Clinical Case Studies8(5) 383 –402© The Author(s) 2009.docx

Clinical Case Studies
8(5) 383 –402
© The Author(s) 2009
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DOI: 10.1177/1534650109345004
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Culturally Sensitive Treatment
of Anger in African American
Women: A Single Case Study
A. Antonio González-Prendes and Shirley A. Thomas
Abstract
Culturally sensitive clinical practice challenges practitioners to
recognize the cultural significance
and importance of clients’ behaviors and belief systems. This
article reports a case study of the
treatment of anger in an African American woman. Presented
within a framework of cognitive-
behavioral theory, the case illuminates three important issues
that influence experience and
expression of anger in African American women: the influence
of gender role socialization
on the mode of anger expression; the experience of
powerlessness, rooted in historical and
contemporary discriminatory and oppressive realities; and
culture-related messages that

create unrealistic expectations of strength. The article addresses
conceptualization, assessment,
treatment processes, and clinical strategies, as well as
limitations of a single case study, implications
for practice and recommendations for future research.
Keywords
African American women, anger treatment, cultural sensitivity,
cognitive-behavioral
1 Theoretical and Research Basis
Culturally sensitive treatment approaches must be able to
conceptualize, recognize, and evaluate
the client’s belief system and behaviors within the context of
the client’s gender, race and culture,
among other factors. This is particularly important when
working with individuals from minori-
ties and other traditionally disempowered groups, whose beliefs
and behaviors run the risk of
being pathologized when taken out of the context of their
cultures and measured against the
standards of the dominant group. This article presents and
discusses, within the framework of a
case study, central elements of a culturally sensitive approach
to the treatment of anger problems
in an African American woman. The conceptual model for the
treatment approach suggests that,
if anger in African American women is to be understood
accurately, it must be viewed through
the twin prisms of gender and race (Thomas & González-
Prendes, 2009). Previous studies have
underscored the idea that, in order to develop an accurate
understanding of the emotional experi-
ence of women of color, one must be able to integrate issues
related to gender, culture, and race

Wayne State University
Corresponding Author:
A. Antonio González-Prendes, Wayne State University, School
of Social Work, 4756 Cass Avenue, Room #301, Detroit,
MI 48202
Email: [email protected]
384 Clinical Case Studies 8(5)
(King, 1988, 2005). More specifically, related to women’s
anger, deMarraias and Tisdale (2002)
emphasized that emotions are sensitive to the contexts in which
such emotions are experienced.
Therefore, we propose that if anger treatment in African
American women is to be successful,
it must address the contextual nature of that anger, as well as
gender-role and cultural expecta-
tions that have engendered beliefs that affect the experience and
expression of anger in those
women. The model suggests that there are three central themes
that underscore their experience
and expression of anger: the influence of gender-role
socialization messages that dictate to the
woman “socially appropriate” ways to express her anger;
culture-related messages translated
into beliefs or self-imposed demands that set up unrealistic
expectations of “strength” among
African American women; and the experience of powerlessness
often rooted in historical as well
as present-day situations of discrimination and
disempowerment.

Limitations of Current Anger Research
A review of current anger research literature reveals several
critical limitations. As DiGi-
useppe and Tafrate (2003) have noted, anger research has relied
too heavily on college student
populations. This focus makes it difficult, if not impossible, to
generalize those findings to
community-based samples of individuals with anger problems.
Another significant limitation
is the overwhelming use of samples that are either entirely or
overwhelmingly male. González-
Prendes (2008) reviewed a series of meta-analytic studies
addressing the effectiveness of
anger research (Beck & Fernandez, 1998; DelVecchio &
O’Leary, 2004; DiGiuseppe &
Tafrate, 2003; Edmondson & Conger, 1996) and reported that,
of a total of 148 studies in the
meta-analyses, only two, both unpublished dissertations,
focused exclusively on women.
Furthermore, none of the available studies focused exclusively
on women of color. The need
for more research among racial and ethnic minorities has also
been addressed in the United
States Department of Health and Human Services Surgeon
General’s report discussing the
impact of culture, race and ethnicity on mental health
(USDHHS, 2001). Yet, as clinical prac-
tice has emphasized the need for evidence-based practices, it is
imperative to produce more
clinical research that examines the effectiveness of clinical
methods with minority popula-
tions. Although a single case study has intrinsic limitations
discussed elsewhere in this article,
it illuminates specific theoretical concepts, client variables, and
practice concerns that could

