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Amella Abraham Case Study Client Background Amella Abraham, age 16, is an African American transgender adolescent girl who lives with her parents, Tameika and Dejon Abraham, and her three older brothers, Amante, Asaad, and Audell, in Jackson, Mississippi. Amella was born Amell Dejon Abraham, but even as a young child, she knew she was different than other kids in her school and neighborhood. She preferred to play with dolls and liked to dress up as a young child, much to the glee of her older brother Asaad, who teased and tormented her ceaselessly, calling her names like “little weirdo” or “sissy-homo.” When Amella was younger, her parents simply ignored her “unusual” behaviors. She sometimes heard them talking to each other about her, saying that “he will grow out of this when he gets to school” or “he just needs God’s guidance and clear rules to understand what’s right and wrong.”

Amella’s parents own the Blue Turtle Inn in the Farish Street Neighborhood Historic District of Jackson. The neighborhood, which was a thriving Black-owned business sector in the 1940s, '50s and '60s, physically crumbled after segregation ended. Recently, business leaders have been trying to revive the district, and Amella’s parents want to do their part. Their diner is a favorite lunch spot. Dejon is a trained chef who has earned regional recognition, and Tameika has a degree in hotel and retail management, taking care of the front end of the diner. Both are very focused on making “our life’s work” a success before passing on the business to their children.

Dejon and Tameika are very religious. They attend their neighborhood Baptist church every Sunday and expect all of their sons to accompany them. They believe that regular prayer and moral conduct are important for true salvation. When Amella was very young, they believed that her tendency to dress “girlish” was a phase of exploration and that strong and directive parenting practices would make their son learn his place. Instead, Amella knew by age 3 that she felt like a girl. At age 11, she began using the pronouns she/her/hers and asked to be called “Amella.” Her brothers, 17, 14 and 13 years of age at the time, were all actively involved in playing football or basketball on their respective schools’ teams and had mixed responses. Audell continued to use male pronouns but made a greater effort to spend time with Amella. He knew she didn’t have many friends and hoped that Amella would “come around” if she had a male role model to look up to. Asaad simply laughed at Amella and said that he would call her “Gaymella” or “Ugly-ella” because she acted gay and was ugly … a promise he has stuck to ever since. Amante has tried not to use pronouns at all and quietly calls her “Amella” when no other family members are around.

Amella is offended by Asaad’s rude comments and frustrated by Audell’s efforts to convince her to embrace masculinity but, in her opinion, they are typical “jocks” and not very bright, and she tries to stay out of their way. She is, however, deeply hurt by what she perceives as her parents’ unwillingness to love her unconditionally. Initially, Amella’s

parents were baffled and dismayed by what they considered Amella’s “unnatural” request. They were unsure about how to deal with it and stuck to their strategy of ignoring it along with her “strange” behaviors. However, by age 12, Amella began dressing more explicitly like a girl, which angered her father, who said, “As long as you live in my house, you better not act like a pervert; God made you as a boy, and it is a sin to pretend to be anything different.”

Amella’s mother has been a bit less severe, but she, too, has continued to try to dissuade “my beautiful boy” from “acting like a girl and attracting attention you don’t want.” She has asked Amella to pray every day for God’s forgiveness and guidance. Once she even took her to see their pastor. He commanded Amella to live like God intended her to, and when she voiced the belief that God intended her to be happy as whoever she is compelled to be, he said she was “taken in by the lies of Satan” and asked her to pray with him.

Present Functioning Things have been very difficult at school lately. Amella enjoys learning and excels at math, but she has had difficulty concentrating on more than one task at a time and is often scolded for forgetting to complete her assignments. Amella has a few acquaintances she sits with at lunch but no one she considers a true friend; the majority of the student body considers her an outcast and treats her accordingly. In the best circumstances, they ignore her, but she also has become the target of both physical and cyberbullying. She has received death threats for being “a pedo” and being a “stain on the community.”

Many of her teachers are also very religious, and most have either directly or more subtly let her know that they do not condone her “indecent and ungodly acts.” They tend to look the other way whenever other kids torment her.

Some time ago, Amella joined an online chat platform in search of a space where she could be herself and talk to others who understand her. There, she was introduced to an engaging multiplayer internet video game and was surprised to discover that she was highly skilled at it due to her ability to hyperfocus.

Amella has been spending more and more time online and has developed friendships with other video game players, several of whom identify as part of the LGBTQ+ community. She is much more comfortable in this virtual world than in the real world and has been staying up into the middle of the night to play and chat to ease her loneliness. She has also begun vaping to “take the edge off” the painful experiences of rejection she endures both at home and at school.

