Counselling an Adult Male with Fetal Alcohol Spectrum Disorder: A Case Study

Contents

Abstract

Acknowledgments

Counselling an Adult Male With FASD: A Case Study

Case Information
Family Background
Developmental History and Status
Mental Status Examination
Mental Health History
Legal History and Status
Bio Psychosocial Screening
Assets and Strengths

Literature Review
Fetal Alcohol Spectrum Disorder: Definition and Diagnosis
Diagnosing Fetal Alcohol Spectrum Disorder
Fetal Alcohol Spectrum and Poor Working Memory
Fetal Alcohol Spectrum Disorder and Social Skills
Emotional Recognition/Processing
Fetal Alcohol Spectrum Disorder and Inappropriate Sexual Behaviour
Inappropriate Sexual Behaviour Treatment
Child Friendship Training and FASD
Play Therapy and Fetal Alcohol Spectrum Disorder
Anger Management

Case Formulation
Case Analysis
Treatment Plan

Treatment Summaries
Sessions 1& 2
Session 3
Session 4
Session 5
Session 6
Sessions 7 and 8
Sessions 9 & 10
Session 11 and 12
Session 13
Session 14
Sessions 15-17
Session 18
Session 19

Results

Discussion

References

Abstract

The present case report describes counselling an individual with Fetal Alcohol Spectrum Disorder (FASD). The 24-year-old male client suffers from FASD resulting in cognitive impairments, a lack of social skills, signs of inappropriate sexual behaviour and the need for anger management. The present paper will assess the effectiveness of different forms of therapy applied to aid the client to manage with his behavioural concerns which include cognitive behavioural therapy, play therapy, anger management, and child friendship therapy. To complement the client’s learning difficulties a client-centred approach will be used, along with facial recognition exercises, and an increased use of role-playing and visual aids. Numerous articles suggest further research needs to be completed to grasp a better understanding of adult FASD, since many articles focus on therapeutic interventions for adolescents and children.

Acknowledgments

I would like to thank a number of individuals who helped me throughout my educational career. First and foremost, I would like to give thanks to my parents who have helped me throughout my post-secondary and graduate studies. I would also like to thank Mary van Gaal, who was my practicum director and was a vital component during tough times at Yorkville University. If it was not for her, I may not have completed my graduate degree as early as I did. I would also like to thank Dr. Don Pazaratz as he provided me an opportunity to work with him and his colleagues at his facility. My supervisors, Theresa and Debbie, also deserve credit as I was able to gain an extensive amount of knowledge about the counselling field as they were there to guide me throughout the entire process.

Counselling an Adult Male With FASD: A Case Study

Jason Doe^[1] is a 24-year-old Inuit male who was admitted to Haydon Services when he was 17 years old from Nunavut. He was brought to Haydon due to years of being neglected by his parents, being abandoned by family, as well as being forced to live with years of both emotional and physical abuse. After his biological parents abandoned him and his younger siblings, the family was spread out to different foster homes. Jason was then relocated to Oshawa, Ontario under the care of Haydon Services. Due to the heavy use of alcohol by Jason’s mother during pregnancy, Jason has been recently diagnosed as having Fetal Alcohol Spectrum Disorder (FASD). Fetal Alcohol Spectrum is a disorder that occurs when the fetus is introduced with alcohol while in the uterus likely leading to substantial cognitive impairments, temperaments, and physical deformities. While at Haydon Services, I was initially shadowing my colleagues and observing the clients during therapeutic sessions and was later informed that Jason Doe would be the client with whom I would be conducting a counselling intervention.

Case Information

Family Background

Due to administrative issues between Haydon Services and the Social Services of Iqaluit there was limited paperwork and background information regarding parts of Mr. Doe’s past history. Mr. Doe’s biological mother abandoned Jason when he was very young. He last saw or heard from his mother in December of 2008. Jason’s father physically abused him and his younger siblings. He displayed no signs of involvement with his children, was later incarcerated and eventually passed away in 1998. Jason lives separately from his younger siblings, and per his recollection, they all lived within different foster placements. Throughout the majority of Jason’s life, he was emotionally and physically abused, homeless on the streets of Iqaluit, Nunavut and reported that he never received any real love or care from his family, or developed any healthy attachment bonds. Such events in one’s life can lead to emotional volatility and a lack of boundaries between the self and others (Kiel, Paley, Frankel & O’Connor, 2009). Upon entering foster care, he was evicted from every residential home setting due to his bitterness and anger towards his foster parents, and they were all unable to manage his aggressive nature, tantrums and bullying of the other residents of the home. Due to a lack of resources available to Jason in Nunavut, Jason was moved by Social Services to live in an assisted adult care facility in Oshawa, Ontario.

Jason has been living in the group home since he was 17 years old along with two other Inuit individuals from Nunavut whose names are Caterina and Tim. Jason is able to live with a sense of freedom at his present residence due to the unique philosophy of the group home setting. The facility follows a client-centered approach while enabling the residents to live with freedom, direction and providing input when needed which in turn has led to significant success within this facility. Jason enjoys trips with his caregivers, engaging in daily activities, chores, and partaking in arts and crafts programs. Jason does not attend school or work currently due to other social limitations.

Developmental History and Status

Case-notes state that while Jason’s mother was pregnant with Jason she was consuming alcohol heavily through the majority of her pregnancy due to her own alcohol abuse and possible dependence. Such events lead to Jason being born with Fetal Alcohol Spectrum Disorder (FASD). Individuals with FASD have facial malformations, growth deficiencies, social skill deficits, cognitive impairments, and indiscriminate social behaviour (Laugeson, Paley, Schonfeld, Carpenter, Frankel & O’Connor, 2007). While speaking with Jason and examining his behaviour, his social skills, and physical appearance, it appears the symptoms presented validate his diagnosis of FASD. Jason exhibits signs of being alert and aware of his surrounding environment. During sessions, he displayed signs of anxiousness, and nervousness but after opening up and speaking for some time he felt more relaxed. Jason also displayed signs of being upbeat, friendly and outgoing, however at any given time became temperamental and explosive leading to aggressive behaviour not only to other residents and peers, but also at times to staff.

Mental Status Examination

According to the information provided in Jason’s case notes, he suffers from FASD with the developmental capacity of a 10-year-old child. Although Jason has cognitive impairments, his vocabulary is exceptional and he is able to have a functional conversation with his peers as well as staff. He lacks social skills leading to an aggressive nature at times, yet has an active social life with many friends. He tends to travel throughout Oshawa independently visiting friends at the mall, attending church on a regular basis and attending his day-programs during the week. He enjoys several leisure activities. While at the home, Jason is constantly on the phone with friends, surfing the internet, or playing leisure games.

In addition, Jason had difficulties staying on task and understanding the consequences of his actions. It is apparent Jason has anger issues where he lashes out on his peers and workers resulting in both physical and verbal abuse.

Case notes displayed that during his stay at a nearby home he got into a verbal and physical confrontation with an individual with whom he was residing at the time and held the youth under water in the family’s pool. He admitted that this event occurred, and that he only let go of the youth when he was told to do so. Another incident occurred at the local YMCA pool where Jason was extremely upset with a peer who yelled at him for splashing water, therefore he proceeded to physically choke the youth. Jason never understood why he was being confronted by the staff about the situation, but felt justified hurting the boy because he had yelled at Jason for splashing. The case notes support what I was witnessing with Jason because at times he felt he was always the victim and never understood the consequences of his own actions. When Jason would interact with his peers, he became explosive when they did not confine to Jason’s rules. This resulted in Jason being easily offended and explosive. His emotions became extremely intense and when his peers were afraid of him, it appeared that he was oblivious to other people’s feelings and he did not care. In addition, at times he had difficulty verbalizing his anger.

Another symptom of FASD is inappropriate sexual behaviour (ISB). Colleagues at Haydon Services have stated that when Jason was admitted, he was invited to a camping trip where ISB had occurred. Jason ran through the group wearing a pink speedo and began dancing and jumping near the females. Subsequently, a female worker was bent over getting supplies; Jason stood behind her staring from behind with a fully erect penis. Furthermore, Jason would purposely streak through the house naked or would mislead female workers by stating that he was fully clothed and they could enter his room when in fact he would stand naked waiting for them to open the door.