lead to larger empirical research studies.
Adaptive-Healthy Versus Maladaptive-Unhealthy Anger
When discussing anger, it is imperative to differentiate between
healthy and unhealthy types.
Anger is a normal and common human emotion that, in itself, is
neither good nor bad; and indeed
anger often may play a positive adaptive and functional role for
the individual. Therefore, anger
treatment does not focus on the total elimination of anger, but
rather it focuses on enhancing the
healthy expression of it. Healthy anger is experienced through
the realistic and rational process-
ing of information and environmental cues and with mild to
moderate levels of internal
physiological arousal. This type of anger allows the person to
organize cognitive, physical, emo-
tional, and behavioral capabilities in order to take prosocial
constructive action to resolve a
problem. This often includes the ability to express one’s angry
feelings directly, openly, and
appropriately in a way that facilitates healthy outcomes, while
at the same time, respecting the
rights and dignity of the other person or entity.
However, anger becomes toxic for some individuals, when it
becomes harmful and destruc-
tive to self and others. These individuals may experience
internal hyperarousal and find
themselves either “stuffing” their angry feelings, using
aggression, or diverting their anger to
González-Prendes and Thomas 385

other psychopathologies such as substance abuse (Gilbert,
Gilbert, & Schultz, 1998; Larimer,
Palmer, & Marlatt, 1999; DeMoja & Spielberger, 1997), self-
cutting (Abu-Madini & Rahim,
2001; Harris, 2000; Matsumoto et al., 2004), and bulimia
(Meyer et al., 2005). Toxic anger is a
significant internal stressor that increases the risk of health
problems such as: hypertension
(Webb & Beckstead, 2005), coronary heart disease (Bongard,
al’Absi & Lovallo, 1997; Warren-
Findlow, 2006), cancer (Andersen, Farrar, & Golden-Kreutz,
1998); and obesity (Robert &
Reither, 2004; Wamala, Wolk, & Orth-Gomer, 1997). As
Thomas (1995) has suggested these are
conditions that disproportionately impact the health of African
Americans.
Cognitive Theory and Anger
A detailed discussion of cognitive theory is beyond the scope of
this article. However, it is impor-
tant to underscore that cognitive theory rests on key
fundamental assumptions which suggest that
cognitive activity affects emotions and behaviors; that the
content and process of such activity
can be monitored and changed; and that, by restructuring
cognitions in a more rational and bal-
anced direction, one can achieve behavioral and emotional
changes and reduce symptoms
(Dobson & Dobson, 2009; Dobson & Dozois, 2001). Cognitive
therapy approaches (Beck, 1976;
Ellis, 1962) have been used extensively to address a number of
emotional and behavioral prob-
lems including, as indicated earlier, the treatment of anger.
From a cognitive-theory perspective, the experienced of anger
has been associated with cog-

nitive processes such as: the threat to or perception of loss of a
valued object in one’s life (Beck,
1999); external attributions of blame that lay responsibility for
one’s loss on an identified
“transgressor” (Averill, 1982; Beck; DiGiuseppe, 1995; Hareli
& Weiner, 2002); rigid demands
(Eckhardt & Jamison, 2002; Deffenbacher, 1999; Ellis, 2003;
Ellis & Tafrate, 1997); attribu-
tions of intentionality or personalization (Epps & Kendall,
1995; González-Prendes &
Jozefowicz-Simbeni, 2009; Girodo, 1998); and condemnation or
denigration of the identified
transgressor (Beck; Eckhardt & Kassinove, 1998; Ellis &
Tafrate). In defining the experience of
anger, Kassinove and Sukhodolsky (1995) suggest that anger is:
A negative phenomenological (or internal) feeling state
associated with specific cognitive
and perceptual distortions and deficiencies (e.g. misappraisals,
errors, attributions of
blame, injustice, preventability, intentionality), subjective
labeling, physiological changes,
and action tendencies to engage in socially constructed and
reinforced organized behav-
ioral scripts (p. 7).
Anger and African American Women
The experience of anger in African American women must take
into account factors such as
gender-role and culture-bound messages, as well as the realities
of powerlessness. Addressing
the issue of gender-role socialization, several authors (Cox,
Stabb, & Bruckner, 1999; Cox, Van
Velsor, & Hulgus, 2004; Hatch & Forgays, 2001; Munhall,
1993; Sharkin, 1993) have suggested
that cultural expectations and gender-role socialization

