Blake is a nine year old boy who lives in Bedford with his mother, father and younger brother. He is a Caucasian American who is Albino. Blake’s younger brother is also Albino, but neither of Blake’s parents are Albino. Blake’s parents are still married and share custody of the children. Blake and his family live comfortably in a nice neighborhood. The father works in finance and the mother had previously worked in education. The mother currently stays home during the day. Both parents are loving and engage with Blake. However, Blake’s father is not as involved with Blake as he is with Blake’s younger brother. In addition to a lack of attention from his father, Blake’s mother also has exhibited erratic and borderline-like behaviors. There is often a strain on the relationship between Blake, his mother, his father, and his brother. (Name changed for confidentiality). Although Blake has been referred to many different programs and agencies, he is now participating in services at The Edinburg Center in Bedford. The Edinburg Center works with a variety of individuals, but Blake is involved with Children Behavioral Services. He is provided with an In Home Therapist, has had Therapeutic Training and Support, and now has a Therapeutic Mentor (I use to act as TT&S, as I do in many cases, and have since switched to TM for Blake). Blake’s mother essentially requested such services in order to strengthen the relationship Blake holds with certain individuals, and to decrease his social limitations. Such relationships include Blake and his younger brother, along with Blake’s father. However, concerns regarding Blake and his relationship with his mother have been increasing as well. Due to Blake’s trauma history, and the strained relationships within the home, the treatment model that would be explored is Child Parent Psychotherapy. Trauma Experiences. When Blake was five years old, he was a victim of sexual abuse by a peer who attended the same school as Blake. This abuse occurred on a daily basis. This abuse consisted of a “special game” that Blake’s friend would play with Blake in the bathroom at school where the friend would digitally penetrate Blake. The abuse was discovered by Blake’s mother when Blake performed “the game” on himself while in the tub. When asked where he learned this behavior, Blake shared with his mother that his friend taught him this game because it “feels good”.
After Blake had told his mother about the abuse, his mother informed the school. Eventually, Blake’s peers discovered the abusive situation and began to pick on Blake. Once Blake became a victim of teasing within his school, Blake would refuse to discuss the situation. Blake was unaware that this game was traumatic until negative attention was given to the situation. Blake’s mother states that he began exhibiting extreme anxiety, and would often throw tantrums. These tantrums would include hitting, biting, throwing objects, yelling, and kicking. Blake’s mother believes that these trauma’s still affect Blake’s behaviors. Blake’s behaviors following the abuse include difficulty controlling his emotions, which causes Blake to feel sad. Blake also seems to struggle with attachments with his parents. Blake was unable to recover from this trauma properly and he now struggles with relationships across all environments (Breidenstine, Bailey, Zennah & Larrieu 2011).
With Blake’s case in particular, there are many factors relevant to his current situations. One of the main possibilities for Blake’s emotional imbalance would include his previous history of sexual abuse. Such events are certainly traumatizing and can lead to future behavioral issues, and issues with depression. Blake’s abuse occurred somewhat frequently, which is an even greater risk factor for future dilemmas. A history of sexual abuse for a child certainly impacts the other members of that child’s family as well (Akman, Beitchman, daCosta, Hood, Zucker, 1991). Blake and his family often struggle with their relationships with one another.
When a child is a victim of sexual abuse, they also often show behavioral issues. These issues may include aggression and emotional outburst (Akman et. al, 1991). Blake often lashes out on his mother and brother. His anger is prevalent throughout our sessions when his mother or his brother are around. Blake is almost unable to control his annoyance, especially with his brother. Blake’s prior trauma could certainly effect said relationships, and aggressive outbursts.
Adaptions to Trauma. Blake’s behaviors have put a strain on the relationship between him and other individuals, in particular, with his family and friends. Blake has become extremely independent and struggles to rely on various relationships (Streek-Fischer & Van der Kolk, 2000). Blake’s father and brother often find it difficult to engage with Blake, however, Blake has not yet expressed that these are issues for him (Blake’s mother has informed the team of such views on Blake’s problems within the family).
For the past few months, Blake has not been exhibiting unwanted behaviors as often as he normally does. He has slightly more control with his anger, and does not lash out as frequently. However, Blake’s “normal behavior” does include raising his voice or yelling; even when a situation does not call for this. Blake continues to struggle with regulating, and expressing his emotions of a regular basis (Van der Kolk, 2005). While at home, Blake constantly wants to participate in somewhat violent an aggressive games that may include Nerf Guns or swords (Streek-Fischer & Van der Kolk, 2000). These games also include various enemies that Blake insists on killing or injuring in some way. If Blake is presented with a structured game, such as Uno, he is extremely reluctant to participate and will constantly ask to play a game of his choice. Blake’s mother states that these control issues have been getting more and more severe.
From various observations and interactions with Blake, it has been noted that he has been engaging in imaginary play very frequently. Blake will often ask to play a game that includes imaginary lasers, cameras, traps, enemies, locations, passcodes, weapons, forts, etc. (Nijenhuis, Van der Hart, Steele, 2004). Even as an adult, these games are difficult to follow along with. Blake has been changing the rules of his games often and does not explain any details about the game to the participating parties. Blake will often comment on how some individuals do not remember the rules, even when the rules have not been clearly stated.