According to staff, Jason demonstrated no tendencies towards substance/drug use, suicidal thoughts or self-harm. Jason’s health is exceptional and through observation and asking Jason there were no signs of abuse or neglect

Mental Health History

When Jason first entered Haydon Services, he received counselling on a variety of concerns and issues using several different forms of therapy. Dialectical and behavioural therapy was used and Jason was taught focused awareness and to mentally catch and release emotions without holding onto them and trying to understand them. Data from the case-notes suggested Jason would often examine his feelings and held onto his emotions if he felt he was at fault for a mistake he made. Therefore, Jason was encouraged to face threatening feelings and let such emotions pass without constantly re-examining them. Occasionally Jason reported improved emotions after practising these techniques. Another treatment intervention used was to help Jason develop self-control. Jason was shown how to respond to outbursts and keep himself calm no matter how angry he was feeling. Since Jason had great difficulty accepting constructive criticism or any disapproval, staff members were instructed to provide him with positive remarks and praise even when he demonstrates negative behaviours. Jason was also to practice acceptance and tolerance of others who disagreed with his opinions or interests. Rather than to explode on his peers, Jason was to understand that he was not being disrespected or rejected, but that his peers had their own desires and interests. The goal of his therapy was for him to become aware of his contradictions and realise that just as he did not like to be controlled or threatened by others, his peers wanted the same.

Legal History and Status

Due to the many incidences throughout Jason’s life with residential home settings, Jason had many run-ins with the judicial system. When he choked a teenager at the local YMCA for yelling at him, he was charged for assault, but the charges were later dropped. Jason was kicked out of that group facility and was then placed into another Haydon Services group home. A few years ago, Jason was charged with indecent exposure and mischief when he began to masturbate in public at a group day-program while in the presence of a large group. These charges were also dropped once Jason completed therapy with a local psychiatrist. Further criminal charges included, assaulting a peace officer and threatening death while the local police department had come to the group facility to handle a situation.

Bio Psychosocial Screening

Employees at Haydon Services reported that a few years ago Jason was tested for a variety of sexually transmitted infections (STI) due to his ISB. Case reports further acknowledged that in the past Jason had spent hundreds of dollars on hotel rooms with unknown individuals. However, Jason was tested negative for all STIs. Jason’s hygiene practices are not consistent and he needs constant reminders to take showers, brush his teeth, and wear clean clothes.

Jason has a very busy social life due to numerous friends and is often busy while travelling throughout Oshawa, Ontario. Jason attends church every Sunday, while during the week he attends a brain-injury day program where individuals socialize, and complete arts and crafts. Jason also enjoys playing leisure games at the home, talking on the phone with a wide variety of friends and occasionally goes to the YMCA to swim and workout.

Jason takes two different types of medication, which include 100mg of Seroquel in the morning and another 50mg before bedtime. Zoloft is taken at 50 mg daily along with 900 mg of iron each day. According to staff, Seroquel was used for Jason’s aggressive nature and behaviour problems .

Assets and Strengths

Jason displays a high degree of vocabulary and is able to form a functional conversation and make friends quickly, however he also deteriorates relationships just as quick due to his erratic behaviours. Jason’s ability to travel in Oshawa and understand travelling routes is exceptional, allowing him to travel throughout Oshawa with ease. His ability to understand travel routes with a lack of cognitive abilities is remarkable Thus, allowing him to travel independently and given greater freedom than his housemates who suffer from more severe mental health disorders. Jason also displays mediocre signs of mathematical abilities, however has a significantly hard time budgeting and tends to spend frivolously.

Jason displayed typical characteristics of one managing with FASD. The demonstrated characteristics included cognitive deficits, a lack of empathy, inappropriate sexual behaviour, aggressiveness and erratic behaviour.

Literature Review

Fetal Alcohol Spectrum Disorder: Definition and Diagnosis

Fetal alcohol spectrum disorder (FASD) results in the mental retardation and physical malformations associated with exposure to alcohol while in utero. In addition, growth retardation and facial defects are present, while central nervous system abnormalities result in neurocognitive and behavioural problems (Sadock & Sadock, 2007). The incidence of FASD in the general populations is 1 to 4 per 1000 live births annually, while as many as 10 to 20% in Aboriginal Canadians (Greenbaum, Stevens, Nash, Korean & Rovet, 2009). Alcohol affects the fetus during pregnancy differently in each trimester. During the first trimester, brain cells may be adversely affected. During the second trimester, facial features may be disrupted and the hippocampus may be affected during the third trimester. In addition, it has been reported that alcohol consumption during the first two months is likely to greatly affect the fetus, as opposed to later during the pregnancy (Liles & Packman, 2009).

Diagnosing Fetal Alcohol Spectrum Disorder

According to the Diagnostic and Statistical Manual of Mental Disorders: (DSM-IV-TR), Diagnostic Criteria for Mental Retardation clinical features of FASD include borderline intellectual functioning, mild to moderate mental retardation, irritability, and memory impairment (DSM-IV-TR, 2000). Many sufferers of FASD tend to have difficulty in meeting the standards of daily functioning relative to their age. These include communication, self-care, home living, social/interpersonal skills, self-direction, academic skills, health and safety.

Borderline intellectual functioning is an IQ level of 71-84 and is apparent with many sufferers of FASD. Furthermore, mild mental retardation is categorized as an IQ level between a score of 50-69, while moderate mental retardation is categorized with an IQ level between 35-50. Severe mental retardation entails an IQ score between 20-35 (Sadock & Sadock, 2007; DSM-IV-TR, 2000). Fetal alcohol spectrum disorder (FASD) affects the fetus while in the uterus. Individuals suffering from FASD after birth display symptoms including growth retardation, abnormal facial features and central nervous system defects. Growth retardation includes deficiencies in height, weight, body proportions, brain growth and brain size. Facial abnormalities include a thin upper lip, shortened eyelids, small eyes appearing widely spaced apart, and flattened maxillary area Central nervous system defects in individuals with FASD include delayed intellectual development and behavioural problems (Liles & Packman, 2009). Sadock and Sadock (2007) state that delayed intellectual development leads to cognitive impairments, poor executive functioning skills, inattention/hyperactivity, and poor social skills.

Secondary difficulties of FASD include emotional consequences, being temperamental, ISB, difficulty with short-term memory, difficulty developing associations between concepts, as well as aggression. Social difficulties appear to be significantly problematic in FASD-suffering individuals. Researchers found that these individuals tend to be impulsive, excessively demanding for affection and physical contact, intrusive, lacking social judgment and being insensitive (Liles & Packman, 2009)

Fetal Alcohol Spectrum and Poor Working Memory

Neuropsychological impairments are displayed among FASD patients. Attention span, executive functioning, intelligence, as well as working memory are significantly defected (Sadock & Sadock, 2007). Working memory is mental workspace used to support cognitive thoughts in need of processing and storage. Many patients with FASD have poor working memory causing them to be forgetful and unable to process complex thoughts (Sadock & Sadock, 2007; Loomes, Rasmussen, Pei, Manji & Andrew, 2008).

Loomes and colleagues (2008) hypothesized that verbal rehearsal is essential in improving working memory in FASD patients. Rehearsal aids help patients with recall by constantly maintaining information while it is being stored. Hence, information is constantly refreshed through cues, and phonological stimuli (Loomes et al., 2008). Keeney and colleagues (1967) found that when an experimental group received training on how to rehearse information their memory scores on tests significantly improved when compared with the control group. All subjects had low memory spans and the experimental group was told to whisper the names of the items repeatedly, while the control group was given no instructions. The researchers discovered that rehearsal was preferred among the subjects due to the lack of demanding resources (Keeney, Cannizzo & Flavell, 1967). Loomes and colleagues’ study (2008) included 33 subjects managing FASD with a mean age of 8 years old, where nearly 60% of the individuals were Aboriginal. The subjects were tested over two sessions. The pretest was a digit span test that displayed their baseline scores, whereas the first post-test consisted of the researcher instructing subjects to whisper the names or numbers to themselves so they would not forget them. Post-test two consisted of a new digit span test along with a reminder of a rehearsal strategy. The control group did not receive such instructions. The study found that the experimental group scored significantly higher on the digit span test across the sessions, as well as in comparison to the control group. The control group displayed no increase in scores.

Loomes and researchers (2008) suggested that rehearsal and repetition training among FASD clients are critical in aiding memory deficits. Although a brief instruction was provided, the subjects scored higher on post-test measures. Working memory is important in tailoring interventions, therapy, and behaviour modifications in allowing subjects to utilize what they have learned for future situations and managing challenges in daily living.

Fetal Alcohol Spectrum Disorder and Social Skills

Neurocognitive deficits affecting FASD subjects include inattention, hyperactivity, poor language performance, as well as poor executive functioning. Executive functioning manages cognitive processes within the brain. These processes include attention, problem solving, inhibition, mental flexibility and self-control. As a result, significant difficulties occur including, understanding social cues, and communication (Kiel et al., 2009). Many studies have discovered through parental reports that children exposed to alcohol while in the uterus, lack consideration of feelings and rights of peers, fewer social skills, and greater resistance for authority figures than mentally retarded children (O’Connor, Frankel, Paley, Schonfeld, Carpenter, Laugheson, 2006). Researchers have noted that as patients age there is greater risk for peer rejection, and the development of behavioural concerns.