messages shape the manner in which
anger is experienced and expressed by women. Such messages,
reinforced from an early age,
discourage women from expressing anger directly and promote
the view that such direct expres-
sion threatens the stability of their relationships. The outcome
of these dynamics, according to
Cox and colleagues, is that women often find themselves
diverting or rerouting their anger
expression in four ways: containment (e.g., a conscious attempt
to avoid expressing anger, often
accompanied by prolonged physical responses); internalization
(e.g., suppression); segmentation
(e.g., dissociation from angry feelings, with little or no
awareness of them); and externalization
(e.g., use of aggression or projection of blame for one’s
uncomfortable feelings).
Besides the socialization process that African American women
are exposed to as a function
of their gender, they also may be influenced by culture-bound
expectations of strength.
Beaubeouf-Lafontant (2007) argued that the concept of the
strong African American woman is
grounded on problematic assumptions that create unrealistic
characterization, demands and
expectations that tyrannize African American women and,
paradoxically, increases their risk of
depression and other emotional distress. Similarly, Harris
(1995) suggested that this notion of
“strength” may often cut both ways: in one way it can be seen

as a virtue needed to overcome
adversity; on the other hand, it may create the false image of a
“superwoman,” who sees it as her
duty to help others, while ignoring her own distress. Harris
(1995) goes on to state “this thing
called strength, this thing we applaud so much in Black women,
could also be a disease” (p. 1).
As Thompkins (2004) asserted, too often the ideal of the strong
back woman compels the woman
to assume the role of caregiver, engaging in self-sacrifice and
self-denial to attend to the needs
of others. The woman may then find herself caught in a double-
bind: on the one hand she may
experience anger and resentment related to the lack of control
over her own life and the lack of
attention to her own needs, and on the other hand she may feel
that expressing anger and dis-
satisfaction is nothing more than complaining, and therefore a
sign of weakness. It might then
follow that legitimate anger feelings are left in silence or
diverted into other forms of anger
expression (Cox et al., 1999; Cox et al., 2004).
Another significant factor that influences anger in women is
powerlessness (Fields et al.,
1998; Thomas, 1995; Thomas & González-Prendes, 2009).
Although the experience of power-
lessness seems to be more common among African-American
women, who are more likely to
suffer from disparities related to income, education,
employment, and poverty, the disempower-
ing experience also affects middle-class African American
women, even those who have achieved
relative professional success (Fields et al., 1998; Richie et al.,
1997). It could be argued that a
feeling of powerlessness in African Americans is not only a

function of socioeconomic dispari-
ties but also could be paradoxically influenced by the same
culture-bound messages of strength
that create unrealistic expectations for African American
women. By emphasizing the impor-
tance of caregiving, self-denial and enduring adversities against
all costs, paradoxically the
woman may be left feeling less control over her own life.
Perceived control and optimism have
been associated with less emotional distress (i.e., depression
and anger) among women experi-
encing a high number of exposures to acute and chronic
stressors (Grote, Bledsoe, Larkin,
Lemay, & Brown, 2007). Mabry and Kiecolt (2005) have
proposed that a sense of control, the
idea that one controls one’s outcomes, mediates the experience
of anger more for African Ameri-
cans than for Whites.
2 Case Introduction
Karen is a 51-year-old, single, African American woman with
one adult daughter and two grand-
children. She has a master’s degree in education and has
completed all the course work for a
doctoral degree in counseling. She has been a public school
teacher for nearly 30 years. She is
well-liked and well-respected by her students and colleagues.
Karen, the oldest of three siblings,
comes from a family in which women were viewed as strong,
determined, self-reliable, and striv-
ing to improve their lives by working to achieve the top of their
potential. That path had been
established for generations, and was most evident in the
example set by Karen’s mother, a single
mother who, while living in a low-income housing project in St.
Louis, Missouri, had worked

