The Case of L Presenting Problem Client presented in the emergency room (ER) having been brought in the previous night by her parents. Following an argument with her parents, L cut her right wrist. L's mother reported that L started screaming rapidly and became physically violent toward her prior to cutting her own wrist. Psychological Data L is a 17-year-old Hispanic female who resides in Pennsylvania with her mother, father, and older sister. She is in 11th grade at the local public school. L appeared to be of average to above-average intelligence, as she was able to respond to numerous questions in an articulate and intelligent manner. She was well versed about world history and current affairs. Her mother confirmed that she has done well in school, maintaining a B+ average and participating in various school activities (e.g., chorus, school paper) until last year. L slowly dropped out of many activities she liked in the past. Her mother noticed about 8 months ago that L had also begun having difficulty doing schoolwork. Erratic behavior arose during episodes when L also became irritable and explosive. During these repeated episodes, she became quite defiant, cut classes, had to be placed in school detention, and had even assaulted the principal. L has numerous friends and believed she can relate to all types of people. She has a boyfriend who adores her, but she said she doesn't feel the same about him. The school counselor confirmed that L is outgoing, popular, and smart; but during these episodes she became another person, one who is very violent and difficult. Medical History A physical examination by a staff doctor revealed superficial cuts on L’s left and right wrist. The cuts appeared to be a few weeks old. There were cigarette burns on her right wrist that looked to be approximately one week old. In questioning L about the cigarette burns, L responded, "I just wanted to see how it felt—now I know." When questioned about old cuts on her left wrist, she responded, "I don't want to talk about it." L weighs 103 pounds and is 5’ 6” tall. L denied any dieting or fasting, but her mother noticed over this past year that her weight has dropped. Substance Abuse History L denied any drug or alcohol use. When she was questioned regarding such, her response was "I could do drugs if I wanted to. I don't want to, because it’s dumb." Family History L’s mother is 42 years old and works as a secretary for a large telephone company. Her father is 49 years old and operates a small landscaping business. Both are U.S. citizens, with a cultural background from Guatemala of which they are proud. Both have 2 a high school education. L’s sister is considerably younger, aged 8. Their relationship is described as unremarkable, although L’s mother noted that the younger sister stays away when L is upset. Marital circumstances are uncertain, although the parents admitted that they are trying to keep the family together for their children, and they are of .

1. The Case of L
Presenting Problem
Client presented in the emergency room (ER) having been
brought in the previous night by her parents. Following an
argument with her parents, L cut her right wrist. L's mother
reported that L started screaming rapidly and became physically
violent toward her prior to cutting her own wrist.
Psychological Data
L is a 17-year-old Hispanic female who resides in Pennsylvania
with her mother, father, and older sister. She is in 11th grade at
the local public school. L appeared to be of average to above-
average intelligence, as she was able to respond to numerous
questions in an articulate and intelligent manner. She was well
versed about world history and current affairs. Her mother
confirmed that she has done well in school, maintaining a B+
average and participating in various school activities (e.g.,
chorus, school paper) until last year. L slowly dropped out of
many activities she liked in the past. Her mother noticed about
8 months ago that L had also begun having difficulty doing
schoolwork. Erratic behavior arose during episodes when L also
became irritable and explosive. During these repeated episodes,
she became quite defiant, cut classes, had to be placed in school
detention, and had even assaulted the principal. L has numerous
friends and believed she can relate to all types of people. She
has a boyfriend who adores her, but she said she doesn't feel the
same about him. The school counselor confirmed that L is
outgoing, popular, and smart; but during these episodes she
became another person, one who is very violent and difficult.
Medical History
A physical examination by a staff doctor revealed superficial
cuts on L’s left and right wrist. The cuts appeared to be a few
weeks old. There were cigarette burns on her right wrist that
looked to be approximately one week old. In questioning L
about the cigarette burns, L responded, "I just wanted to see

2. how it felt—now I know." When questioned about old cuts on
her left wrist, she responded, "I don't want to talk about it." L
weighs 103 pounds and is 5’ 6” tall. L denied any dieting or
fasting, but her mother noticed over this past year that her
weight has dropped. Substance Abuse History L denied any drug
or alcohol use. When she was questioned regarding such, her
response was "I could do drugs if I wanted to. I don't want to,
because it’s dumb." Family History L’s mother is 42 years old
and works as a secretary for a large telephone company. Her
father is 49 years old and operates a small landscaping business.
Both are U.S. citizens, with a cultural background from
Guatemala of which they are proud. Both have 2 a high school
education. L’s sister is considerably younger, aged 8.
Their relationship is described as unremarkable, although L’s
mother noted that the younger sister stays away when L is
upset. Marital circumstances are uncertain, although the parents
admitted that they are trying to keep the family together for
their children, and they are of the Catholic faith. Treatment
costs for L have been an additional difficulty for the family, but
they said they are very worried about L’s lack of self-control
and discipline. Extended family are far away and mostly still in
Guatemala. L’s parents were not aware of any other family
members with psychiatric problems. Psychiatric History L was
evaluated three times at the community hospital ER during the
past 4 years. Hospital evaluations were usually done after
suicide attempts or threatening violent behavior toward others.
L thought that the clinicians trying to diagnose her only had
book skills and no people skills. She assumed that no one will
ever know what is wrong with her; she did not plan to tell them
because she doesn't like them.
L said she knows she “is not crazy,” but she was convinced that
the therapist thought she is crazy or a “bad” kid. "They're just
experimenting with me," L said. L indicated that she had been
prescribed medications to alter her mood, but she couldn't recall
what it was, as she stated, "I don't need those; nothing is wrong
with me." L's mother reported that L was involved in outpatient