More recently, social-information processing was a concept examined greatly upon in regarding social skill deficits with FASD patients. Many social cognitive theorists pose that negative early life-experiences contribute to one’s representations of the self, others and the individual’s social world, thus influencing one’s behaviours. For instance, a hostile parent or caregiver may force a patient to feel unworthy. Consequently, the patients may view others as hostile/victimizing, while assessing peer relationships as unsupportive. Accordingly, maladaptive and poor social-information processing patterns are developed (Kiel et al., 2009). Further evidence has postulated that poor child-mother relationships are linked to distorted social-processing during childhood (Burden et al., 2005). Negative social information processing patterns have been associated with aggressive and incompetent social interactions, where subjects tend to attribute benign scenarios of peers with hostile intentions (Keil et al., 2009).

Another study by Mcgee and colleagues (2009) which examined social information processing consisted of subjects with FASD with a mean age of 9 years old. Subjects were given vignettes of peer entry and peer provocation scenarios. Subjects were told to assess the scenarios and it was found the experimental group (FASD subjects) selected fewer pro-social goals, provided a greater number of aggressive responses and a lower number of competent responses. Competent responses were rational answers leading to a solution. Subjects with FASD viewed competent responses as being less effective and useless, while irrational responses such as violence more effective (Mcgee, Bjorkquist , Price, Mattson & Riley, 2009). To complement Mcgee and colleagues’ study (2009) O’Connor and his research study (2006) compared subjects with FASD to socially delayed subjects not exposed to alcohol at birth. The study found that subjects exposed to alcohol provided a significantly greater number of hostile attributions and were positively correlated to aggressive responses (O’Connor, Paley, Keil & Bernier, 2006). Both studies demonstrate that FASD subjects are susceptible to greater aggression, and impulsive actions.

Emotional Recognition/Processing

Greenbaum and researchers (2009) stated although that observable behaviours may be the culprit to poor interpersonal relationships, underlying cognitive mechanisms also play a key factor. The study examined social cognition and emotion processing in 33 children suffering from FASD in comparison to ADHD children and controls (average functioning subjects). Emotion processing looked at the capabilities of subjects to understand facial expressions, recognizing emotions on cartoon faces and modelling the facial expressions on cartoon faces. The results found that FASD subjects scored significantly lower than both control and ADHD subjects, where they were unable to accurately match a facial expression with the verbal demand of the researcher. Although both FASD and ADHD subjects have difficulties with social skills, the main difference is that ADHD patients were able to predict how a peer may feel in a situation and act accordingly to their peer’s facial emotions. Subjects with FASD on the other hand, may continue to verbally or physically abuse a peer due to their inability to comprehend their peer’s reactions (Greenbaum et al., 2009). Consequently, a greater number of behavioural problems and social conflicts tend to occur. Examining both Kiel and colleagues’ study (2009), as well as Greenbaum’s study (2009), provides great support for the argument that it is vital for subjects with FASD to receive training on understanding facial emotions of their peers and learning social skills.

Fetal Alcohol Spectrum Disorder and Inappropriate Sexual Behaviour

Inappropriate sexual behaviour (ISB) is one of the most prevalent secondary disabilities in patients suffering with FASD. Inappropriate sexual behavior includes any compulsive sexual behaviour a person diagnosed with FASD constantly acts upon, such as compulsive and public masturbation, touching others, sexually offensive comments, and invading peers’ personal space (Novick, 1997). Previous research suggests FASD subjects who had the greatest difficulty with impulsivity, and response inhibition during childhood were highly susceptible to committing sexual offences during puberty (Novick, 1997). To complement the research, Streissguth and his research team (2004) discovered that FASD subjects who had been victims of violence, sexual abuse or physical abuse during childhood, increased the chances of ISB later in life. The risk for FASD subjects with ISB increases three to four fold as opposed to one growing up in a nurturing/stable home, consequently, ISB treatment is vital (Streissguth, Bookstein, Barr, Sampson &Young, 2004).

Inappropriate Sexual Behaviour Treatment

Treatment for ISB patients suffering with FASD includes short psycho-educational programs, residential treatment facilities, and day treatment programs. Psycho-educational programs tend to be the greatest approach to helping FASD subjects since they are designed for cognitively impaired individuals, and focus on the need to be practical, efficient, flexible and individualized. Researchers feel such programs must be developed in accordance to subjects’ strengths and weaknesses. Since many FASD subjects have difficulty understanding basic concepts due to poor cognitive levels, they may have to rely on verbal processing, visuals, or role-playing (O’Malley, 2007). Treatment typically includes examining differences between appropriate behaviour and inappropriate behaviour, exploring rules that are expected of individuals when in contact with peers, as well as understanding triggers prior to having urges when an offence takes places. Typical treatment programs ignore poor memory in FASD and cognitively impaired individuals, hence leaving the subject in a vulnerable position. Therefore, upon understanding basic concepts of the treatment it is vital to examine retention and generalization of the information in an assortment of environments (O’Malley, 2007). Constant repetition of the information given to patients must be in a variety of formats and engage the client for active listening. Therapists must examine if the subjects remember what they have learned and when, where and with whom, certain behaviour is allowed. Recommended approaches include visual diagrams, role-playing, informational videos, and basic testing (O’Malley, 2007).

Individualized programs for FASD patients displaying ISB behaviour include enabling the subject to comprehend and understand rules and what consequences can occur when the rules are not followed. Therapists typically begin by speaking to the client about what rules they currently follow at school, home or work. Clients are asked whether they know what makes a good rule to follow, consequences of failing to recognize rules, and what could happen if there are no rules. Therefore, the main objectives of initial sessions are to allow the client to understand rules meant to keep them and their peers safe. Other key concepts examined include boundaries (physical space between people, dividing lines), private places, sexual innuendos (wanting to touch others), and emotions (anger, sadness, love, attraction). Upon understanding these concepts, clients are given practical training where they are asked how close one should get to another, when it is appropriate to touch someone and where it is inappropriate to touch someone (Novick, 1997). Therefore, it is highly recommended that role-play or visuals be used to demonstrate such information, as they are well suited for FASD subjects learning novel material (Laugeson et al., 2007). Role-playing can be highly effective in assessing the understanding of concepts where individuals can act out a scenario and the client is to answer how an actor broke a rule or obeyed a rule. For instance, therapists can ask the client, “When is it okay for someone to touch you or for you to touch someone ?” or “How did Katie break a rule?” (Laugeson et al., 2007; Novick, 1997).

Child Friendship Training and FASD

Child Friendship Training (CFT) is an evidence-based social skills intervention that has been found to be highly effective with autistic subjects, as well as attention-deficit/hyperactivity disorder subjects. Child friendship training utilizes parental/caregiver involvement in developing social networks and is largely based on the social learning theory (Laugeson et al., 2007). Social learning theory is the idea that learning is based on the interaction among people (O’Connor et al., 2006). The focus of CFT is examining conflict-avoidance scenarios, building a social network of friends with caregiver/parental assistance, learning how to handle losing in games, becoming a positive winner, and entering a group already at play. Subjects were taught these vital skills through modelling, coaching, constant rehearsal and repetition, as well as role-playing (Laugeson et al., 2007).

Child friendship training was used in a study to assess its effectiveness on improving social skills patterns in subjects with FASD. The study consisted of 100 subjects with a mean age of 9 years old who were divided into two groups: the delayed treatment control group (DTC) and the child friendship training group. The CTF group (n = 51) received 12 sessions in 12 weeks and during this groups’ post-treatment assessment, the DTC group (n = 49) were evaluated. As stated earlier, the focus of CTF was to assist subjects to learn how to join a group already at play, gain new friends, develop a conversation, and make friends. Subjects were given cartoon vignettes of hypothetical social situations and were asked to score them using a variety of social domain scales. Through the analysis of hostile attribution measures and behaviour scales such as communication and social skills, it was discovered that CFT had significantly decreased hostile attributions when clients were entering peer groups already at play. Therefore, subjects decreased negative hostility towards peers and were better equipped with social skills to join peer groups already at play, as opposed to DTC where subjects had negative feelings toward their peers during introductions. In addition, subjects displayed great knowledge of appropriate social behaviour, increases in social skills and decreased problem behaviours at the 3-month follow-up assessment (Kiel et al., 2009).

Kiel and colleagues (2009) study found that many FASD clients tend to display negative social patterns, such as aggression and hostile intentions of peers. The results of the CFT study provide further support that by addressing such hostile attributions towards peers using CFT, social skills can be significantly improved causing better communication amongst peers and building a larger social network (Kiel et al., 2009).