full-time to support her family. She also attended law school in
the evenings, and eventually
graduated.
3 Presenting Complaints
Karen initially went to see her primary-care physician,
complaining of physical symptoms,
including headaches, high blood pressure, poor sleep, and
feelings of tenseness and fatigue. In
addition, Karen had related that over the past year she had
struggled with on-and-off depressed
mood, crying spells, social isolation, irritability, and anger
bouts. Her anger bouts, although often
felt in silence, were at times punctuated by verbal outbursts
directed at an individual or entity.
Karen tended to feel the episodic bouts of depression following
her anger episodes. Upon exam-
ining her, the physician recognized that Karen’s symptoms were
likely related to multiple
personal and occupational stressors that Karen was facing and
for which she had not allowed
herself the time to process and find a healthy resolution. The
physician suggested that Karen seek
professional counseling to help her address some of those
stressors.
4 History
During her initial visit, Karen related how, in the past year and
half she had experienced a number
of significant losses in her life including the deaths of her
brother, sister, and father. At about the

time that Karen sought treatment, her oldest daughter had been
diagnosed with terminal cancer
and her step-father, the man she thought of as her father, had
been diagnosed with a malignant
brain tumor. Since Karen’s mother was advancing in years and
struggling with her own health
issues, Karen had assumed the role of major caregiver; this
while still handling her full-time
employment responsibilities as a teacher, as well as other
personal responsibilities.
Karen also related how over the past 2 years she had witnessed
the steady deterioration of the
educational atmosphere at the public school where she taught
and the administration’s apparent
unwillingness to address important issues. Teaching was
Karen’s passion. She was extremely
dedicated to her students and strived to provide them with the
best learning experience, in the
face of increasing difficulties in the urban school in an area of
the city populated by low-income
people. During the past year, there had been an increased in
gang activity and the level of vio-
lence had increased both inside the school and in the
surrounding area. On a number of occasions,
the school had gone on “lockdown,” while the police swept the
building to search for gang mem-
bers and weapons. Teachers often felt that they worked in an
unsafe environment, with a lack of
supplies adequate to perform their duties. Karen, along with
other teachers, also felt that the
school administration did not care about improving the
educational environment. The increas-
ingly chaotic work environment prompted Karen to start
questioning whether to continue
teaching. This created a great deal of consternation because she

found deep meaning and sense
of personal satisfaction in her teaching, particularly to
disadvantaged, disempowered, and under-
privileged students. Karen’s frustration grew as her effort for
advocacy and action appeared to
fall on deaf ears. Although initially she did not recognize it or
acknowledge it overtly, Karen
often felt a profound sense of powerlessness in the face of such
personal and professional stress-
ors. In the face of that powerlessness Karen would find herself
alternatively blaming others (i.e.,
the school administration, society, etc.) and experiencing
intense anger, or blaming herself as
being “weak” and “not strong enough” and feeling depressed.
Reacting to these multiple losses and issues in her life, Karen
projected a cynical view of the
world. She saw the world as a “cold and calloused place” and
people as “uncaring.” At times she
questioned if she were doing a disservice to her students by
trying to inject them with hope, when
she “knew” they would be mistreated by the “unfair and
uncertain” future that her students were
about to face in life.
Nonetheless, Karen presented with a number of significant
strengths that would be considered
throughout the course of treatment. Internally, Karen was an
intelligent, insightful, and creative
woman with a particular aptitude for music and writing poetry.
Although she was not a religious

