thought you cleaned up your room good yesterday, but something was wrong with it and you weren’t allowed to go outside. Going outside is your favorite thing, and she is always taking it away from you. So now you get worried whenever you do a chore and she is watching you. You sigh a lot as you talk about this stuff. If asked what your dad says about this, say he has told you that you will have to leave if you can’t make your stepmother love you. Sometimes, if you worry too much, you get clumsy and fall on things or drop things, and then these things break. This seems to happen a lot when you are supposed to bring your plate to the sink. If the dishes get broken, your stepmother gets really mad. If asked if you are ever sad, you say that you are sad most of the time because your stepmother does not love you and she has told you that your real mom doesn’t love you either.
Your stepmother used to say that it was wrong the way your real mom raised you. Now she says you are bad and she can understand why your real mom ignored you most of the time. When she says this to you, it makes you cry. If asked about what you do when you are angry, you say that maybe you want to smash things. Sometimes you smash your own toys. When you are smashing stuff, you feel better, but then later you get sad because you don’t have that toy anymore. Your stepmother makes you mad all of the time now and so you don’t have many toys left. So you yell at her and call her names instead of breaking your toys. It really makes her mad when you call her a witch. You are glad she is mad because then she feels the way you feel. If asked why she makes you so angry, you might say she has too many rules and they all stink. If asked what you want to happen, say you really want to kick your stepmother, but you know you can’t. If asked why not, say because she would take all your stuff away from you. Your dad has told you that you will be out of the house if you don’t shape up. You have been told by CYS that you will never go back to your real mom and so there is nowhere to go if your stepmother kicks you out. As much as you hate her, you don’t know what will happen to you if she kicks you out. You think about this sometimes and feel really scared. If the interviewer is being nice to you during this discussion, you might say you think you could be happy forever if the interviewer would take you home.
How do you think?
You expect adults to like you at first because they have always seemed to. You also expect that somehow, for some unknown reason, the adults will go from liking you to hating you. You don’t understand what it is that goes wrong but it always does. You don’t have any ideas about what you might do that gets adults mad at you. You know adults own the world and you do, initially, try hard to please them. You want them to approve of you and love you. You don’t spend much time thinking. You like to be on the move. You have a hard time sitting still, so even when eating your snack, you tend to wander around the kitchen looking at stuff while you eat. You don’t understand why you should do your homework before playing. Playing is fun and homework is boring, so obviously you should play not do homework
What do you like about yourself?
You like the pictures you draw. You make a lot of drawings in your free time and give them to your dad or the teachers at school. You used to make drawings for your stepmother. She used to put them on the refrigerator, but now she rips them up and tells you to get back to your homework. If given the opportunity, you draw a picture of a heart, put the interviewer’s name in the middle, and then give the heart to the interviewer.
How have you been doing in school?
You moved two months ago into a new school as a result of your change in custody. If asked about school, say your real mom didn’t send you to school very often. Your stepmother makes you go every day. In school, your teacher has told you that she likes you but that she wants you to try harder to learn things. She says you are behind everyone else in reading and math and that you need to learn to be organized and not hand in such messy work. Your teacher says she thinks you are smart. She thinks you aren’t doing your work because you haven’t learned to be responsible. If asked how you relate to other children at school, you say that the boys let you play with them on the playground but none of them plays with you outside of school.
How is your health?
When you were living with your mother, you had no contact with doctors beyond the stuff that is handled at school. You recently spent the whole day at a doctor’s office having loads of tests. Children and Youth Services paid for it, but you know your stepmother requested it. The doctor told your stepmother that you are not growing as well as you should. He thinks you need to eat more and eat lots of healthy stuff so you will grow more. You liked this advice because you were hungry a lot at your real mom’s place and it didn’t feel good. Your stepmom does feed you a lot, but she ruins it by yelling at you for not having good table manners. The doctor gave you some special cream for your leg. It is healing well, but your stepmother says you will always have a scar because your real mom took such bad care of you.
How do you relate to others?
At first, your stepmother seemed to like you. She would cuddle you at night and read you stories. She bought you all new clothes and toys. She was very pleased that you moved in. Problems started as soon as school started. She was very angry that you ruined all your school clothes. She has told you over and over that you can’t wear dirty and torn clothes to school and that she can’t afford to keep buying you new stuff. You used to cry when she said this stuff to you, but now you get mad and yell back at her. You think her rules are stupid and she can’t make you follow them. Your father is a salesman who travels all over the country on business. He is only home once in a while. He has told you that he believes that all of your problems are your old mom’s fault. He used to see you a few times a year before you came to live with him. He was nice during these visits, but he never seemed to notice that things were bad at your mom’s house. He does think your stepmother yells at you too much, and you have heard him telling her that. You have also heard him telling her that any real woman would know how to handle a seven year- old boy. You don’t know what he means by “real woman,” but you can tell it really upsets your stepmother. When she begins to scare you with threats of kicking you out, you say, “You aren’t a real woman anyway. Dad says so.” This always makes her run off and cry. You think your new teacher is okay. She is trying to help you learn to read and she likes your pictures. You wish she would stop checking your homework so carefully. Your teacher last year didn’t do that. You don’t know why she has to be so picky about your homework. Once, when she sent you to the corner for not doing your work, you started to cry. She then took you out of the corner and comforted you. You really liked it when she gave you a tissue and helped you blow your nose. You asked her if she would like to take you home. She gave you a hug and just sent you back to your desk. You overheard her having an argument with your stepmother on the phone. Your stepmother was really mad when she saw you later that night. She told you that it was your responsibility to get your homework done and that she wasn’t going to be pushed around by your school teacher.