Blake’s mother claims that there are classmates of Blake’s that would like to engage with him, but that Blake is not always willing to engage with others. Blake’s mother also states that Blake would like to engage with his fellow classmates, but that he is sometimes unable to portray appropriate social skills. Blake tends to not interact well with others since his imagination is sometimes difficult to engage with, and keep up with. Blake also needs to be in control most of the time. Other children, and his younger brother, find it difficult to follow along with the various games that Blake is interested in. Blake is also sometimes intense while playing, and is unable to show flexibility during certain games or events. Blake’s frustrations are often shown when he is not engaging in activities of his choice. Blake also struggles with his emotions greatly, and has previously engaged in “unwanted” behaviors such as tantrums, yelling, slamming doors, hitting, etc. (Van der Kolk, 2005).
As far as Blake’s relationship with his family, Blake has not engaged much with his brother or father, and often gets agitated with his mother. While at the home, it is noticed that Blake will often yell at his mother for trying to participate, or for “interrupting the session”. Blake has been under the impression that the IHT, TT&S and TM were solely at the home to “play” or “hangout” with him. Although attempts are made to include the younger brother, Blake almost refuses to interact with him. Blake has not yet been able to identify the reasoning behind his frustrations with his brother and their relationship becomes more and more distant as provider enter the home.
Socio-cultural Environment. Although Blake’s mother has attempted to engage Blake in programs and services that would cater to Blake’s trauma, Blake’s mother is not consistent. Blake’s mother often cancels session’s last minute, or is not home at the time of the session. Blake struggles to stay organized as he mirrors some of his mother’s behaviors (Streek-Fischer & Kolk, 2000). In addition to a lack of engagement in services, Blake’s mother can also be inconsistent with rules and regulations of the household. Blake is unable to follow various rules as he is allowed to do things during a certain time, but is unable to do the same thing during another time. Blake has shown that he has trouble keeping up with rules while in the community as well. Blake’s mother also ignores or does not address various behaviors that Blake portrays. Such behaviors may be crucial as he develops as a child.
Blake’s father is often absent due to work. Blake’s father has admitted that he does not find commonalities with Blake and that they struggle to find activities that they both enjoy. When Blake and his father do interact, the conversation is minimal. Blake’s father and Blake’s younger brother get along very well and often play sports with one another. Blake recognizes this, which seems to make him resent his younger brother as he is mean and sometimes cruel towards his brother. Blake does not seem to have a secure attachment or relationship with his father or his brother (Van der Kolk, 2005).
While assessing Blake’s environment for healing and coping with his trauma, it does not seem as though he is fully able to deal with his trauma properly. Reasons for this include the lack of consistency, the lack of organization, lack of emotional connection, lack of attention for various behaviors, etc. within the home. Treatment Model. Since Blake has not had strong relationships with his parents, and due to the lack of engagement with the parents, I felt as though Child Parent Psychotherapy would be useful within this case. Blake’s mother expressed extreme remorse for “not being able to protect” Blake during his trauma. Blake’s mother was not able to process her son’s trauma since the event was traumatic to her as well. Blake’s mother’s reactions to the event were not meant to harm Blake, but her inability to cope with the trauma was mirrored in Blake’s behaviors (Appleyard & Osofsky, 2003). The concerns regarding Blake’s attachment is also affiliated with his trauma. It is believed that neither of Blake’s parents were able to process the trauma in a way that is supporting for Blake (which is not judged as it may be impossible to “properly” deal with trauma in some scenarios).
According to Appleyard and Osofsky, various questionnaires regarding the family history may be implemented within this treatment process. Such assessments would include stressors for the parents, history of the relationship between the child, concerns with the parents, supports for the parents, techniques and skills used by the parents, and information regarding the parent’s childhood. Within this treatment method, it is also crucial to witness interactions between the child and the parents (Appleyard & Osofsky, 2003). For Blake’s case, it would be imperative to have both his mother, and his father involved in the In-Home Therapy sessions. However, the father is often traveling for work so this has been difficult.
As explained in the table, Multisystem Intervention Strategies for Families Experiencing Trauma, the following interventions would also be useful while working with Blake’s family: family history (some of the family history has been gathered during initial meetings, however it would be helpful to explore the history in more depth), trauma history (the team has reviewed the trauma history of Blake, but we have not discussed this trauma with Blake himself; it would possibly be beneficial to receive Blake’s perspective of the trauma), psychiatric assessment (would be beneficial for both Blake and his parents), parenting assessment (in order to address what techniques have been used in the past, and what would be helpful in the future), psychological an cognitive assessment, parent-child interaction assessment (would be beneficial as there are not many positive reactions between Blake and his parents), individual treatment with parent (especially since the father is not present most of the time, and since the mother often cancels sessions with the IHT), individual treatment with the child (Blake does engage in TM services), parent counseling (in order to have the parents cope with the trauma, and to help the mother with organization, stabilization, and consistency and to strengthen the relationship with Blake and his father), parent education (specifically with trauma in children and coping skills/ interventions), crisis intervention, case management (which the team consistently keeps up with), and referrals and community support (the team has been actively working on this, but it has been difficult as the mother struggles to keep up with the community supports) (Appleyard & Osofsky, 2003).
Treatment Relationship. Blake and I do have a strong relationship. We have been working together for a while now and I believe that he is beginning to trust me more and more. At the beginning, Blake was reluctant to engage in our sessions. Due to his reluctance, I decided to play the games of his choice to build a relationship. We then started to make compromises four our sessions, which Blake eventually agreed on. Blake has yet to discuss his trauma, but our relationship continues to grow. Some of the struggles with empathizing with Blake includes his reluctance to participate in various activities. Blake often says cruel comments when he does not want to engage in certain activities and begins to insult others. As this was expected, it is not too difficult for me to empathize with his emotions and behaviors. Blake’s behaviors do tend to disrupt the coping process, but our work continues to show through Blake’s emotions and behaviors.
