Running head: CASE STUDY
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Case Study
Anne Lebednik
Southwestern College
CASE STUDY
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Case Study: Anthony
Anthony1 is a 9-year-old boy in 4th grade, white, and the youngest of three children.
There is a 5-7-year age gap between him and his older brothers, 14 and 16-years-old,
respectively. His 14-year-old brother has epilepsy, though is now on medication to prevent
seizures. Anthony’s birth was normal and a planned pregnancy. He lives with his mother, father,
and brothers in Ft. Worth, TX and attends a local arts school. His mom describes him as her
“buddy.” She also reports that the family’s Christian faith is “very important” in Anthony’s life.
She’s concerned because Anthony’s anxiety has risen drastically in the last year. Additionally, his
school performance has declined and extracurricular effort has dropped. Anthony’s presenting
anxiety often centers on a fear that something will happen to his mom. Consequently, he feels
separation anxiety when she leaves his sight. He also gets anxious when thoughts of his mom
dying pop into his head at school, making it difficult to concentrate. Anthony fears his mom will
be “shot” or “choked.” His mom reports that the family has experienced 4 deaths in the last year:
two uncles and two grandparents. She also reports that 4 years ago, Anthony and his brother were
in the car when his brother began having epileptic seizures. She was driving and crashed the car
while trying to help Anthony brother. She sent Anthony, then 5 years old, to get help. In addition
to the recent deaths and car accident, Anthony’s mom reports having choked on a burrito a few
years ago. She reports that Anthony had severe anxiety when he entered 2nd grade but had a
teacher who noticed and was able to help him. He also experiences bed-wetting; otherwise,
Anthony is in excellent health.
Anthony's mom decided to try art therapy when Anthony's fears began affecting his
concentration in school.
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Pseudonym
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Assessment of Anthony and His Problem
During intake with his mom, Anthony reported his strengths as “brain smart,” nice to
others, thoughtful, and empathetic. His emotional sensitivity has been apparent in subsequent
sessions as well. For his limitations, he and his mom reported, “Unrealistic fears.” His coping
skills include using his words to describe how he’s feeling and using essential oils at home to
calm his anxiety. We did not discuss other resources during intake but we’ve been exploring
them since, which I will discuss in this paper. I asked Anthony to do two art directive
assessments (see images2): Person Standing in the Rain, and Kinetic Family Drawing. Anthony
refused drawing that day but complied during our first one-on-one session. To make the
drawings, Anthony engaged with gel pens versus the provided colored pencils or markers,
possibly bringing structural order to chaotic emotions (Hinz, 2009). He completed the Person
Standing in the Rain first.
In the Rain drawing, the sky and clouds are loose lines of blue at the top of page, and the
ground is a line of green at the bottom. Rain appears in two levels, though it doesn’t touch
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Note. A signed Release of Information form from the client is on file.
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anything below. No visible lightning or sun. The person has a blue rectangle body/arms/legs (as
also in the Family drawing), and orange/beige hands, same as the head. Appearance of hands
suggests a sense of agency or able-ness. The person has no prop for protection from the rain, but
buttons appear on the body suggesting a possible coat, colored in yellow. Anthony reported the
person is "a random person." A green tree appears at the right of the page and a green flower, the
size of the person, stands between the person and tree. The person is smiling. When I pointed out
the person was smiling, Anthony reported that the person "likes the rain," and “that's why he
doesn't have an umbrella.” Despite possible vulnerability with not having an umbrella, Anthony's
statement suggests a positive outlook or association with the rain, or adaptability/resilience to
things outside his control. The presented developmental stage aligns with Lowenfeld's
"Schematic Stage” ("Lowenfeld’s Stages of Artistic Development," n.d.). as evidenced by a
baseline and shape symbols for people and objects, etc..
Notable elements in the Family drawing (above) are a neon green box as a baseline,
purple corner sun with rays pointing downward to family, and built-up gestural marks to fill in
the sun. Family members (neon orange) have rectangles for bodies and legs; no hands, feet, or
necks. All people stand on the base line. Though not the tallest, his mom is the largest figure with
her head emphasized in built-up spiral/circle marks, standing between his dad and brother.
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Anthony is the smallest at far bottom left in the box. His brothers are much taller than Anthony,
and his dad is at far right. The family is not engaged in an obvious activity, although they are
standing outside. If viewed from Lowenfeld's Schematic Stage, objects of importance are often
drawn larger than objects of lesser importance. Based on this context, his mom would appear to
be of most importance, with Anthony possibly viewing himself as least significant in the family.
Again, the artistic developmental stage aligns with Lowenfeld's Schematic Stage, as evidenced
by a baseline, and shape symbols for people and objects, etc.