How do you view of your life
You are glad you are with your dad. You eat much better at his house. You can admit that your stepmother is a good cook and has bought neat stuff for you. If she would stop being mean, you would be glad to be living with her.
Practice deepening interview with Anthony
Anthony acts out his feelings without really being aware of them. Help Anthony deepen his emotional awareness by identifying his possible feeling state and how he may be expressing it through his nonverbal behavior.
Use information from Anthony’s profile to guide you. An example is provided.
Anthony: She sent me to my room again. I showed her. I broke that truck she just gave me!
CLR: You were mad that she sent you to your room, so you showed her that you were mad by breaking the toy she gave you.
Anthony: My dad didn’t come home to play with me like he promised, so I hid in the closet and she couldn’t find me.
CLR:
Anthony: She yelled at me for being dirty, so I flushed my homework down the toilet.
CLR:
Anthony: The kids next door never let me play ball with them. Yesterday, I saw their ball in our yard. When no one was looking, I grabbed it and hid it in our garage.
CLR:
Anthony tries to change the subject whenever a sensitive topic comes up. Write a redirecting comment that supports Anthony emotionally but encourages him to face the issue he is trying to avoid. Be careful to phrase your redirect so that it doesn’t sound like a criticism. Use information from Anthony’s profile to guide you. An example of a redirect, to prevent avoidance, is provided.
CLR: What did you say that led your stepmother to call you a liar?
Anthony: Did you ever get called a liar when you were a kid?
/ know it feels bad to talk about your stepmother calling you a liar. What did you say that she called lying?
CLR: Did you do your homework today?
Anthony: The teacher was so unfair to me today. I was sitting in my seat like everyone else but then David, who sits behind me, poked me with a pencil, so I had to turn around and poke him back. The teacher blamed me for not paying attention and made me sit in time-out during recess!
CLR:
CLR: Tell me what happened when you saw your mother yesterday at Children and Youth Services.
Anthony: My stepmother says my real mom doesn’t love me. Do you think she loves me?
CLR: Did you follow your schedule today when you got home from school?
Anthony: What was your schedule like when you were a kid?
Anthony often feels that no one listens to him. In response to his comments, make a summarizing statement that demonstrates you are listening, that highlights a theme, that serves as a transition, or that decreases his emotional intensity. Use information from Anthony’s profile to guide you. An example of using summarizing, as a transition to a related issue, is provided.
Anthony: My stepmother hates me. No matter what I do, she thinks I am bad. She yells at me after everything I do. I tell her that she is the one who is bad, not me. Even my dad thinks she is bad because I heard him tell her she isn’t a real woman because she can’t control me. But even though it is her fault, my dad says I have to listen to her or I will have to leave.
CLR: She yells and yells no matter what you do. You don’t want to listen, but your dad says you will have to leave if you don’t. Did you do anything today because she asked you to?
Write another summarization in response to Anthony’s previous comments that highlights a theme that comes through in his comments.
Anthony: At school all the other kids sit in their seats all the time, but I don’t like to. I don’t want to sit. I like to move around. The teacher has a lot of great stuff in her room. I like best to get there before everyone else so I can look around at all the shelves and touch stuff. The teacher doesn’t seem to mind me touching the stuff before class, but she gets really mad when I do it during reading or something. Why does everyone have to pick on me?
CLR:
Thought questions related to Anthony
- Is there anything you could do to enhance your ability to establish an effective working relationship with Anthony? Be specific and detailed in describing your ideas.
- How might you react internally if Anthony grabs something in the interviewing room threatens to throw it through the window? What if he starts coming toward you while threatening to kick you?
- Anthony has a history of acting out aggressively in response to his negative emotions. Assume that the two of you have been talking about his relationship to his biological mother and you can see the tension building up inside him from his nonverbal cues. What might you say to Anthony if he threatens to do something aggressive in the session?
- What might you do if Anthony starts throwing objects at you?
- Discuss how Anthony’s trauma history may figure into the behaviors that his stepmother finds troubling.
- Discuss how you might help Anthony’s father and stepmother understand the needs of a child who has experienced trauma and neglect.