person, she saw herself as highly spiritual. Throughout her life
she had been an activist, fighting
for women’s issues as well as confronting racism, sexism, and
other forms of discrimination and
oppression of disempowered populations. Externally, Karen
seemed to have a healthy support
network made up of family and friends. She belonged to various
civic groups. However, when in
need, she felt hesitant and reluctant to use that support as she
did not want to “burden others with
my problems.” On the contrary, she was the one that others
came to when they needed support or
advice. Her narrative seemed punctuated by a prevailing theme:
the need to be “strong” in the
face of adversity. She recognized that that often meant that she
could not allow herself to appear
vulnerable to others. Others viewed her as the one who “kept it
together.” Often she found herself
attending to others’ needs and striving to make things better for
them, even when she felt over-
burdened by doing so. That need to be “strong” was passed on
to Karen in overt and covert
messages and actions by her mother. Her mother’s stoic
determination made a significant impact
on Karen’s view of self, others and the world; the fact that her
mother had raised her family as a
single parent while going to law school and becoming an
attorney and a judge, without much
complaining, created a challenging role model for Karen.
5 Assessment
The initial assessment consisted of a structured biopsychosocial
assessment interview and com-
pletion of the Brief Symptom Inventory, (Derogatis, 1993) on
which she had elevated scores in
the depression (52), anxiety (45), and hostility (62) categories.

In addition, Karen was asked to
subjectively rate the frequency (how many times per week) and
intensity (how strong each epi-
sode) of her anger episodes for the 4 weeks prior to coming to
treatment. She did so by using a 0
to 10 subjective units of distress measure (Wolpe, 1990) and
maintaining a log of such data (0 =
no anger and 10 = enraged) for the duration of treatment. At
pretreatment Karen indicated that
she experienced 2-3 anger episodes weekly with an average
intensity of 8-9. Her mode of anger
expression seemed to divert such expression into a form of
anger containment as defined by Cox
et al. (1999) and Cox et al. (2004). In this form anger diversion,
the woman “holds her tongue”
and contains her anger, which remains active but covert, and
leads to physical symptoms (Cox,
Bruckner, & Stabb, 2003).
Following the assessment process, Karen and the therapist
reviewed the information and
developed a list of concerns. Three main concerns emerged: (a)
unhealthy experience and expres-
sion of her anger, (b) episodic bouts of depression that seemed
to follow her anger outbursts, and
(c) unresolved grief issues related to the multiple losses in her
life. After reviewing this data,
Karen acknowledged that she often experienced feelings of
anger and also described her difficul-
ties in processing and expressing such angry feelings. She
described a cycle in which she would
experience a setback or adversity, followed by the experience of
anger. She would hang on to her
anger silently, for fear of hurting other people’s feelings.
Meanwhile she would suffer headaches,
tension, restlessness, poor sleep and rumination as to how she

“should” have handled the situa-
tion. At times, days or weeks later, she would just “explode”
verbally at either the original object
of her anger or some other unsuspecting target. Following this
“outburst” Karen would feel
guilty and depressed, fueled by self-condemnation for having
“lost control.” She indicated that
she had been experiencing these episodes for approximately 2
years and decided on her anger as
the main focus of therapy.
The goal of her treatment, as expressed by Karen herself, was to
be able to manage her
angry feelings in a healthier manner. A key aspect of the
success of cognitive-behavioral ther-
apy centers on the client’s and therapist’s ability to define the
target problem in behavior-specific
terms. Therefore, Karen was asked to describe what “managing
her anger in a healthier
manner” meant to her, and how she envisioned herself behaving,
feeling and, most important,
thinking differently, once that she had successfully completed
therapy. Karen agreed that, as a
homework assignment, she would work on defining what she
wanted to get out of treatment.
Three main objectives emerged. Behaviorally, Karen wanted to
be able to verbally express her
feelings of anger assertively and appropriately and she wanted
to do so without the guilt and
depression that she often experienced following her maladaptive
forms of anger expression.