Play Therapy and Fetal Alcohol Spectrum Disorder

Play therapy is based on effective communication for children of all intelligences and is utilized as a way of expression that can not only allow individuals express their feelings, but also can help decrease anxiety and stress (Johnson & McLeod, 1997). Tools used in play therapy to help express feelings and anxiety provoking thoughts include toys, games, and art where safety and non-judgement is of high importance. A meta-analysis of nearly 94 research journals have provided great support that play therapy is highly effective for a variety of populations suffering from diverse mental illness concerns. Control is given to the child to help guide the session, which not only helps the child feel a greater sense of confidence, but also opens doors for self-expression and possibly gain greater self-control (Johnson & McLeod, 1997). Landreth (2002) states that play therapy is equivalent to adult talking therapy and is a strong gateway of self-expression. Play therapy helps the child express experiences, feelings about what they have experienced, wants, needs or wishes, and his/her perception of themselves (Landreth, 2002).

Often FASD subjects tend to have negative views of the self, and a significant lack of confidence. Such views occur due to being negatively labelled while growing up, and negative early-life experiences. However, play therapy has been highly effective in providing FASD clients with unconditional positive regard, and a greater sense of control over their surroundings. Hence, subjects are easily able to vent their feelings and emotions (Liles & Packman, 2009).

Johnson and McLeod’s study (1997) consisted of six labelled children suffering from a variety of mental illnesses including ADHD, mental disability, cognitive deficits, and impairments in expressive and receptive communication. The symptoms of subjects were highly comparable to FASD individuals. Subjects of the study completed six play therapy sessions on a weekly basis. It was found that play therapy helped facilitate the expression of feelings, and provided opportunities for the subjects to express their emotions and anxiety-provoking thoughts. Both feelings and control were displayed through dialogue, and body language. For example, one subject who initially lacked self-control, was living with a dysfunctional family, surrounded by an unstable home environment needed to express his emotions due to high levels of aggression. His violent and aggressive statements he initially made decreased significantly during just six sessions of play therapy. Another subject of the study began the sessions very aggressively, and was in great need of control. The subject would change rules to force the therapist to lose playing a game, and the subject’s toys would damage all other toys. However, as sessions continued the subject began to play fairly with the therapist and admitted he had no control at home even though he greatly craved it.

Landreth (2002) is further supported by Johnson and McLeod (1997) where it was discovered that when subjects were given opportunities to express themselves, and given control of the sessions, the subjects reported they also gained a better sense of self-control in a variety of other environments (Johnson & McLeod, 1997). To complement Liles and Packman’s study (2009), a similar study by Bleck and Bleck (1982) examined play therapy with disruptive children with social skill deficits. Upon completion of the study, it was found play therapy decreased disruptive behaviours, allowed subjects to clarify and accept their own and peers’ feelings, greatly improve interrelationships, as well as display a positive self-concept of themselves (Bleck & Bleck, 1982).

Literature has supported that play therapy can be an effective tool in helping subjects with FASD to manage their feelings, emotions and behaviours. Liles and Packman (2009) feel that play therapy helps subjects gain a sense of self-responsibility, possess a positive self-concept, and gain a better understanding of social relationships. This may be due to play therapy being a platform where FASD subjects are given control of the sessions along with an empathetic counsellor and constant encouragement (Liles & Packman, 2009).

Anger Management

Cognitive behavioural therapy (CBT) is highly recommended by many researchers within the mental health areas, especially anger (Willner, Jahoda, Rose, Hood, Felce et al., 2011). Many individuals with a learning disability such as FASD patients tend to display aggression through verbal or physical means. Studies have found that more than 50% of the learning-disabled population display forms of aggression. Although medications have been used to decrease impulsivity and anger issues, CBT has been highly successful in decreasing anger and aggression without any pharmacological side effects. Cognitive behavioural treatment examines one’s thoughts, beliefs and perceptions that play an integral role in how one behaves and feels. Therefore, examining oneself can greatly help alter how one interprets peer relationships, and react to conflict situations (Willner et al., 2011). In addition, many studies have provided excellent support that anger management is highly effective in helping people with learning disabilities and treatment gains have been consistent during follow-up assessments. Furthermore, a significant correlation was reported between decreased anger reactivity and increased usage of coping skills in recent studies (Willner et al., 2011). Treatment for individuals suffering with cognitive impairments should be based on a psycho-educational group examining concepts of anger such as emotions, triggers which evoke anger, physiological and behavioural components of anger, and coping skills to manage anger. It is highly recommended to develop discussion with the clients about what makes people angry and to address acceptable ways to display one’s anger. In addition, treatment must include a focus on scenarios and subjects’ experiences with anger, and developing alternative ways to manage with negative experiences for a better outcome (Willner et al., 2011).

To complement Willner and colleagues’ study (2011), Howells and researchers (2000) examined how aggression and anger can be reduced through subjects recognizing anger during the initial stages, as well as managing their moods appropriately. The study examined five subjects (M= 33) with learning disabilities and IQ levels ranging from 55 to 69. Subjects met for twelve sessions and included teaching subjects how to recognize emotions and feelings in others, being aware of triggers, and consequences of losing control in negative situations. Treatment was delivered using a variety of formats including role-play and video-based work where both subjects and facilitators worked together. For example, when subjects were taught how to recognize emotions and anger in peers, the therapist provided subjects with a cartoon vignette and subjects were to identify how the cartoon character was feeling and how subjects were able to identify the emotions. Post-treatment assessments revealed that subjects felt more engaged and in control of their anger, while also feeling confident in utilizing the techniques they had learned (Howells, Rogers, Wilcock, 2000). It appears that by understanding triggers, and utilizing alternative coping strategies, subjects felt greater self-control and self-awareness. In addition, through role-playing and visual exercises the techniques and skills learned during treatment were easier to understand and apply (Howells et al., 2000).

Many researchers have recommended a variety of teaching methods for individuals suffering with FASD. Therefore, another approach to anger management of CBT is through the traffic light method, which has received great success in therapy (Rossiter, Hunnisett & Pulsford, 1998). The traffic light metaphor is based on each colour representing a different stage in problem solving. Red means STOP ( individual must define the problem, recognize feelings, and identify goals). The client should try their best to stop their feelings of anger and identify a means of relaxation. Orange means THINK (generate solutions and develop coping mechanisms). The clients are recommended to draw pictures of bubbles explaining what had happened, how they felt and what they were thinking of during the situation. The green light means DO (choose the best solution). Clients are urged to write how they would handle the situation differently and choose a solution, which indirectly helps the client deflect their anger/emotions. Such a system utilizes the concept of an appealing visual aid with simple concepts through short phrases (Rossiter et al., 1998).

The study examined how effective the traffic light system could be for subjects with learning disabilities. Participants were six subjects (M= 40) from residential treatment facilities with mild to moderate IQ levels, and anger problems. There were eight sessions focused on identifying emotions, relaxation techniques, as well as having the subjects role-play the different signals (Rossiter, 1998). Although the study did not examine whether anger had been reduced in clients through experimental methods, subjects’ and caregiver/parents’ reports state clients were able to control their temper and appropriately cope with the anger. Subjects also enjoyed learning about relaxation techniques, the use of role-playing emotions and learning new skills. A negative aspect of the traffic light method was subjects had difficulty speaking in front of others and would rather have individual sessions. Positive feedback from both the staff and subjects provide great support that the traffic light method utilizes a variety of formats (visual aid/role-playing) which make the technique more enjoyable and allow subjects to become better engaged (Rossiter, 1998).

Similar to Rossiter and colleagues’ study (1998) another study examined anger management and consisted of role-playing, problem solving and relaxation for learning disabled patients. The study consisted of 33 subjects (M= 28 years old) with intellectual disabilities and an average IQ level of 65.The results found that there was a reduction of 31% in post-treatment scores when compared to baseline measures ( Lindsay, Allan, Parry, Macleod, Smith et al., 2004).

Overall findings of anger management treatment highly recommend that it is an effective means of therapy for individuals suffering with learning disabilities and cognitive impairments (Lindsay et al., 2004; Willner et al., 2011; Rossiter et al., 1998).

Case Formulation

Fetal Alcohol Spectrum Disorder (FASD) occurs when mothers expose their fetuses’ to alcohol during pregnancy, potentially causing mental retardation for the child at birth. Jason displayed the physical characteristics of FASD including growth retardation, facial deformations, webbed hands, thin upper lips, small eyebrows and through verbal consultations from my colleagues a history of delayed development.

