The Case of David

David, 25 years of age, applied to the North Miami Counseling Clinic after hearing about their sliding-scale psychotherapy program for people involved in the performing arts. At intake, this Cuban American male reported that he had been under pressure by his partner to "get his life together" by seeking psychotherapy services.

The patient, however, could not afford seeing a private practice practitioner. The clinician at the counseling clinic reported that David presented in an anxious manner and appeared internally preoccupied. The clinician also noted that David was tangential in the way in which he spoke about his presenting problem.

David reports that he "can't function at a level that pleases him and lives in a fantasy world." He often feels disconnected from life and his immediate surroundings. David states that he often struggles with feelings of worthlessness, low self-esteem, apprehensiveness and depression.

He can easily become verbally abusive and violent with family and friends. At times, David states that he often experiences fear of leaving his home, and as a result has been dismissed from a number of jobs. David is very concerned with his appearance stating that he is frightened with the idea of becoming overweight; therefore, he exercises on a daily basis and is overly conscious about this daily caloric intake.

David's ultimate career goal is to become a soap opera actor. He has had a few small parts in Spanish soap operas, which are often filmed in Miami by Mexican and South American producers. At auditions, however, producers have told David that he will never truly succeed as an actor and should consider a different type of career.

He refuses to accept the appraisal of his acting ability stating that he is convinced that one day he will become "a well-known soap opera star." David is presently employed as a part-time manager in a South Miami Beach physical fitness center. David's housing situation is unstable, as he appears to drift from one's friend's apartment to another. He states that making consistent rental payments on an apartment is difficult for him because he spends most of his earnings on clothes and male skin products.

On several occasions, David's father has grudgingly bailed him out financially. David believes, however, that his father helps out financially as a way of preventing him from ever returning back home. The patient presently lives with his male partner, Paul, a high school teacher whom he met several months ago at a local gym.

David wishes that he could totally be dependent on Paul, but his partner apparently cannot stand the patient's smothering dependence and resents it. The patient describes adjusting poorly both to his sexuality and capacity for intimacy. He describes feeling little pleasure in his sexual encounters; generally feeling sexually used and then "discarded like an old rag."

David was raised in Miami by his parents and paternal grandmother. The family emigrated from Cuba to Miami in the 1960's fleeing Fidel Castro's oppressive political regime. David's history reveals a very unstable childhood and adolescence.

He describes his father as a rigid, domineering and controlling man who vacillated between being an overprotective and punitive parent. David felt valued by his father only when he was able for fulfill his father's wishes. David described his mother as a "sweet" and "extremely shy" woman. His parents' marriage reveals a history of chronic discord with frequent verbal abuse and occasional physical threats. David claims that his father was unfaithful to his mother. He recalls seeing his father with numerous partners over the years.

As a child and adolescent, the patient remembers worrying about who would take care of him and where would he live if his father ever abandoned the home for another woman. David also recalled how his mother would often retreat to the bedroom for days following any serious confrontation with the father. The patient states that during his childhood years he felt extremely close to his paternal grandmother who was always present irrespective of the level of chaos that may have been present in the home.

David is the second of three male children. He remembers his older brother as volatile and extremely demanding when they were children. The patient was fearful of the older brother and worried often because of the demands that this sibling would place on the parents.

David describes himself as being passive, not making any demands, and subsequently receiving very little attention from his parents. The patient remembers with sadness the birth of his younger brother when he was four. David states that his younger brother's birth made him feel abandoned and displaced; therefore, he would often hit and scratch himself as revenge against his parents.

His fantasy life has been a source of comfort during significant moments of emotional stress. When the patient feels inadequate, confused and alone by his circumstances he finds tension-reduction in fantasies of future success as a soap opera actor.

Upon graduating from high school, David attended a local university where he hoped to major in drama and the performing arts. During his first semester of college courses, however, he began to feel out-of-body experiences and he recalls feeling completely disconnected from himself. The patient began to experience fear at the thought of commuting from his home to the university campus on a daily basis. Irrespective of this overwhelming fear, the patient managed to pass all of his first semester courses while developing a few significant friendships with

fellow freshman students. By the end of the second semester, however, David was no longer connected to his university friends and failed three of his four courses. The patient was placed on academic probation and was encouraged by a freshman advisor to consider an academic leave from his studies.

During this time, David began to experience symptoms of anxiety, poor concentration and an inability to relate to people around him. He believed that people in his neighborhood were making fun of him and were envious of his determination to become a renowned Spanish soap opera actor.

Due to the intensification of these symptoms, the patient was admitted to a local inpatient psychiatric hospital unit for one month where he was primarily treated with medication. Although David was extremely concerned that he would become overweight as a result of the side effects of the medication, he does recall that his symptoms ameliorated rapidly as a result of this type of intervention.

Six months post-hospital discharge, David enrolled at a local community college, believing that he was well enough to pursue his studies in drama and the performing arts. He continued to have problems with his concentration

and once again started to believe that his fellow students were envious of him because of his acting potential. Feelings of confusion and anxiety exacerbated to the point that the patient required a second psychiatric hospitalization. David's symptoms once again improved as a result of this second hospitalization, but it seems that he was discharged from the hospital without a solidified follow-up outpatient plan. At discharge, the patient opted not to continue his college studies and began to work (usually on a part-time basis) while actively pursuing an acting opportunity.

David's partner is not aware the he has had two previous psychiatric hospitalizations. The patient fears that his partner will abandon him if he is honest with him about his past. David is seeking psychotherapy services at this point in his life because he is worried that he may "lose control", and he is mortified at the idea of losing his partner. David presents as a very frightened and discouraged man.

Using the case of David, discuss the following issues:

l. How does minority stress model affect our understanding of David.

2. How does ideas surrounding intersectionality help us to better understand David?

3. What are some of the risk and promotive factors that we need to take into account in our work with David.