A Minor (?) Client

Tommy, age 17, is brought by his parents to see Ben, a counselor in private practice. During the intake session with the parents and Tommy, the parents tell Ben that they are concerned about Tommy’s performance in high school as well as his overall social adjustment. Tommy had been an athlete throughout middle and high school, but about 6 months ago he was dismissed from the baseball team by the coach and school administrators. The situation that led to the dismissal involved an incident during a practice in which Tommy had an argument with a teammate. After practice, he got into a fight with the same teammate and another player in the locker room. Tommy was viewed by the coaching staff as the instigator of the argument, and observers supported this view. Tommy believed the coach did not like him and was singling him out, as other players had argued and scuffled without serious consequences. Within a few days of the fight, Tommy got into a verbal altercation with a teacher over a grade. These combined events led to him being dismissed from the team and suspended from school for a week.

Tommy’s school performance has declined from grades of A and B to failing or barely passing most classes. He also has changed his group of friends, spending his time with individuals his parents view as troublemakers and drug users. In fact, his parents have caught Tommy drinking and smoking marijuana several times, and they suspect additional drug use. He has become increasingly defiant with his parents by withdrawing from his family, staying out far beyond his curfew, and hanging out in dangerous areas of town.

Ben meets with Tommy individually after completing the intake with the parents present. Tommy denies that he is using any drugs except marijuana and states that he believes his parents are overreacting. He describes his drug use as “normal high school stuff.” He says that he plans to return to school, pull up his grades, and graduate on time and that he hopes to play baseball at a college or university. When Ben asks Tommy if he wants to continue in counseling, Tommy says that he does. When Ben gently questions whether Tommy’s response is motivated more by a desire to avoid further dissention with his parents than by a sincere desire to receive counseling, Tommy denies this.

During the next six weekly sessions, Tommy remains marginally engaged in the counseling process: He answers questions and carries on a conversation but will not actively explore his internal struggles, feelings, or actions that led to his current situation. Ben structures some sessions as family sessions and sometimes sees Tommy individually. In both situations, Tommy maintains the same stance: “I’m fine, my parents are simply overreacting.” By contrast, Tommy’s parents believe his substance abuse is more serious than he admits. They have removed all alcohol from the house to prevent him from drinking it and report that they discovered he has used Xanax recreationally. Also, they state that Tommy was once involved in a situation in which someone pulled a gun on him and friends when (the parents assumed) they were at a house to purchase drugs. Taking into account the parents’ report, Ben diagnoses Tommy with a substance use disorder and submits paperwork for reimbursement to the family insurance company. Ben also includes a diagnosis of an adjustment disorder with conduct disturbance.

When the family receives notification from their insurance company about the claim, they are upset to learn that a diagnosis of a substance use disorder was given. They are concerned that such a label will follow Tommy and negatively affect his future. Tommy, also, is very concerned, fearing that such a diagnosis might prevent him from being able to play baseball at a college or university. Tommy is particularly upset because he disagrees with the diagnosis, maintaining that his substance use is “normal” and that he isn’t “stupid enough to get into trouble with drugs.”

A complicating factor in the case is that Tommy turned 18 during the 6 weeks he was in counseling, making him legally responsible for remaining in counseling and confounding the question of who gives consent for treatment. Initially, Tommy’s parents had reviewed and signed the consent for treatment documents, and Tommy had given his assent. The parents had paid for counseling services. Ben was unaware of the birthday, although the information was in the client file.