According to the DSM-IV-TR, an individual must present intellectual functioning with an IQ score of 70 or below (DSM-IV-TR, 2000). In addition, one must display impairments on at least two areas of daily functioning listed. Jason displayed significant deficits in all of the areas including, communication, regular self-care, daily living practices, social/interpersonal skills, and use of community resources, self-direction, functional academic skills, work, leisure, and health safety.

In order to formulate an appropriate treatment plan and diagnostic impression for Jason, I had to shadow my colleagues and spend enough time with Jason to build a strong sense of rapport and trust. I felt that by developing these two factors, future counselling sessions could be more effective. I looked over case notes of Jason’s and learned of his past positive and negative experiences. I read over Jason’s case notes and discussed issues with staff to have a better picture of the individual I was going to counsel. Therefore, after consulting with my supervisor we were able to develop a treatment plan for Jason.

Initially I spent a great amount of time playing leisure games with Jason, having general conversations, telling him stories of my life, as well as being an active listener when he wished to speak. In addition, I observed Jason in various settings. This included individual as well as group settings. I also observed Jason in public outings. I observed how he behaved with his housemates, supervisors and examined how receptive he was to my colleagues’ form of talk therapy. Consultation with my colleagues significantly helped me to assess and determine what interventions would be most effective. The staff told me about their experiences with Jason and how they managed his erratic behaviour. I learned a great deal from the staff at Haydon services as they described many incidences that occurred at their facility, and the methods they used to manage them. I was informed that Jason’s body language at times that would define his moods and his past familial experiences.

While conversing with Jason, he appeared to be extremely friendly during our interactions, however he would continue to display aggressive behaviour with his peers and some of my other colleagues. I believed he was acting this way towards me as he did not know me very well.

I was able to meet with my supervisor to gain a different perspective of Jason, as my supervisor and I looked over his case notes and history. It was interesting to see how his past actions coincide significantly with his diagnosis of FASD. His interpersonal skills and displays of aggression, violence, and impulsivity have been affecting him throughout his time in Nunavut as well as in Oshawa. These behaviours were also evident within his family relationship.

Prior to my counselling sessions with Jason, I disclosed some information regarding myself such as my likes and dislikes, and also inquired his interests. I did this in order to build trust and rapport. In order to incorporate a client- centered approach, I wanted Jason to have input in his sessions and inquired on what he enjoyed about counselling and what he disliked about past counselling sessions. I felt that understanding his views on his past counselling sessions might help me develop a training intervention suited to my client’s need and he would feel a sense of personal investment in this intervention. I asked Jason what aspects of life he would like to work on, and he stated that he would like to be more liked by his housemates. He also wanted to be calmer and not as anxious around the home. I felt that he needed greater confidence and self-esteem to help with his behaviours, as well as to find alternative strategies to manage his aggressive nature.

Case Analysis

Jason suffered with FASD , therefore a multitude of symptoms were displayed including aggressive behaviour, temperamental attitude, inappropriate sexual behaviour, and cognitive impairments which consequently affected his learning and memory capacity. Therefore, a counselling plan was developed in accordance to these factors to help support him and alleviate these symptoms. Research states visual aids are highly recommended with the FASD population and they are greater visual learners, as opposed to auditory learners. Furthermore, role-playing and modelling behaviour were regarded as highly effective teaching mechanisms for memory retention (Loomes et al., 2008).

The focus of the treatment plan was Jason’s lack of social skills, ISB as well as implementing techniques for anger management. Jason’s confidence was significantly low due to past familial issues, hence providing Jason with appropriate social skills may help him develop better interpersonal relationships and increase his self- esteem and confidence. According to my colleagues, Jason had many experiences of ISB. Due to the legal and ethical concerns that may occur with future acts of indecent behaviour, treatment of ISB was vital. Lastly, anger management was also important as case notes described uncontrollable anger, as well as his aggressive behaviours towards his housemates as well as staff at the facility. Treatment was based on his strengths using visual aids, and role-playing, while also trying to increase his confidence and self-esteem.

Treatment Plan

Through research as well as affirming comments from case notes and colleagues it is apparent Jason has several social skill deficits which may be a key factor for Jason’s display of aggressive behaviour. Therefore, I have decided to use role-playing techniques to demonstrate positive behaviours and appropriate social interactions for Jason, along with visual aids in order to help him learn appropriate social behaviours. Child friendship training is also another technique that will be used to help Jason get along with his housemates. Modelling-out appropriate behaviours may enable Jason to understand the information from a convenient perspective. Facial processing recognition exercises will also be applied to help Jason differentiate from different facial expressions and emotions. As mentioned in the case analysis, ISB is needed to be addressed due to the significant impact it was having on Jason’s well-being and also the well-being of others. There will be a large emphasis placed on the use of role-playing and visual aids to allow Jason to understand boundaries between people and appropriate behaviour. In addition, victim empathy can help Jason understand differing perspectives of the offender and the victim. Anger management is vital for Jason’s growth, as he needs to control his anger and aggressive nature. Anger management provides Jason time to understand triggers, emotions, to develop alternative strategies, and coping mechanisms. Both role-playing and visual aids allow Jason to understand the concepts for convenient learning as they are spread around the facility, acting as reminder cues. It would be beneficial to allow Jason to become part of the role-playing scenes and in developing visual aids to indirectly increase his self-esteem and to help Jason become better engaged with the sessions. Research has documented play therapy as also being an effective technique with the FASD population. Jason tended to have difficulty communicating his feelings to my colleagues and so play therapy can be an effective treatment tool.

My supervisor agreed with the aforementioned techniques to be implemented with the help of confirming research. I felt that to treat Jason efficiently, treatment techniques must address his strengths and weaknesses, hence visual aids and role-playing were heavily implemented. Addressing Jason’s lack of social skills, ISB, and anger concerns were extremely vital for positive daily functioning, as well as Jason’s growth and development and over all happiness and well-being.

Treatment Summaries

When I first started practicum I spent a number of sessions shadowing my colleagues and building trust and rapport with Jason at the facility. I needed to gain his trust and respect before I felt treatment would be effective. Jason and I began speaking on general issues, his hobbies, and things he enjoyed. Playing video games and leisure activities with Jason helped form a trusting bond between us. In addition, I was able to speak to colleagues for their input and techniques they used with Jason during both group and individual counselling. I observed the way they interacted with Jason and how they managed with Jason’s negative behaviours.

I also did my own research and examined case notes to understand more about FASD and its symptoms. Research helped me implement new treatment techniques, and gain an understanding on how to develop a treatment program for memory retention. On the other hand, case notes helped me develop these techniques to complement previous treatment, as well as understanding Jason’s behavioural tendencies. Prior to counselling sessions, I consulted my supervisor with my treatment plans and goals for his feedback.

Sessions 1& 2

During Jason’s first session we went over the Service Acknowledgement Form, Limits of Confidentiality, and the Benefits and Risks of Counseling. The focus of the first session was mainly to build trust and rapport. I needed to get to know Jason better and allow him the same chance. I wanted to know what he wanted out of our sessions and what his expectations were of me and vice-versa. It was important to me that Jason was involved in our counseling session so he could be engaged. In addition, we spoke about his experiences with previous counselors and what he liked and disliked in those sessions. Due to Jason’s FASD, he has cognitive impairments and I wanted to make sure he understood confidentiality, as well as the limitations of confidentiality. Within our first two sessions, rapport was built through playing leisure games together and I felt playing games may help him open up to me in future sessions. Through leisure activities and games I felt common interests and similarities may help Jason relate to me and trust me if our bond was stronger, thus allowing greater two-way communication between us. It appeared that Jason was suffering from a lack of confidence and needed to also increase his self-esteem. I allowed him to win many of the games we played in order to help him increase his confidence, and I frequently provided him with positive praise and reinforcement through comments or a tangible reward such as ice cream, or donut. I felt that by providing him with positive praise he might gain the confidence needed to open up further to me.

During our second session, Jason began to let me know about his family life in Nunavut, the nights he was homeless and about many physical fights with friends, family and even strangers. He described these occurrences with immense anger. Therefore, we changed the subject onto his life at the Haydon facility about both his positive and negative feelings. Jason described how he enjoyed being able to move about freely in Oshawa and was very proud of his knowledge of the Oshawa transit system. Furthermore, he began to let me know that he disliked having dinner with his housemates and felt he should eat alone. I also asked Jason to describe what he considered a positive environment within the house consisted of, as it was evident that Jason continued to have difficulties with his housemates and staff. He mentioned he often argued with his peers and had close situations involving physical fights. Jason also spoke about an intense argument he had with my colleague so both Jason and I began to examine his hassle log journal entry. Together we analyzed how he was feeling before the intense argument, during and after the argument. Furthermore, we developed alternative solutions to such intense arguments. It was important for me to let Jason provide many key points as it showed he was engaged, took the exercise seriously and seemed to be actively learning. We ended the session in a positive manner where Jason advised he enjoyed the games we were playing and I let him know I needed some advice on how he wins so much. Furthermore, I commended him on how he was able to open up to me today.

