In this case study some details of the client’s profile have been changed to ensure his
anonymity. Further, the report has been written as if the trigger event has
only just occurred, whereas in reality the client had already moved
beyond this point at the time of writing. This was done in order to address
the assessment guidelines more accurately—in particular, to avoid pre
empting the actionplanning process. A brief sketch of the client’s current
situation is provided as a postscript to the case study.
Age: 28
Gender: male
Nationality: Thai, with Australian residency
History: moved from Thailand to Australia in 1990
moved to San Francisco in 1996 to live with his new partner, George
was required to leave the United States every three months to renew
his short stay visaexemption (he was not eligible for a working visa
or green card, and the US has no partnerreunion program for gay
couples)
returned to ‘live’ in Brisbane in June 1998 following advice from US
immigration officials that he had exhausted his access to visa
exemptions, and that he would not be permitted to return to the US
unless his entry status were to change
Since his return to Australia Kohut has been working on a business proposal which he
hopes will allow him to return to the US with a working visa. While
waiting for the outcome of his visa application he has been seeking work,
and has found this extremely difficult. He has an undergraduate degree in
geology, but this is not sufficient for him to work as a geologist or an
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academic. He has an incomplete diploma in hospitality management, but
cannot find work at a level appropriate to his skills and experience in this
area. He has finally accepted work as a waiter, where he is being paid a
very low wage and is working extremely long hours. He has been lucky
enough to find several shortterm opportunities to housesit, which have
helped him keep his expenses down. However, each time he has to move
he is reminded of how transitory his current life circumstances are: “My
whole life fits into a few boxes”; “I’m a man of 28 and I’ve got nothing”.
The trigger event for Kohut’s crisis is the news that the application for a working visa
has fallen through, leaving him with no obvious prospect for being
reunited with his partner.
Presenting Symptoms
The client had been experiencing some of these symptoms and reactions before the
final trigger event occurred, but in a much milder and less persistent
form:
sleep disturbances (earlymorning waking; difficulty in getting to sleep)
obsessive thoughts and difficulty concentrating
frequent bouts of tears and feelings of great sadness
low motivation
problems at work (lateness, dropping trays, incorrect food orders, etc.)
withdrawal from social contact
loss of appetite; poor eating habits; weight loss; loss of enjoyment in food
feelings of worthlessness (“I deserved this”; “I’m totally hopeless at everything I
do”; “It’s all my fault”)
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catastrophising thoughts and comments (“My life’s a total disaster”; “This is never
going to end”)
frequent nosebleeds
skin eruptions.
to the US. While this remained a possibility his comments about its
chances of succeeding were relatively realistic—it was quite a long shot.
However, he must have been investing it with much more significance
than he was prepared to admit, because when he learned that the
application had failed, his already low level of coping diminished
suddenly. For Kohut, the event therefore meant that he was never going to
get the chance to be reunited with George, and he clearly saw this as a
personal failure: his business proposal “wasn’t good enough” to earn him
a working visa. This perception was being reinforced by the poorly paid
and unsatisfying work he had been forced to accept, and the difficulties
he was having in performing even in such a lowly job. As a result of this
way of conceiving of his situation, he was seeing his future as bleak,
lonely and painful, with no obvious opportunities for him to advance
himself professionally and personally.
The client’s perceptions of his situation and his future are perhaps realistic up to a
point. First, if he is unable to find an alternative way of being reunited
with his partner that is acceptable to them both, he will have to work his
way through considerable grief over his loss, and eventually come to
terms with life without his partner. (George is not in a position to move to
live in Australia.) Second, his assessment of his work prospects is quite
realistic in the short term, because unless he can find a way of completing
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his hospitality diploma or upgrading his qualifications in geology, he will
probably find it difficult to move beyond the sort of work he is currently
doing. However, his perceptions are unrealistic in the sense that he is
ignoring or downplaying a wide range of valuable skills, knowledge,
experience and other resources he can draw on to help him through his
crisis, and which might eventually help him to create a new life for
himself.
Social Supports
Among the resources available to Kohut are two very close and supportive friends in
Brisbane, Jon and Mark, who have almost become parentfigures for him.
They have offered him a great deal of emotional and practical support,
but he is cautious about relying on them too greatly because he does not
want to exploit their generosity. He partly acknowledges the ways in
which he enriches their life, but does not place as much significance on
this as on his own needs and frailties.
The client also has several family members living in Australia, including his mother
and a sister in Brisbane. He does not have any other Thai friends, and so
relies on his mother and sister almost exclusively for contact with his
cultural and linguistic roots. However, his mother does not know that he
is gay, and this creates a distance between them. Kohut does not feel free
to talk openly with her about the emotional turmoil he is going through
because it is so closely connected to his relationship with George.
However, she remains a potential source of practical support and cultural
“nourishment” for him. On the other hand, he feels he can talk quite
openly with his sister, and she is a potential source of considerable
emotional and practical support. He has access to electronic mail through
Jon and Mark, and is therefore able to communicate daily with George in
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San Francisco, although George is not very understanding about the way
Kohut is dealing with his situation: he feels Kohut is overreacting, and
does not always give Kohut the sort of emotional backup he would like.