Second, she wanted to be able to set healthy, reasonable limits
as to how much she would take
on or how much she would help others and she wanted to learn
“how to relax.” Third, from a
cognitive perspective, Karen wanted to be able think that it was
okay to not always be avail-
able to others, and to think that it was okay to take care of
herself without feeling guilty for
doing so.
6 Case Conceptualization
Karen’s anger was conceptualized, using a cognitive-behavioral
conceptualization model out-
lined by Beck (1995) which identifies various levels of
cognitions and their impact on the
individual. Equally important, to increase the cultural relevancy
of the conceptualization
process, the schemas that supported her anger were framed
within significant gender-role
and culturally relevant factors that affected her mode of anger
expression. Karen’s references
to depression were conceptualized as the result of engaging in
strong and persistent self-
condemnation and self-blame, usually following her anger
outbursts and her perceived “loss
of control.” Beyond those incidents, Karen did not present with
any symptoms of depression,
nor did she have any significant history of depression;
therefore, we agreed that anger was the
primary problem.
Karen’s core beliefs related to how she viewed herself and the
world/others. Her views of the
self were underscored by these beliefs such as: “I am
competent,” “I am strong,” and “I am a
helper.” She saw the world as “hostile,” “cold,” and “uncaring.”

Out of these central beliefs,
Karen had developed important rules which she used to guide
and measure her behavior, as well
as the actions of others. Some of these rules were: “I should be
able to help those in need,” “I
should stand against the uncaring world that oppresses
disempowered people,” “I should endure
without complaint,” and “If I fail to help others, then I am a
failure.” These beliefs and rules had
translated into strategies that Karen used throughout her life.
These strategies emphasized self-
denial and attention to others’ needs. In addition, Karen often
felt that others should recognize
that she was overworked and therefore should stop being so
demanding of her time. Yet, she was
unable to verbalize such wishes to others. When others
continued to demand her time, Karen
concluded that they were insensitive and just did not care. This
type of blame was seen as a piv-
otal factor that fueled both her anger and depression. Whenever
she felt frustrated in her attempts
to achieve certain outcomes, she blamed others and her
emotional response was anger directed,
although unstated, at the perceived transgressor. Conversely, on
those occasions when she
blamed and belittled herself for not being “strong” and “losing
control” by acting angrily, she
experienced depression and guilt.
A critical aspect of working with clients with anger problems is
the establishment of a thera-
peutic alliance. This is particularly true when working with
angry clients, whose view of the
world is punctuated by suspiciousness and mistrust
(DiGiuseppe, 1995; González-Prendes &
Jozefowicz-Simbeni, 2009). In these situations, it is imperative

that the client be engaged and
actively included in every aspect and step of the treatment
process. In Karen’s case, from the first
interaction of the assessment process, it was imperative that she
felt a sense of ownership of
the treatment process. In cognitive behavior therapy, one strives
to establish a collaborative
empirical alliance (Beck, 1995) that empowers the client by
getting her involved in the
decision-making process, from the identification of the
problems, to the establishment of the
goals, the formulation of homework assignments, the design of
behavioral experiments and other
strategies. Cognitive-behavioral therapy has been described as
an empowering approach because
it acknowledges the client’s expertise about herself and her
ability to control and change her
thinking; engendering changes in her emotional and behavioral
responses (Hays, 1995).
7 Course of Treatment and Assessment of Progress
Karen’s treatment took place more than 20 individual therapy
sessions of 50 minutes in length.
The first 12 sessions were weekly, followed by 6 every-other-
week sessions. The last two ses-
sions were follow-ups at a 3-month and 6-month point after the
initial 18 sessions were completed.
Treatment followed a cognitive-behavioral model that
acknowledges the primary role of cogni-
tions (i.e., judgments, meaning, attributions, etc.) in
determining how one responds, emotionally

and behaviorally, to life situations (Beck, 1976; Ellis, 1962).
We employed a person-in-environ-
ment perspective to frame Karen’s beliefs within important
sociocultural perspectives that gave
special meaning to her actions.
The overall cognitive-behavioral treatment occurred within a
three-stage framework as out-
lined by Meichenbaum (1985, 1996). The goal of the first stage
was to help Karen understand her
anger. This entailed helping her to understand how her
idiosyncratic thoughts and …
Tiffani Bradley
Identifying Data: Tiffani Bradley is a 16-year-old Caucasian
female. She was raised in
a Christian family in Philadelphia, PA. She is of German
descent. Tiffani’s family
consists of her father, Robert, 38 years old; her mother,
Shondra, 33 years old, and
her sister, Diana, 13 years old. Tiffani currently resides in a
group home, Teens First,
a brand new, court-mandated teen counseling program for
adolescent victims of
sexual exploitation and human trafficking. Tiffani has been
provided room and board
in the residential treatment facility for the past 3 months.
Tiffani describes herself as
heterosexual.
Presenting Problem: Tiffani has a history of running away. She
has been arrested on
three occasions for prostitution in the last 2 years. Tiffani has
recently been court
ordered to reside in a group home with counseling. She has a
continued desire to be
reunited with her pimp, Donald. After 3 months at Teens First,