Session 3

During group therapy, clients received training on respect and boundaries, and also the general rules of the home. The roles of each staff member in the facility were also discussed and in this meeting, Jason revealed how he felt useless and unwanted in the home. I used this as a catalyst for our individual session and Jason revealed that his parents never loved him and did not care for him, as well as his years of abuse and neglect. Jason told me he was constantly rejected for everything he did as a child. It seems like this is where Jason’s need for approval and significant lack of confidence stems from. I wanted Jason to begin writing down his feelings and emotions on paper so he can see his thoughts on paper. This was a mini-introduction to the technique and I let him know we would be speaking on it in the future. Jason needs constant reassurance and self-esteem building, therefore we began play therapy which allowed him to have more control of the session. We played leisure games and Jason told me of a fight which had encompassed during the week with a fellow housemate due to miscommunication. We spoke on these circumstances and he told me the fight started because they were name-calling one another and joking around until it got serious. Jason revealed that some of the name-calling reminded him of previous foster care facilities and this really upset him. I asked him how he felt the workers at Haydon were treating him, and he confirmed to me that it was like what he thought a family environment should be like. He felt much better at this point that he was not constricted, as he was in the past. I let him know not everyone in the house is able to walk freely around Oshawa the way he is and I let him know he is given a lot of freedom because he is extremely independent. He enjoyed hearing these comments and it seemed to lift his spirits and have a positive effect on his confidence. I could see he left our session with greater confidence.

Session 4

Numerous times in the past Jason engaged in unacceptable sexual behaviours where he would stare at women’s body parts, as well as getting too close and ignoring personal space among his peers and workers. During the week, Jason had opened the door naked to the staff and at another point was purposefully behind a woman bent over while in his speedo. Although colleagues have stated he received treatment and his behaviour was far worse in the past, I felt he needed a reminder of his inappropriate sexual behaviours therefore, CBT was needed to help Jason. Together Jason and I looked through case-notes of his past inappropriate behaviours and we spoke about them. Jason revealed that he likes the attention he receives when females look at him completing certain acts. I let him know not all attention is good attention and I jotted down points on a chart to let him know the differences of good and bad attention to enable him to visualize the differences. Jason is a visual learner, hence I began asking him to role-play how close one should be when speaking to a peer. During role-play sessions, Jason would often invade personal space of his peers and I then modelled out adequate space between people. In addition, we began drawing charts of appropriate and inappropriate contact amongst peers. Jason began to understand why people were giving him dirty looks at times and he acknowledged that having the drawings helped him understand differences so he could see for himself.

Session 5

I continued further role-playing with Jason regarding appropriate contact amongst peers. Repetition is very important for the FASD population, therefore I felt it was vital to remind Jason of our previous session. In addition, together we began creating visual boards and potential criminal offences he could face due to his inappropriate sexual behaviour that may result in landing him in jail. I showed him videos of how jail was so he could imagine it for himself. I let him take control of the session and had him explain to me what he thought about jail after viewing the video, if he could manage being in jail, and how he would not have the freedom he has now while at Haydon. I commended him on his viewpoints and let him know he was correct. In addition, during our session we began addressing empathy, feelings and different perspectives regarding an event. I made sure Jason explained to me the concept of empathy and differing perspectives before we continued. We discussed an event he revealed to me where Jason stared at a stranger in an inappropriate manner for quite some time to the point where the individual gave him a dirty look, yelled and ran off while he was shopping at the mall. I asked for his opinion of the situation and hesitated he enjoyed having the girl give him this attention. I later asked him about the woman’s feelings and he was not too sure until I provided some cue points stating there were reasons she provided a dirty look, was screaming and ran off. I then had Jason watch a role-play of another client and I played the woman. Upon seeing the role-play, he was able to understand the other perspective and acknowledge empathy for the woman feeling disrespected, angry and saddened.

Session 6

Today’s session was based on our earlier exercise in the day. My colleagues and I went out with Jason to observe and document his manners and behaviours with strangers. It was apparent Jason did have urges to inappropriately watch and make comments towards females in the stores. Initially, Jason made “cat calls” at females, told his peer derogatory comments about a female customer, and occasionally stared deeply at women’s bodies. However, with the help of a few reminders and cues we were happy to see that Jason frequently controlled himself and began to think before he continued with his actions. It was apparent his lewd behaviour decreased however, upon returning home I was able to debrief him on his manners and behaviours. In addition, I felt today would be an exceptional time for him to focus on empathy and to understand the perspectives of the females he had met earlier in the day. It was crucial we began the session with him completely understanding the concept of empathy, hence I had him explain to me what empathy was with examples. We examined the victims’ point of view and how they felt, how it may have altered their mood, and if it was disrespectful. Jason was able to acknowledge the females may have felt embarrassed, disrespected and angered. Jason also displayed signs of resentfulness. Jason explained to me that he had urges to make such comments because he wanted the attention. I reminded him the different types of attention and we reviewed over the charts we previously made together. In addition, I felt it was also important to complete role-playing so Jason would be reminded of the events. I played the female role, while a colleague acted Jason’s role. Upon completing the role-playing scene, Jason explained how he should have acted towards them and was able to explain to me the body language of the females. I commended him on his ability to see the details of body language and be able to understand the facial expressions of the females.

Sessions 7 and 8

I recently completed some research on the FASD population and discovered that FASD tend to have difficulty processing peer emotions and facial expressions. This may be a significant factor for Jason’s aggressive nature, lack of social skills because he may have difficulty understanding a peer is in pain, discomfort or is sad, thus enabling Jason to continue acting in harmful behaviour towards them. Therefore, Jason and I began creating visual aids about cartoon pictures and matching them to moods and expressions. I felt this exercise would greatly benefit Jason to understanding the different types of expressions so when he sees these same expressions on his peers it may help him realize how they are feeling. Jason revealed to me while making the visual aids that he had difficulty trying to match the faces to the expressions, however I reassured him he would get support and we would complete the exercises together.

During our next session, I was able to introduce Jason to a social-skills technique known as Children’s friendship Training (CFT). I felt this might be vital to help improve relations between Jason and his housemates. Jason told me he was not getting along with the other housemates and constantly got into verbal arguments but left the room before things got too out of hand. I praised him for his self-control and that he left the room. He seemed proud of himself and I let him know he did a great job. Child friendship training was utilized to help teach Jason good communication skills therefore we began to practice introductory statements, general discussions, manners and being polite. Joining a group already at play was another exercise within CTF I had Jason practise. We continued with role-playing and I asked Jason to join my colleague playing a video game. Jason at first just jumped in and interrupted him to play, however CTF was based on guidance and caregiver involvement. Therefore, I provided him the necessary cues to join in on playing the video game. We utilized the politeness and manners he learned earlier and modelled out appropriate behaviour to be accepted with peers. In addition, we practised appropriate reactions to manage when peers do not allow him to join in, brainstormed reasons for being rejected from group-play as well as the importance of taking “no” for an answer. I let Jason know that everyone is different and we all have different personalities, likes and dislikes. Hence, when an individual does not want to play the same game/activity as he did, it is not the individual who was being rejected, but there was only a clash of personalities, which is completely normal. On the other hand, the same two individuals may enjoy a different activity and their personalities may then complement one another. To help Jason understand this concept I wrote down activities my colleague enjoyed and my hobbies. I showed Jason the numerous differences between us due to personality, however we were still able to be friends and were not rejecting one another. Jason understood this example, which enabled him to see differences within personalities. Jason was immensely engaged in this technique since he was part of the therapy. He expressed he enjoyed this aspect greatly. Jason was leaving for Calgary so I wished him well, thanked him for his time, and commended him on his bravery to be flying to Calgary for a week.

Sessions 9 & 10

Today was Jason’s first day back in session from his trip to Calgary. We began discussing events of his trip, which he enjoyed, and how he felt coming back to Haydon Services. We began to speak on Jason’s numerous calls from Calgary and it was then when he revealed that upon coming home he ran straight to his room and cried by himself in the dark. Normally, Jason would bully his housemates; however, it appeared Jason was better able to cope with his emotions upon coming back from his trip. I wanted to understand how he was feeling and although I knew it was difficult for him to express himself, after reading a few papers I noticed play therapy was an effective method to allow individuals to express their feelings. During play therapy, we began discussing his trip again and I allowed him to inform me of the Calgary Stampede and what it was and we played video games and with his action figures. Initially, I allowed him to win repeatedly on games but noticed he was jamming the controls. Occasionally, I would win to assess his ability to manage losing. However, he began playing more aggressively. I let him know it was making me upset to keep losing. Once Jason was able to recognize he was in control and I expressed my feelings, he too began opening up. Jason revealed to me that his foster parents in Calgary did not give him the freedom he wanted and he felt that he was rejected by them and had feelings of being an outcast.

