The following paper was written based on two vignette’s given to the class from our professor, Dr. Susan Holt. The vignette’s are posted before the paper to give context to the assessment and treatment in the paper.
*TRIGGER WARNING: The following content does contain description of abuse so please proceed with the understanding that it could be trigger for some individuals.
Vignette #1
Alan
Alan is a 35-year-old cisgender African-American, HIV negative gay man who has been mandated by the court to attend 16 sessions of individual therapy for anger management counseling. He reports that he and his partner, Jackson (who is 38 years of age, cisgender Caucasian, HIV +), have lived together for five of the six years they have been together and, for the majority of their relationship, there have been frequent arguments that culminate in physical fighting. Alan reports that he was arrested after Jackson called the police during a recent argument and reported to them that Alan was abusing him. Although Alan indicates that it was Jackson who initiated the incident that resulted in the call to police, Alan feels remorseful, has no resentment about the arrest, and feels close to Jackson. He indicates that, in fact, Jackson has been exposed to a consistent amount of stress recently – both on the job and in his personal life - and states that he understands the reasons for his partner’s “irritability” and doesn’t want to hold it against him. Furthermore, Alan indicates his belief that any additional stress could jeopardize Jackson’s health that has already been compromised by HIV and he feels badly that they argued. Although Alan reports that it is generally Jackson who initiates the majority of abusive incidents that occur in their relationship, he reports that he is quick to engage in the fighting and usually has no desire or intention to disengage once the fighting begins. On occasion, he has initiated the fights out of “frustration”. Their fighting usually includes name-calling, hitting, shoving, and kicking and, while they generally argue about financial issues, their arguments have also focused on how they will spend their social time together and how to divide household chores. Both men also throw and break objects on occasion.
Alan reports periodic problems with anger management outside the home (he tells you that he has “road rage” but generally doesn’t act it out) and mentions that he often feels frustrated because he can’t be himself or “out” about his relationship and sexual orientation in most areas of his life. He indicates that he and Jackson are out to a few friends and several of their family members but rarely attend gay events or socialize with other gay couples. In fact, he indicates that the majority of their friends are heterosexual couples and states that he and Jackson prefer it that way because it makes their life seem “more normal”. When Alan and Jackson have attended gay events or socialized with other gay couples, Alan reports that they usually argue afterwards. When they socialize with heterosexual friends, they usually have 1 – 3 drinks prior to the event but Alan admits to drinking more frequently when they attend gay events or socialize with other LGBTQHI people. Alan also discloses that he has utilized “meth” several times and enjoys the feelings it generates in him. Further, neither Alan or Jackson is out at work and fear that it would jeopardize their employment as well as the relationships they have with co-workers. Jackson has a 5-year old niece who visits them once a month but Alan maintains that they have never argued in front of her. They have discussed marriage several times and, although these conversations have generated positive feelings in both about their relationship, each of them feel hesitant about following through with it because they assume that the marriage “won’t last”.
Alan reports that he became aware of his sexual orientation in adolescence and attempted to conceal it from family and friends until he was in his late twenties. When he disclosed to his parents that he was gay, they promptly “disowned” him. He currently has occasional strained contact with his mother and siblings but rarely talks to his father. Despite the conflict in his relationship with Jackson, which he considers to be “normal for gay relationships”, he is adamant that he has no intention of leaving the relationship and is committed to making it work. Alan reports a history of depression and periodic episodes of “intense anxiety” which, he indicates, have never been treated because he “grew up in a family that didn’t believe in airing problems.” Further assessment reveals that Alan has had a history of panic attacks since the age of 19. He also indicates that he believes they increased in frequency and severity approximately 5 years earlier.
Vignette #2
Gina
Gina is a 32-year-old Asian bisexual female who presents with symptoms consistent with Post Traumatic Stress Disorder including inability to concentrate, hyper-vigilance, sense of a foreshortened future, irritability and outbursts of anger, reactivity, and avoidance of various feelings and environments. She and her partner, Alisa (age 40), have lived together since the beginning of their three year relationship.
Gina reports that Alisa, who is cisgender and Caucasian, often criticizes her and makes racist and homophobic comments when angry. Although Alisa’s criticism of Gina is commonly expressed through name-calling, yelling, and verbal put-downs, it has periodically culminated in physically abusive behaviors including hitting, slapping, punching, choking and sexual assault which appears to be increasing in severity and frequency. Gina reports that Alisa frequently threatens suicide after telling her that she is “impossible” to be with because she is so “lazy and stupid.” Otherwise, their arguments have no particular focus and Gina reports that Alisa is frequently “angry about everything”. Gina indicates that she has been abusive to Alisa when she feels irritable or angry about her life but reports that her abusive behaviors generally consist of hitting and shoving. She reports that she has been feeling increasingly irritable for the last few months but doesn’t know why she has been feeling this way. Gina also indicates that she is convinced that she is doing something unconsciously that triggers Alisa’s abusive behaviors and indicates that she apologizes repeatedly but this seems to have little impact on Alisa’s attitude towards her. Alisa reports that she struggles with depression as well as anxiety and regularly smokes pot to relieve the anxiety.
Gina and Alisa are out to very few people and spend the majority of their recreational time at home watching movies. The middle child of three children, Gina indicates that she has little contact with her family except in cases of emergency although she reports that her younger sister just had a baby that she brings to her home occasionally. Gina reports that she was physically, emotionally, and sexually abused through-out her childhood by her father and that the emotional/psychological abuse escalated into verbal 3 assaults by both parents about her sexual orientation after she came out to them at age 30. Although Gina maintains contact with her younger sister, she reports that their relationship is not close. She is not out to either of her siblings, including the younger sister, and indicates that both of her siblings “are probably homophobic and wouldn’t want to know me if they knew the truth about me. My younger sister would definitely want to keep her baby away from me if she knew.”
During the 5th session, Gina reports that she is feeling very concerned about Alisa’s well-being because she believes that Alisa’s suicidality has been escalating since she (Gina) began attending therapy. Gina feels responsible for this increase in the level of Alisa’s depression and suicidal ideation and tells you that she is considering terminating therapy because of it. Despite the abuse in the relationship which appears to be escalating in frequency and severity, Gina has no intention of leaving the relationship and fears that harm will come to Alisa if she were to leave. She also states that she believes she can defend herself if she needs to do so. In addition to her consideration to leave individual therapy, Gina has encouraged Alisa to consider couples therapy so they can work on their relationship problems together. As she is leaving her session, Gina tells you that she is transmasculine, has begun the process of transitioning, started taking testosterone six months earlier, and has been terrified to mention any of this to Alisa for fear of what Alisa may do. She also mentions that she initiated an argument with Alisa during the week and hit Alisa “out of frustration” two days ago when she was pondering how to tell her about her transition.