Tiffani said that she
had a strong desire to see her sister and her mother. She had not
seen either of
them in over 2 years and missed them very much. Tiffani is
confused about the path
to follow. She is not sure if she wants to return to her family
and sibling or go back to
Donald.
Family Dynamics: Tiffani indicates that her family worked well
together until 8 years
ago. She reports that around the age of 8, she remembered being
awakened by
music and laughter in the early hours of the morning. When she
went downstairs to
investigate, she saw her parents and her Uncle Nate passing a
pipe back and forth
between them. She remembered asking them what they were
doing and her mother
saying, “adult things” and putting her back in bed. Tiffani
remembers this happening
on several occasions. Tiffani also recalls significant changes in
the home's
appearance. The home, which was never fancy, was always neat
and tidy. During
this time, however, dust would gather around the house, dishes
would pile up in the
sink, dirt would remain on the floor, and clothes would go for
long periods of time
without being washed. Tiffani began cleaning her own clothes
and making meals for
herself and her sister. Often there was not enough food to feed
everyone, and Tiffani
and her sister would go to bed hungry. Tiffani believed she was
responsible for
helping her mom so that her mom did not get so overwhelmed.
She thought that if

she took care of the home and her sister, maybe that would help
mom return to the
person she was before.
Sometimes Tiffani and her sister would come downstairs in the
morning to find empty
beer cans and liquor bottles on the kitchen table along with a
crack pipe. Her parents
would be in the bedroom, and Tiffani and her sister would leave
the house and go to
school by themselves. The music and noise downstairs
continued for the next 6
years, which escalated to screams and shouting and sounds of
people fighting.
Tiffani remembers her mom one morning yelling at her dad to
“get up and go to
work.” Tiffani and Diana saw their dad come out of the
bedroom and slap their mom
so hard she was knocked down. Dad then went back into the
bedroom. Tiffani
3
remembers thinking that her mom was not doing what she was
supposed to do in the
house, which is what probably angered her dad.
Shondra and Robert have been separated for a little over a year
and have started
dating other people. Diana currently resides with her mother
and Anthony, 31 years
old, who is her mother’s new boyfriend.
Educational History: Tiffani attends school at the group home,
taking general
education classes for her general education development (GED)
credential. Diana
attends Town Middle School and is in the 8th grade.
Employment History: Tiffani reports that her father was
employed as a welding

apprentice and was waiting for the opportunity to join the
union. Eight years ago, he
was laid off due to financial constraints at the company. He
would pick up odd jobs
for the next 8 years but never had steady work after that. Her
mother works as a
home health aide. Her work is part-time, and she has been
unable to secure full-time
work.
Social History: Over the past 2 years, Tiffani has had limited
contact with her family
members and has not been attending school. Tiffani did contact
her sister Diana a
few times over the 2-year period and stated that she missed her
very much. Tiffani
views Donald as her “husband” (although they were never
married) and her only
friend. Previously, Donald sold Tiffani to a pimp, “John T.”
Tiffani reports that she was
very upset Donald did this and that she wants to be reunited
with him, missing him
very much. Tiffani indicates that she knows she can be a better
“wife” to him. She
has tried to make contact with him by sending messages through
other people, as
John T. did not allow her access to a phone. It appears that over
the last 2 years,
Tiffani has had neither outside support nor interactions with
anyone beyond Donald,
John T., and some other young women who were prostituting.
Mental Health History: On many occasions Tiffani recalls that
when her mother was
not around, Uncle Nate would ask her to sit on his lap. Her
father would sometimes
ask her to show them the dance that she had learned at school.
When she danced,