It appeared needed some reminders of the previous day’s play therapy session, hence we continued with play therapy the following day to help Jason express his feelings. Jason again revealed how inferior he felt due to being confined to his home in Calgary. I began to introduce a game where we utilized a doll into our session as another avenue for play therapy to represent his foster mother. We began to develop visual boards of his opinions and points he was sharing and then role-played potential dangers which may have occurred if he was able to wander alone in Calgary without any supervision. I wanted the session to focus on the dangers because then he may be able to understand the reasons behind his foster mother’s rules to help diffuse the anger in him. We began to role-play harassments that may have occurred, I showed him a video of a public brawl, and we role-played robberies. Jason has difficulty understanding why the staff act in the manner they act, consequently resulting in shouting matches and increased aggression. Therefore, I felt enabling Jason to understand and see for himself that the potential dangers that existed would help defuse his anger. Near the end of our session, Jason appeared much calmer than he was before and I commended him on his ability to have self-control during play therapy. I also noticed that Jason seemed a lot more intrigued and interested during role-playing sessions, as opposed to speaking much of the time. I will try gearing more examples with Jason through role-playing. In addition, it seemed he was having a lot of fun in our session and his confidence seemed to grow through constant praise of his acting skills and his capability to better understand situations.

Session 11 and 12

The focus of session was on inappropriate sexual behaviour. A previous meeting with Dr. Pazaratz states rehearsal and repetition are key fundamentals when managing FASD patients, especially with Jason. Therefore, we began by looking at rules of the house, rules of the city and how rules are formed and why are they made. In addition, we examined what are consequences to not following rules. A research article I recently read examined that it is important for individuals to understand rules are put in place to keep people safe. Once the concept of rules is understood, personal space, boundaries, and personal areas would then be easily examined. Jason noticed the connection between rules of society and rules for people, hence he told me he liked how I started with speaking about rules of society first and then moved onto rules and boundaries of people. We created another visual board and I asked Jason to compare some of the rules the facility had in place which included no physical fights, no stealing and no a curfew. We spoke on the importance of the rules. Jason revealed that he felt safe at the home because nobody would hit him, or steal his valuable items as he was used to in Nunavut. We compared these rules to boundaries between people and personal space. We used dolls to portray disobeying boundaries, and again used role-playing to act out personal space between people. Boundaries included the acceptability of touching peers and stating comments. Jason initialized the conversation at this point and exclaimed to me boundaries were just like the rules put in place at the home where his peers would not hit him and vice-versa. He also responded by stating people are given boundaries so they would not invade peers’ personal space and touch one another inappropriately or else consequences would occur. Jason told me he enjoyed this exercise because he feels part of the treatment, compared to previous counsellors who only would speak without him being able to participate. I let Jason know I was impressed by his self-awareness and how quick he was able to grasp the similarities between rules of the home and boundaries and the division of personal space.

During the following session visual aids were created which were made to help Jason understand the meanings of private places (butt, breast, genital areas), as well as sexual emotions, and respect for one another. Jason felt the pictures were humorous. We spoke on sexual emotions people have for one another and grouped them in categories of which were appropriate or not. I wanted Jason to examine why certain people are able to hold one another in public or on television, while others should not be. For example, husband and wife would be an appropriate relationship to hold one another, whereas a salesperson and a customer should not behave in such a manner. Jason exclaimed that in the past he would hold onto salespersons which he felt were his friends and that there was nothing wrong with it. However, I let him know the relationship between a married couple and two acquaintances are very different. We began to write down notes on each type of relationship and Jason was better able to understand how the two were different. Jason explained that now he wished he did not hold onto that salesperson from the past, as their relationship was much different from a married couple. Although I understand his initial indecent acts from years ago were long behind him and he received both medical and counselling treatment, I feel that these rehearsal exercises were vital for his development. In addition, although Jason was learning many skills from our sessions I found that he did have difficulties utilizing what he learned from time to time in his daily life as staff had complained about behavioural problems. Therefore, rehearsal and repetition exercises for his inappropriate sexual behaviours are needed. I ended the session off on a good note letting Jason know he was very clever for examining different types of relationships. He was thrilled to hear my compliment.

Session 13

The session was based on Jason’s anger because during the week an incident happened where Jason had a huge argument with Tim and a colleague of mine. Jason yelled at them screaming profanities and insulting Tim. Todays’ session examined this situation so I decided it would be best to use play therapy. We were playing a video game where I teamed up with someone else and he was competing against us. I had a gut feeling jealousy may be a significant factor as I have noticed during my time at the facility that he would occasionally feel jealous when another housemate would play with me. Therefore, I felt that if he was competing against a colleague and myself, his emotions may be expressed easier. While playing I noticed that he became agitated that I had picked another partner instead of him and he displayed anger by pressing furiously on the controller and yelling at the television. While playing with anger he asked me why I was not on his team and I explained that changes do occur and even if someone does not want to play that doesn’t mean he/she is angry. I let him know people have different moods and like to try new things. Overtime, he disclosed to me about the huge argument during the week and he admitted he was jealous that my colleague had played with Tim instead of him. He was very jealous and felt neglected. At this point, it was important for Jason to understand people like to try new things. I showed him a picture of two sports teams and I drew arrows to show how teammates tend to leave their friends go to different teams due to a number of reasons. Jason revealed the picture and directions on the photo helped him understand the concept better. Jason explained that the jealous feeling he had made him angry and he felt he needed to scream aloud. I asked him whether he felt it would be good to apologize to both my colleague and Tim and at first, he was reluctant but later agreed. I praised him for this act. Through further discussion, he exclaimed that play therapy made him feel better because he did not openly have to state his feelings and emotions, and that playing the video games and talking in general helped open him up. I was very impressed by his self-awareness at this point and praised him repeatedly.

Session 14

The focus of the session was on anger management and to be related with his previous outburst. Anger management seemed to be a viable option to examine to grow from our previous play therapy sessions. We completed a mini-exercise and I wanted to remind Jason and exemplify how people have their own interests and hobbies by creating charts on each clients’ and staff member’s hobbies and dislikes. It was important for Jason to see that although there were not many similarities the group was still able to be friends. Jason told me he was extremely upset at Tim for being annoying and always wanting things his way. I decided it was time to look at the triggers, positive outcomes and consequences of his actions. Jason revealed the trigger of the outburst was when Tim complained about needing someone to help him play the video game and Tim always got things his way at the home. At this point Jason had enough of Tim’s whining and had to scream at them. I decided to make another visual board writing down pros and cons of the situation. Jason revealed the positive outcomes of the situation, where he was able to get his frustration out and express his emotions. I praised him on his self-awareness. We examined negative aspects of the situation and Jason stated his face turned red and he was breathing hard. We examined his environment and Jason revealed he was alone all day and nobody wanted to speak to him. As we began, writing down the comparison list Jason displayed better understanding and discovered his verbal aggression was not worth the negative consequences he was forced to endure those couple of days. I let Jason know I was proud that he thought of these insights on his own. Furthermore, we began to come up with solutions for alternative behaviours and how the situation could have been handled differently. I had Jason role-play situations using alternative solutions. The solutions we examined included, having Jason walk away and leave the room to cool off, or open up and try to express himself to Tim about how Jason was feeling. Subsequently, Jason stated this solution might have caused Tim to re-think the situation.

We looked at “I” statements and completed fill in the blank sentences on a visual board and I encouraged Jason to practice the sentences with me. Jason found this exercise fun and we took turns acting the scene out. I praised Jason on his acting skills and it appeared Jason left the session in high spirits.

Sessions 15-17

Today’s session began with an exercise enabling Jason to match different emotional states and facial expressions of happiness, sadness, illness etc. I felt it was time to remind Jason of different emotional expressions. In addition, we began to continue a previous session of anger management by reviewing “I” statements of how he felt. I had a colleague join us and we acted out a scene where my colleague and I were arguing over television time. I then displayed a stick figure with bubble thoughts that had “Feelings” and “Thoughts” written on them. I showed Jason an example of this exercise by writing down what my thoughts were and how I felt afterwards. I was able to give Jason examples of “I” statements this way and helped him utilize a method to begin to examine how he was feeling and thoughts about the situation. Jason explained that by seeing the drawings on paper he understood where he would be able to start to speak on his emotions and feelings to his peers. To complement the earlier exercise we then examined a social situation where Jason revealed he rejected a peer. Jason explained a housemate wanted to borrow his shirt and Jason furiously yelled “No” to him. Hence, it was important to improve Jason’s verbal assertion skills on how to effectively say “No” to a peer in an appropriate manner being polite, therefore I gave him examples. I responded by asking Jason if he felt yelling at his housemate for wanting to borrow his shirt was appropriate and if he felt it would improve their friendship. Jason responded and wanted to apologize to his housemate upon the end of the session. I applauded his character.