3. counseling on at least four occasions as well as being placed in
a shelter once after school truancy, running away from home,
and threatening to assault her. A social worker was even sent
for home visits for a 3-month period. Each time, L would
abruptly end therapy by becoming verbally abusive or totally
noncommunicative toward the therapist and would adamantly
refuse to continue therapy. She even admitted to shoving a desk
toward a therapist and threatening her with a pencil. When
questioned about this behavior, L responded, "Well she told me
to express myself and let my true feelings out, so I did." (L also
laughed and glanced at her mother during this exchange.) L’s
mother was particularly perplexed and overwhelmed by these
behaviors.
She stated that her husband is completely frustrated and angry.
Both admitted that L’s behavior is part of the considerable
strain on their marriage. L denied being under any continued
psychiatric care even though it was recommended numerous
times. She refused to go, stating, "The therapists are the ones
who are crazy." L was first seen in outpatient counseling 9
years ago after she began to have nightmares and experienced
tremendous anxiety after her godmother threatened to kidnap
her. Her godmother became obsessed with L when L was 6 years
old, first threatening to kidnap her then. Her godmother had to
be institutionalized after exhibiting bizarre behavior. Recently,
the godmother started threatening to kidnap L again. Three
years ago, L was sent for counseling after she ran away from
home after getting a bad report card and also discovering that
her parents were considering a divorce.
L requested therapy, as she reported that at 8 years of age she
was sexually molested by an older man in the community (who
is now deceased). She expressed having mixed emotions,
because she viewed her perpetrator as her friend. By pretending
that nothing 3 happened, she could think of him as a nice old
man, and she didn't have to deal with the thought of something
this bad happening to her. L’s mother reported that she herself
was raped at 8 years old and that L had knowledge of this. Two

4. years ago, L and the entire family again became involved in
outpatient counseling after L's godmother accused L's mother of
child abuse. L's mother thought this was largely done out of
spite. An investigation by Child Protective Services revealed no
abuse. Mental Status (1 day after she had been evaluated at the
ER) L presented casually, disheveled, in shorts and a tee shirt,
and with minimal makeup. L admitted to being in a nasty mood.
There was little eye contact, and conversation was difficult.
Thought and speech patterns were clear. Affect was flat. She
was oriented to time, place, and person. L denied feeling
depressed. When questioned about her suicide attempt the
previous day, she suddenly became quiet and teary eyed. She
lowered her head and responded, "You don’t understand, he
made me do it. I don't want to hurt myself." L denied even
remembering cutting her wrist, saying, "He must have done it or
made me do it.” L was questioned about the person she was
talking about. She related that there has been a male presence in
her life since she was 6 years old and that he makes her do
things that she doesn't want to do or things she can't even
remember. This presence showed up after the funeral of her best
friend, Michael
. L said he communicates with her through her mind. She
seemed distressed when speaking about him. Her mother
appeared distressed and fearful as well. L’s mother confirmed
that L had trouble sleeping and concentrating at school after the
funeral. She did not want to attend Girl Scouts anymore,
because the uniform had gotten tight and the male presence was
laughing at her. L’s mother remembered how scared she had
become on a few occasions when L attempted to run out into
traffic. Every time L’s mother yelled at L for doing that, L
stated that the male presence explained that this was how she
could join her friend Michael. L’s mother took L to a therapist.
When L entered the third grade, L’s mother took her out of
therapy. L reported that during her awake hours she can't see
this presence, but she can sense him. She said she does see him
in her dreams, and his appearances in them have intensified

5. within the past year. In her dreams, he torments children, and he
controls people through a haunted mirror and a magic book. He
reads and controls thoughts. L described him this way: “He
looks in his 40s, but is really ageless. Always dressed in dark
colors, but I can’t tell the exact colors he wears. I know his
eyes are powerful, but I never really look at his eyes.” L was
asked why she never shared this information before. She stated,
"Because I would be put in the hospital and medicated—and I
told you, I'm not crazy. I know you don't understand, but I am
him and he is me, and he eventually wants to totally control
me."
She admitted to acting out impulsively at times, such as
throwing things for no reason. L reported that the presence was
in the room during this interview. When questioned about why
he doesn't influence her now or make her do something, she
replied, "He's too smart, he wouldn't do that." L also mentioned
that during the past 4 couple of months another male presence
has been with her. This new presence seems to be controlled by
and intimidated by the primary presence. The two males
communicate with one another about how to hurt the children in
her dreams. L ended the session by saying, "I know this sounds
weird, but this is what is happening to me. If you tell any other
therapist, I'll deny it, because I don't want to be put away.