her father and Nate would laugh and offer her pocket change.
Sometimes, their
friend Jimmy joined them. One night, Tiffani was awakened by
her uncle Nate and his
friend Jimmy. Her parents were apparently out, and they were
the only adults in the
home. They asked her if she wanted to come downstairs and
show them the new
dances she learned at school. Once downstairs Nate and Jimmy
put some music on
and started to dance. They asked Tiffani to start dancing with
them, which she did.
While they were dancing, Jimmy spilled some beer on her. Nate
said she had to go to
the bathroom to clean up. Nate, Jimmy, and Tiffani all went to
the bathroom. Nate
asked Tiffani to take her clothes off and get in the bath. Tiffani
hesitated to do this,
but Nate insisted it was OK since he and Jimmy were family.
Tiffani eventually
relented and began to wash up. Nate would tell her that she
missed a spot and would
scrub the area with his hands. Incidents like this continued to
occur with increasing
levels of molestation each time.
4
The last time it happened, when Tiffani was 14, she pretended
to be willing to dance
for them, but when she got downstairs, she ran out the front
door of the house. Tiffani
vividly remembers the fear she felt the nights Nate and Jimmy
touched her, and she
was convinced they would have raped her if she stayed in the
house.
About halfway down the block, a car stopped. The man

introduced himself as Donald,
and he indicated that he would take care of her and keep her
safe when these things
happened. He then offered to be her boyfriend and took Tiffani
to his apartment.
Donald insisted Tiffani drink beer. When Tiffani was drunk,
Donald began kissing her,
and they had sex. Tiffani was also afraid that if she did not have
sex, Donald would
not let her stay— she had nowhere else to go. For the next 3
days, Donald brought
her food and beer and had sex with her several more times.
Donald told Tiffani that
she was not allowed to do anything without his permission. This
included watching
TV, going to the bathroom, taking a shower, and eating and
drinking. A few weeks
later, Donald bought Tiffani a dress, explaining to her that she
was going to “find a
date” and get men to pay her to have sex. When Tiffani said she
did not want to do
that, Donald hit her several times. Donald explained that if she
didn’t do it, he would
get her sister Diana and make her do it instead. Out of fear for
her sister, Tiffani
relented and did what Donald told her to do. She thought at this
point her only
purpose in life was to be a sex object, listen, and obey—and
then she would be able
to keep the relationships and love she so desired.
Legal History: Tiffani has been arrested three times for
prostitution. Right before the
most recent charge, a new state policy was enacted to protect
youth 16 years and
younger from prosecution and jail time for prostitution. The
Safe Harbor for Exploited

Children Act allows the state to define Tiffani as a sexually
exploited youth, and
therefore the state will not imprison her for prostitution. She
was mandated to
services at the Teens First agency, unlike her prior arrests when
she had been sent
to detention.
Alcohol and Drug Use History: Tiffani’s parents were social
drinkers until about 8
years ago. At that time Uncle Nate introduced them to crack
cocaine. Tiffani reports
using alcohol when Donald wanted her to since she wanted to
please him, and she
thought this was the way she would be a good “wife.” She
denies any other drug use.
Medical History: During intake, it was noted that Tiffani had
multiple bruises and burn
marks on her legs and arms. She reported that Donald had
slapped her when he felt
she did not behave and that John T. burned her with cigarettes.
She had realized that
she did some things that would make them mad, and she tried
her hardest to keep
them pleased even though she did not want to be with John T.
Tiffani has been
treated for several sexually transmitted infections (STIs) at
local clinics and is
currently on an antibiotic for a kidney infection. Although she
was given condoms by
Donald and John T. for her “dates,” there were several “Johns”
who refused to use
them.
5
Strengths: Tiffani is resilient in learning how to survive the
negative relationships she

has been involved with. She has as sense of protection for her
sister and will sacrifice
herself to keep her sister safe.
Robert Bradley: father, 38 years old
Shondra Bradley: mother, 33 years old
Nate Bradley: uncle, 36 years old
Tiffani Bradley: daughter, 16 years old
Diana Bradley: daughter, 13 years old
Donald: Tiffani’s self-described husband and her former pimp
Anthony: Shondra’s live-in partner, 31 years old
John T.: Tiffani’s most recent pimp

Clinical Case Studies8(5) 383 –402© The Author(s) 2009.docx

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