Summary of Progress, Diagnosis, and Treatment
So far, I’ve seen Anthony in 4 weekly sessions at about 50 minutes in length each. While
it’s still early in our therapeutic relationship, I am seeing a pattern of fixation on death in general
(not limited to that of his mom’s) at the root of his anxiety. We spent parts of the second and third
sessions talking about his thoughts of his mom dying, as they had come up during school both
weeks. During our fourth and most recent session, he shared how he had gone to the nurse
because his anxiety made him feel sick to where he felt he would throw up. When I asked what
happened that brought on his anxiety, he reported that he accidentally breathed in some water
instead of air. While coughing from the water, his best friend said that if he breathed in enough
water, he would die. Anxious, he went to the nurse’s office. Once he burped instead of throwing
up, he felt better. This tells me that, while he might miss his mom the most if anyone close to
him were to die, his anxiety around death extends to his own mortality.
I can’t say definitively yet if Anthony has felt anxious his whole life or just mostly in the
last year or two, or whether the 4 recent family deaths are the only catalyst, but his recent
separation anxiety suggests unresolved trauma. So for now, I have diagnosed him with
Adjustment Disorder with Anxiety (F43.22) and Unspecified Trauma-and-Stressor-Related
Disorder (F43.9). For treatment goals, Anthony, his mom, and I have cited two objectives that we
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formed during intake to increase coping when anxiety presents: verbally expressing emotions
when feeling anxious 2 out of 3 times, and implementing 2 new anxiety coping skills, usable at
school. This brings me to methods of treatment.
During the third session, we went a little deeper by exploring what he thought he might
do if something did happen to his mom, and, who he would turn to, thereby increasing awareness
of support. He said he might feel very sad and cry, and he wept. He also said he would go to his
dad and brothers. I noticed his eyes were downcast, so I asked him to find my eyes and follow
me in rhythm using our hands and feet in a beat. After a few seconds of ‘drumming,’ he laughed
and appeared more relaxed, suggesting co-regulation with rhythm is useful treatment for working
with Anthony. In addition to increasing his awareness of support, and co-regulating with rhythm,
I’m looking at resourcing as another method of treatment.
In the second half of our fourth session, we began using sand tray. I asked him to choose
a figure for himself and his anxiety, respectively. He chose a panda for himself and a tree for his
anxiety (which became 3 trees). He buried his “anxiety” under as much sand as he could and
placed himself on top of a mountain. He smiled, looking triumphant. Then he said solemnly,
“But it’s not like that,” and switched the places of the panda and tree, half-burying the panda. I
asked him if anything else needed to be in the sand tray. He found a big bear to be his mom and a
globe of the earth. Looking at the earth, he said, “Well… God made the world, right?” I said yes.
“…So I guess this could be God.” I asked where God would go. He said, “On top of the
mountain… He makes me feel better.” This revealed a meaningful spiritual resource, and
possible means of resilience as in his Rain drawing. He also pulled out a dinosaur/gecko before
that, reporting, “He helps.” We’re not sure yet what the dinosaur/gecko represents, but Anthony
appeared excited when he asked if we could continue the sand tray at our next session.
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I believe that building Anthony awareness of support, resources, and regulation practices
will be key to helping him cope with his anxiety and achieve his treatment goals. Implementing
some regular practice appears key too, as “completing coping activities as a routine rather than
intervention, can be instrumental in helping to reduce anxiety” (Turner-Bumberry, 2019, p. 13).
Additionally, I’m fully aware that bracketing my counter-transference will also be vital for
letting his process unfold freely. While I haven’t yet noticed any transference from Anthony, I’ve
noticed counter-transference in me in the form of distrust and even a little anger (possible
jealousy?) at how close he and his mom are. This could be due projection from my childhood, as
I too had intense anxiety to the point of nausea at times, but had insecure-avoidant attachment.
Regardless, I see where I have healing to do. I also notice counter-transference around the
Christianity piece, requiring cultural adaptation and exploration of possible spiritual wounding
on my part.
Reflective Comments
Though it feels bumpy to me at times, I believe my work with Anthony is on the right
track. I would like to have started off following Tracy Turner-Bumberry’s advice of not asking
processing questions for several sessions (2019) as she does with young clients, but I appreciate
having her book as a guide for using regulating directives with kids. Additionally, I’m returning
to Hinz’s Expressive Therapies Continuum for her points on reducing anxiety through structured
materials first before easing into unstructured. I also intend to introduce psycho-education
around the purpose of emotions (Hinz, 2009). Through these means and positive regard, I look
forward to progressing with Anthony.
References
Hinz, L. D. (2009). Expressive therapies continuum. New York, NY: Routledge.
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Lowenfeld’s Stages of Artistic Development. (n.d.). Retrieved from http://www.d.umn.edu/
artedu/Lowenf.html
Turner-Bumberry, T. (2019). 2, 4, 6, 8, This is how we regulate!. Eau Claire, WI: PESI
Publishing.
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