ADJUSTING IS NOT EASY 2
Victor – Adjusting is not easy
Client Concerns
Symptoms Behaviors Stressors
Sadness Verbally aggressive at school Parents’ Divorce
Anger Fighting Father remarriage
Hopeless Argumentative w/Mom &
Sister
Household dynamic
Lower grades Withdrawal from peers
Tearful
Assessment
Assessments for adjustment disorder are new to the field. The adjustment disorder
diagnosis was at the clinician's discretion for some time, and then the New Module 20 self-report
measure was introduced. This questionnaire was developed to assess the level of risk for
adjustment disorder from a stress response perspective (Cornelius et al., 2016). Nevertheless, this
measure needs to align fully with DSM criteria and needs further research. Therefore, the
diagnostic interview adjustment disorder (DIAD) will be used to assess the level of impairment
through specified stressors that fall into the DSM criteria (Cornelius et al., 2014).
Diagnostic Impressions
Victor developed emotional and behavioral symptoms after his father remarried four
months ago. This transition significantly impaired Victor biologically and psychologically, and
his symptoms relate to adjustment disorder, persistent with mixed disturbance of emotions and
conduct F43.25.
Signs and Symptoms
DSM-5-TR: Adjustment disorder, persistent
with mixed disturbance of emotions and
conduct F43.25
Client’s signs/reported symptoms:
Criterion A The client reports crying at night, and the
mother confirms arguing with the mother and
siblings.
ADJUSTING IS NOT EASY 3
Criterion B
1. Distress – Out of proportion
2. Social/Occupational Impairment
B1. The client’s teachers report he fights in
school, and his grades are lower.
B2. The client reports no interest in goal-
directed activities (i.e., driver's training).
Criterion C The client has no mental health history
Criterion D The client has not experienced loss due to
death
Criterion E The client's father remarried four months ago,
and the client lost hope of reconciliation
between their parents.
Other DSM-5-TR Conditions Considered
Major depressive disorder was a condition considered for diagnosis. The feelings of
sadness and outbursts of anger, along with disinterest in activities and crying at night, raised the
question of depression. However, the client did not have five identifiable symptoms, and the
symptoms are a normal response to parental divorce (APA, 2022). Additionally, this clinician
considered separation anxiety disorder as the separation between the client's parents that
happened two years ago. However, there was no excessive fear concerning the separation from
his father, and the client did not want to interact with his father after he remarried. Lastly, the
client's symptoms were reflective of someone going through the process of grief or bereavement-
related stress related to the dissolution of his parents' marriage. However, no physical death is
associated (APA, 2022).
Developmental Theories and Systemic Factors
Systemically, the client is being subjected to factors beyond his control, impairing many
aspects of his life. From a family systems perspective, the ebbs and flows of the family system
impact an individual’s anxiety, emotions, and expectations (Watson, 2012). Within the client's
family structure, an immediate breakdown has taken place with his mother and father separating,
divorcing, and remarrying for his father. These dramatic changes are influencing the client's
ADJUSTING IS NOT EASY 4
response to his environment. For example, under ecological theory, the environment impacts the
child's development. The family structural changes are new to the client's maturation, and the
client is still learning to process the changes as he ages (Saracho, 2023). As one can see, when
the family system has dysfunction, it seeps into other relationships, schools, and communities.
Multicultural or Social Justice Considerations
Ethnically, families of Hispanic origin are solidified and stay committed through
adversity. Maintaining the family dynamic and structure is highly important in Puerto Rican
heritage. This ethnic and family background could be why the client hoped for reconciliation
with his parents. McGoldrick et al. (2005) noted family unity, welfare, and honor are essential to
Latino culture. The family is committed to protection and responsibility for the system, not
individual agendas. Culturally, Puerto Ricans are having difficulties adjusting to the culture in
America, so any disruption to the family nucleus can cause further complications, pressure, and
feelings of isolation. Therapeutically, listening, validating, and learning the culture will aid in the
helping relationship (McGoldrick et al., 2005).
Treatment Recommendations
Key Issues for Treatment
Understand the level of and address anger.