The following day we began to use the traffic light system for Jason’s anger issues. The Traffic light system combines the simple concepts of thinking about one’s emotions, recognizing feelings and taking an appropriate action plan through simple steps. The main benefit of this system was that the colour symbols helped simplify complex concepts into three steps (Rossiter et al., 1998). Together we were able to create a visual board about the steps of Red (Stop and think of problems/understand emotions) Orange (think what can happen and rules to follow) and Green (act on rules/choose the solution). I was able to find a video online where two friends were arguing and together we were able to identify when each signal step should be utilized. I felt it was a good time to provide guidance while Jason was completing the exercise so he could retain the information for future sessions. Subsequently, we began to role-play a scene where the signal steps were utilized and Jason wrote down what should occur during each signal. Jason needed guidance but exclaimed he enjoyed the signal exercise, as it was similar to a crossing light so he would easily remember. This was an exceptional system as it combined the simple concepts of thinking about one’s emotions, recognizing feelings and taking an appropriate action plan.

Session 18

I understood that in a small time-frame, Jason may not be able to change his behaviours but I felt that every session and exercise we did together helped make a difference in his life and daily functioning. Therefore, due to Jason’s cognitive impairments and memory difficulties I felt it was important to provide him with a review session. Jason revealed that it would be fun to review some of the past techniques as he enjoyed them and he admitted that he forgot some exercises. Therefore, we continued with role-playing and a colleague and myself acted out a scene where I was yelling offensive comments to a female actor and staring at her obsessively. My colleague performed the appropriate actions (anger, sadness, yelling). Jason found this scene humorous yet when we provided him the necessary cues he began to control himself. I asked him to describe to me how the female felt due to my actions and I asked him how was the personal space, and boundaries between us. Jason answered correctly when I asked him to correct personal space between the actors. In addition, Jason remembered what empathy was and he let me know the female may have felt disrespected, embarrassed, hurt and scared; feelings he would not want to feel himself. I commended Jason on his great work for the day and let him know I was enjoying his time and working with him.

Session 19

During our last session together Jason was quite emotional as he let me know he would miss our talks together. We reviewed over social skills and Jason revealed that that he had an issue earlier in the week with a peer when they were all playing a game. Jason felt hurt when he was rejected from his peers and he stated he tried to be as polite as possible to join in on playing the game. Jason admittedly said he did was unable to respond to their rejection in an appropriate manner. I asked him how was he able to cope with being rejected and he said it reminded him of his past to an extent. I let Jason know I was proud that he was able to respectfully attempt to join the group already at play from our previous techniques. However, I decided we should go over how to cope with a “no” response. We then practiced some responses he would say. I also wanted him to understand that there may be many reasons why they did not let him play. I asked him what game they were playing, were they almost finished, and asked how many players were there. Jason told me it was a game he enjoyed very much and there were about 6 people playing the game. He began to tell me the players did not include him they did not care about him. I responded letting him know his housemates have lived with him for years, they have shared numerous items and enjoyed wonderful moments together that helped make him feel better about the situation. I asked him if it were possible that they did not let him play due to the waiting time for everyone to join in. He understood what I said and it appeared he agreed that that could be the reason why. We both agreed that it gets frustrating when it takes a lot of time to wait for our turn, however he wanted to still play the game. I praised him on the way he tried to join the game. I wanted to also speak to him about his coping mechanisms and we both thought of other enjoyable activities he may do instead of having to wait to play that game with numerous players.

It appears Jason has made progress throughout our sessions the last few weeks. I am concerned about his memory retention as it was apparent he forgot aspects of the techniques from time to time, yet he enjoyed the exercises and seemed engaged. Jason’s self-awareness and self-control have improved to an extent and staff have stated he has been showing more control over his aggressive nature. Staff have stated he has been able to bring forth what he has learned through the exercises into other environments. We discussed some of his past goals and I praised him on how far he has come from the first day to present. We discussed his future endeavours.

Results

During our last treatment session, Jason and I were able to review his overall progress in therapy. Through collaboration with my supervisor, we recommended that Jason continue to practise the visual boards and utilize them as cues when in need for reminders. Jason has come a long way in comparison to our initial sessions. Jason began therapy with an aggressive nature and was unable to control his anger. However, as we began to utilize role-playing and complement it with visual aids, Jason has shown some growth by leaving the room when he was close to having an outburst with a housemate. Although Jason continued to have his temper tantrums at times, he was able to control himself occasionally as opposed to a few months ago. According to reports from staff/caregiver data sheets the intensity of Jason’s temper tantrums was near 8.5 out of 10 prior to our treatment sessions, while upon completion of our sessions staff scored his anger at 6.5 out of 10. Jason also showed empathy towards those who he offended and it was apparent when he was able to express his emotions when he committed an indecent act. Since the agency did not use assessments, I was unable to statistically identify the decrease in his behaviour, however staff and caregivers stated they noticed an increase in Jason attempting to identify peers’ perspectives. In addition, Jason’s social skills have improved to an extent and he has gained a greater ability to identify different facial expressions. Jason was able to correctly match nearly 90% of the facial expressions, compared to 75% prior to our exercises together.

On numerous occasions, Jason stated he enjoyed being part of the treatment and felt he was more engaged as opposed to listening to a counsellor speak. Through collaboration with my supervisor it is highly recommended that future sessions with Jason include role-playing, two-way discussion, as well as visual aids. Although Jason’s display of inappropriate sexual behaviour may have decreased with previous counselling sessions, Jason needs to continue with help regarding his behaviour. Jason exclaimed his overall experience with our sessions was beneficial and he enjoyed it greatly. Jason reported that he felt his anger had decreased, and he gained a better relationship with his housemates

Discussion

Jason has lived a rigid life due to years of neglect and hardships during his youth, while also suffering from the symptoms of FASD. Although Jason has been able to move forward from his past, he has been forced to manage with his anger issues, ISB and lack of social skills as he grew older. It was apparent these three issues were affecting his daily functioning as they continued to get him into further troubles.

Through my experience with Jason those with cognitive impairments suffer great difficulty when trying to understand or learn new concepts therefore it is the duty of any therapist or counsellor to utilize key techniques aimed at improving the understanding for their clients. Our sessions together proved he wanted to improve his daily functioning and his overall well-being and life experiences. Therefore, Jason was in dire need of techniques that complemented his learning styles and capabilities. I was glad to see role-playing and visual aids worked well with Jason and it appeared he was greatly engaged in all of our sessions.

Furthermore, although Jason was practising the techniques he learned in our sessions, constant repetition out of our counselling environment must be mandatory. The needed reinforcements and consistency in practices learned in the counselling sessions may not have been applied fully with weekday staff, and therefore Jason may have had difficulty learning the new behaviours due to the inconsistencies in the teaching methods used by staff. I was at Haydon Services for weekends only, while during the week other staff and caregivers were looking after Jason. Therefore, expectations of Jason’s support network may not have complemented one another, possibly being detrimental to Jason’s therapeutic success.

Jason was suffering from a multitude of behaviours that needed to be addressed, hence it was a long process to help Jason due to his disabilities. I was impressed by how quickly Jason was able to understand the concepts we spoke of. Although our sessions lead to improvements in Jason’s life, according to staff; it was evident there needs to be further sessions to help Jason with his problems. According to staff employees at Haydon Services, near the end of our sessions Jason appeared to continue to display signs of ISB and anger issues, however not as much as he previously did. Jason’s social skills had improved according to both his housemates as well as staff. Jason seemed to be treating housemates with more respect, however he would occasionally have an outburst.

My experience with Jason was extremely beneficial, as I have gained a far greater understanding of the counselling field as well as the many difficulties that can result from alcohol use during pregnancy. Speaking to Jason about his Native culture was also very important to him, and also increased my understanding of cultural diversity and the need for more understanding and acceptance of cultural differences as a whole. I felt it helped build rapport, and I wish to further utilize rapport and trust as the forefront factors to my future counselling endeavours. I have grown to understand that I must deflect any personal emotions I feel when speaking to a client, while continuing to act in a professional manner. Jason has displayed that his engagement and being able to participate in his own therapy helped his therapeutic sessions. The skills, knowledge and experience I have gained while working with Jason was excellent, and strongly feel Jason and I both have significantly benefitted from our experience together.

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^[1] Names and identifying information have been altered to protect the client.