At first, Amella would vape only once or twice a day in a private wooded area on her walk home from school. However, as time passed, she has grown to crave the peaceful feeling vaping provides and has begun to vape much more often. During the past few weeks, Amella has been vaping more than 12 times a day, including in the school bathroom and behind rows of lockers in between her classes. She knows that she is

being reckless and will get in trouble with school authorities if she were to be caught, but her body has begun to feel like it can’t function without nicotine.

She also knows her parents would be deeply disappointed with her if they were to find out, but she feels she has no other way to numb her stress, anger, and pain. A few days after her 16th birthday, everything came to a head. Amella was caught vaping by a teacher, and the school principal called Amella’s parents in for a conference. Amella’s parents were shocked and embarrassed when they arrived at the school. They thought there must have been some kind of misunderstanding and were baffled to learn that Amella apparently had a significant vaping habit and was unsure if she could stop. Amella’s principal and school counselor noted that Amella had also been acting very tired and unfocused at school in recent months and that they had heard about some bullying incidents. They recommended that the Abraham family seek therapy for Amella.

Week 5 Update: Recent Developments After the school conference, Amella’s parents didn’t seem to know what to do or say to Amella. They mostly ignored her and acted as though nothing had happened. But when Amella stayed up at night to play and chat with her gaming friends, she often heard them speaking in low voices about how Amella’s behavior impacted the family reputation. They decided to arrange another meeting for Amella with their pastor to help her “get her life back on track,” but Amella refused to attend.

Amella continued to vape many times a day, though she made an effort to be more discreet about vaping at school. On a few occasions she tried to go through an entire school day without vaping but was surprised at how difficult it was to cope with her body’s craving for nicotine after going without it for just a few hours. One day the school counselor turned around the corner of the hallway and bumped into Amella just as she had finished vaping. Amella had already put away her cartridge and there was no visible evidence that she had been vaping but the smell was fairly obvious. He invited her to his office for a few minutes.

Amella felt apprehensive but she remembered him from the school conference and recalled that he had been kind. “Amella, I didn’t actually see anything happen just now. But I imagine you might still be vaping at school and I just wondered if you might need some support. I remember we had suggested that your parents could set up a therapy appointment. Did they?"

Amella told him that her parents had only offered an appointment with their pastor whom she had not found helpful or supportive in the past. “I know of a facility that works with teens and adults on substance use as well along with many other issues and there are several professionals on the team that specialize in offering affirming care to LGBTQ+ clients. Would you be interested in something like that?”

Amella paused to think. “I don’t really think vaping is that big of a deal.”

“Mental health clinicians can help clients with lots of issues, not just vaping,” he replied. “Sometimes it can feel good just to talk to someone who understands.”

“Yeah, I guess that’s true. My friend Kai sees a counselor for transition care and Carter sees someone because he’s always sad. Maybe it would give me a place to vent. I guess I’d be open to it.” The counselor called Amella's parents to follow up on the school conference. The Abrahams explained that they had tried to set up an appointment with their pastor but acknowledged that it did not appear to be a promising solution. They were unsure where else to turn. The school counselor explained that many families had had good experiences with a facility affiliated with a research university and that there were several providers he could recommend by name. The Abrahams decided to trust his advice and set up screening and assessment appointments for Amella.

Over the next week, Amella had a series of appointments. She entered into the experience with low expectations, but she found it was more interesting than she expected. Every professional asked Amella what her pronouns were, and a few clinicians even mentioned that they themselves were members of the LGBTQ+ community. Amella found herself feeling a great deal of relief as she talked to professionals who affirmed her identity. As Amella filled out forms and met with professionals for assessment sessions, she spent more time thinking about vaping and the role it has played in her life. She still believed that nicotine was not a “real” drug, but she felt uneasy about the degree to which her body felt like it could not function without it. During one interview, when asked about her goals for the future, she mentioned that she really wanted to move out of state to attend a 4-year college in a progressive city. “I know I’d probably need a scholarship. But I’m a girl interested in STEM and I work hard.” As she spoke with the clinician, she acknowledged that she was a strong candidate for a scholarship but getting in trouble for vaping could interfere with this goal.

Week 6 Update: Interdisciplinary Team Meeting As the screening and assessment appointments came to a conclusion, the interdisciplinary team met with both Amella and her parents to discuss the results. The psychiatrist on the team provided the following diagnoses:

• F15.20 Other (or Unspecified) Stimulant Use Disorder, Nicotine, moderate • F64.8 Other Specified Gender Dysphoria

The social worker on the team invited Amella to begin treatment and explained that the facility was equipped to offer treatment that could serve teens and parents in a variety of ways. Mr. and Mrs. Abraham felt cautious as they didn’t know how well this treatment might align with their religious and cultural backgrounds. But they saw that their daughter was happy and comfortable in the presence of these professionals, they could see that the team was diverse, and they saw that the team’s desire to help seemed

genuine. Together, Amella and her parents signed written consents and scheduled an appointment to develop a treatment plan.