Sadness related to parental divorce.
Express true feelings and emotions regarding family.
Recommendations for Individual Counseling
The immediate recommendation for this client is to engage in family therapy using the
structural/strategic approaches. The client's family needs some empowerment and strengthening
within the family system. This change can only happen if the system is on board with changing
attitudes and behaviors and trying different approaches (Jimenez et al., 2019). Victor, his mother,
ADJUSTING IS NOT EASY 5
and his siblings have gone through dramatic changes over the last few years. They have the
support of family members and the church community; however, Victor's relationship with his
mother and father needs significant attention, and evidence suggests when both parents are
willing to engage in therapy, adolescent behavior symptoms improve (Jimenez et al., 2019).
The client is deeply conflicted, as evidenced by his outbursts of anger, withdrawal from
friends, and crying at night. The client may not know what to do with his feelings as, in the
Puerto Rican culture, machismo is held in high regard to not feel inferior. The client may feel as
if he must angrily express his maleness. On the other hand, Victor could be questioning if his
father should have treated his mother in such a way and be dealing with a cultural transition as
defined by Italian philosopher Antonia Gramsci (Falicov, 2010). Cognitive behavioral therapy is
excellent for working through this transition and harmful thinking patterns.
Several therapeutic techniques can be implemented with this client and his family. As a
clinician, I establish the relationship and make the family feel trust and a safe environment by
joining. Furthermore, with extremely high emotions, the reframing technique would help the
family define the symptoms in a different light. Moreover, Victor, a jumble of emotions, may
benefit from journaling to express himself to his mother and father (Watson, 2012). Medication
would not be considered as this case is more of a systemic issue related to the family.
Specific Considerations
The client is 15 years of age and the only male in the household since his father separated
from his mother and left him and his three sisters. This creates a challenging stage for the client
both physically and psychologically. As an older teenager approaches adulthood, the symptoms
and behaviors concerning the client's maturation must be intensely evaluated and addressed
within the family dynamic (Jimenez et al., 2019). These factors could determine whether it is
ADJUSTING IS NOT EASY 6
depression over adjustment disorder or vice versa. Also, the structural family therapeutic
approach will aid in the household's imbalance and change of structure and demand. With the
client's age and parental disruption, his symptoms communicate an issue in the system that needs
to be addressed systematically (Jimenez, et al., 2019).
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References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental
disorders. (5th ed., text rev.). American Psychiatric Press, Inc.
Cornelius, L. R., Brouwer, S., de Boer, M. R., Groothoff, J. W., & van der Klink, J. J. (2014).
Development and validation of the diagnostic interview adjustment disorder
(DIAD).IInternational journal of methods in psychiatric research,I23(2), 192–207.
https://doi.org/10.1002/mpr.1418
Falicov, C. J. (2010). Changing constructions of machismo for Latino men in therapy: "The devil
never sleeps." Family Process, 49(3), 309-29. https://doi.org/10.1111/j.1545-
5300.2010.01325.x
Jiménez, L., Hidalgo, V., Baena, S., León, A., & Lorence, B. (2019). Effectiveness of structural,
strategic family therapy in the treatment of adolescents with mental health problems and
their families. International Journal of Environmental Research and Public
Health, 16(7), 1255.Ihttps://doi.org/10.3390/ijerph16071255
McGoldrick, M., Giordano, J., & Garcia-Preto, N. (Eds.). (2005). Ethnicity & family therapy
(Third edition.). The Guilford Press.
O'Donnell, M. L., Metcalf, O., Watson, L., Phelps, A., & Varker, T. (2018). A systematic review
of psychological and pharmacological treatments for adjustment disorder in
adults. Journal of Traumatic Stress, 31(3), 321–331. https://doi.org/10.1002/jts.22295
Watson, W.H. (2012). Family systems. In Ramachandran, V. S. (Eds.), Encyclopedia of human
behavior (2nd ed., pp. 184–193) /. Elsevier.
https://ebookcentral.proquest.com/lib/liberty/detail.action?docID=863370.