He is nevertheless willing to give Kohut as much financial support as he
needs, but Kohut is strongly resisting this.
Coping Mechanisms
Kohut has not experienced anything quite like this situation before, and this is partly
what makes his reaction so extreme. This is his first significant emotional
relationship, and there are some aspects of it that concern him.
Nevertheless, he feels committed to George, and does not want to give up
the relationship without giving it a real chance at succeeding, if they can
find a way of being together.
In spite of his inexperience with such a situation, Kohut does have some experience
that can be marshalled to help him, although he finds it hard to
acknowledge this:
his father died when he was fourteen years old, and he was eventually able to
accommodate this loss and move on with his life
he has had to learn to live in a foreign culture, speaking English as a second
language, and has been doing so very successfully for eight years
his departure for Australia caused him considerable anguish because of the friends,
relatives and familiar cultural environment he was leaving behind in Thailand, but
he has eventually come to adjust to and accept this dramatic change in his life
circumstances.
These experiences all have elements that relate to his current circumstances, although
things are exacerbated by the very close and emotionally dependent
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relationship he has developed with George, and the concerns he has about
the longterm prospects of the relationship.
The client also has a great love of music and the arts, and in the past has used these to
help him deal with tension, anxiety and loneliness. However, he has been
so distressed lately that he has become much less motivated to pursue
these interests, and when he does, he often finds it hard to immerse
himself in them because of his obsessive thinking and inability to
concentrate. Nevertheless, these activities give him occasional moments
of relief and pleasure, and could become part of an action plan to help
him work through his current crisis.
One coping mechanism that has not been particularly successful has been the client’s
tendency to withdraw from social contact in response to his situation.
This has not only cut off a source of potential emotional support and
stimulation, but has also helped to make his eating patterns more erratic,
thereby contributing to his weight loss and other health problems. One
aim of intervention might therefore be to mobilise significant others in his
life to play a more active role in coaxing him into a higher level of social
activity.
Conceptualisation of Client
The client’s symptoms meet many of the diagnostic criteria for a major depressive
episode according to DSMIV (Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition—American Psychiatric Association,
1994, p.327). However, the fact that he has periods when his depressed
mood lifts (Criterion A(1) in DSMIV), and that there is a sense in which
he has been undergoing an anticipatory grieving process (Criterion E),
suggest that a formal clinical diagnosis may not be appropriate. A more
rigorous investigation would be needed to clarify this.
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The client’s symptoms also suggest that his selfesteem is low, and there is some
evidence that this may have been the case before he encountered this
crisis—for example, his feelings of worthlessness and catastrophising
thoughts reported above, and the fact that his relationship with George is
marked by a high level of emotional dependence. There are also some
issues from his childhood that could account for low selfesteem, and
these might be the focus of longerterm counselling or therapy.
Nevertheless, his perseverance in finding himself a job against great odds,
his determination to remain financially independent in spite of his
circumstances, and his high level of crosscultural competence are
strengths that could readily be mobilised and built upon in enhancing his
selfesteem.
In summary, I see the most significant cluster of problems as being the client’s sense
that the failure of his visa application is “the end of the line”, his
judgement that what he is going through now is never going to end, and
the sense of worthlessness he has about his life as a result. While he
currently does not have any serious suicidal thoughts or tendencies, this
becomes a risk the longer he remains in such a state of mind. This
suggests that the initial focus of intervention should perhaps be on
grounding him in the reality of the practical support and care that others
are offering him, and seeking to motivate him to take fuller advantage of
this support. However, this would need to be done in the context of
helping him to identify ways in which his overriding need to feel
materially independent can be respected, while nevertheless accepting
support from others. In the longer term, a focus of counselling or therapy
might be to help him work towards a better balance between his currently
exaggerated sense of emotional dependence and his strong need to be
material independent.
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Referral Implications
Because the client might meet the criteria for clinical diagnosis of depression, a referral
to a suitably qualified psychologist may be in order if his symptoms do
not start to improve once the immediate impact of the crisis has passed. If
he were my client I would not want to refer him prematurely because he
has no history of depression prior to the onset of the series of events
leading to the crisis, and there is no immediate risk that he will harm
himself or anyone else. A clinical diagnosis at this stage could cause more
harm than good. Nevertheless, this is something that I would monitor
during the first few weeks of working with him.
Because the client has been living in a state of some distress for several months before
the trigger event, his physical health has deteriorated somewhat. I would
see it as important for him to visit a doctor for a general checkup,
especially since he has not been eating or sleeping well. I would therefore
refer him to a bulkbilling doctor who lives in his vicinity, and urge him
to make an appointment as soon as possible. His long hours of work and
sleeping problems make it possible that he would forget to do this. I
would therefore offer to phone and make the appointment for him, and to
call and remind him when the appointment is due, if I judged this to be
appropriate. The doctor might prescribe tranquillisers or sleeping pills for
him, so I would try to refer him to a doctor who was unlikely to do this
unnecessarily or prematurely.
Once the immediate crisis was under control, there is a range of useful services and
organisations I would refer the client to:
the AntiDiscrimination Commission Queensland (there is evidence that some of
the client’s difficulties in obtaining reasonable work have a basis in racial
prejudice)
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the Department of Training and Industrial Relations (to inquire about the
appropriate award rates and working conditions for his industry, and to establish
exactly what status his incomplete diploma has)
a social support group for gay Asians (the client has no gay Asian friends, and only
limited contact with other people from his own culture)
the Gay and Lesbian Welfare Association’s Gayline (for more general information
about social, cultural and other activities with likeminded individuals)
the Gay and Lesbian Immigration Task Force (GLITF) (this group’s main focus is
on those whose partners are seeking entry into Australia, but it also provides
support and information for those who, like Kohut, are wanting to emigrate in order
to be reunited with a partner).
The client’s English language skills are very strong. Nevertheless, it is possible that he
would prefer to work with a counsellor who speaks Thai, if one were
available in Brisbane. I would offer to research this option for him if he
felt it would make communication easier, although my intuition is that he
might be uncomfortable talking openly about his sexuality to an
“authority figure” such as a counsellor from his own culture, for the same
reasons he has not discussed this with his mother.
perceptions of his situation by seeking to ground him in some of the
positive aspects of his current circumstances and resources:
he is not in any physical danger
he has a small but strong network of supportive friends and relatives
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there may be other options for reunion open to him that he has not yet considered,
which might come to light in our later sessions together, or from talking to GLITF
and other agencies
he has managed to cope extremely well with several major life events in the past
he has some very valuable and enjoyable coping strategies (i.e., his love of music
and the arts) that we can work on reactivating as soon as he has regained his
immediate footing.
Two aspects of the client’s situation which would need prompt attention are his
disrupted sleeping and eating patterns, which are most likely to be
aggravating his mental and physical state considerably. The following
interventions could therefore form part of the shortterm action plan:
lending the client a relaxation tape to get him through the next few days, if it is
inappropriate to introduce him to relaxation techniques while he is in the acute
phase of crisis
teaching the client a variety of relaxation techniques (e.g., progressive muscle
relaxation, visualisation and rhythmic deep breathing), to help disengage his mind
from obsessive thinking and pave the way towards more effective sleep
encouraging him to stay for a couple of days with his friends Jon and Mark, who
live very close by, while he gets his sleeping and eating patterns back to normal. (If
I judged such a suggestion to be crucial in helping him regain his equilibrium, I
might frame this suggestion in terms of “counsellor’s orders”, because of his likely
resistance to this apparent infringement of his independence. I would offer to phone
his friends and check this option with them if he did not feel he could make such an
approach himself.)
suggesting to him that he make time to meet with his sister to discuss his situation
with her. (She is the only person he can talk to in his first language about what is
happening to him, and the strain he is currently under makes it much harder for him
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to have highly emotionally charged conversations in English.) I would also invite
him to ask his sister to come to the next couple of sessions with him if he wanted,
to make communication easier and offer him some cultural grounding while he
comes to terms with his situation.
It might be difficult in the early stages to fully reactivate the client’s use of music and
the arts as a coping mechanism. However, if the opportunity arose, this is
something I would explore within the first few sessions, because of its
potentially healing effect. The following are some options:
setting the client the “task” of listening to some of his favourite music while
practising one of the relaxation techniques he has learned
helping the client to plan an excursion to the art gallery—perhaps using a
visualisation exercise involving some of his favourite paintings, to motivate him to
follow through with this plan
encouraging the client to start a “drawing journal” in which he makes sketches that
encapsulate some aspect of his daily experience, and to bring the journal in to our
sessions together.
Three focus areas for possible counselling or therapy have already been mentioned—
working on building the client’s selfesteem, balancing his high level of
emotional dependence with his high need for material independence, and
exploring some of his childhood experiences. It would be inappropriate to
open up these areas before the client’s more immediate needs had been
addressed, and so I would view these as part of a longerterm approach to
working with him.
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Postscript
Kohut was not my client, and he sought no other professional help with his situation.
Nevertheless, I have been in regular contact with him since he returned to
Australia, and have watched as he has worked through his crisis with the
help of his two close friends, as well as drawing on his own internal
resources. His sleeping and eating patterns have improved considerably,
and many of his other presenting symptoms have been reduced
significantly, although he is not quite back to an optimal level of
functioning.
Perhaps most importantly, Kohut has discovered another option that would allow him
to return to the US—that is, to seek entry into a graduate program at a US
university. This would entitle him to a student visa for the duration of his
studies, and the qualification he obtains could well form the basis for a
successful green card application. There are some disadvantages to the
proposal—most notably, the fact that he would need to become fully
dependent financially on George while studying. This is a cause of
considerable concern for him, given his strong sense of material
independence and his reservations about the future of the relationship.
Nevertheless, he has reached the stage where he realises that he has to
“test the water” more fully before being able to assess his longterm
prospects with George, and has therefore started taking very concrete
steps towards making this new option a reality.
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References
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental
disorders (4th ed.). Washington, DC: Author.
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