SOCW-6111-Discussion Wk 5

PRACTICE

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Mental Health Diagnosis in Social Work: The Case of Miranda

Miranda is a 35-year-old, Scottish female who sought counseling for increased feelings of depression and anxiety. Her symptoms include constant worry, difficulty sleeping, irritability, increased appetite, unexplained episodes of panic, feelings of guilt and worthlessness, and feelings of low self-esteem. She denied any suicidal/homicidal ideation but verbalized feelings of wanting to be dead. She maintained these thoughts were fleeting and inconsis- tent. She reported an increase in alcohol consumption, although clarified it was only when she felt anxious. She denied any black- outs or reckless/illegal behavior while drinking. She denied any other drug use.

Miranda works in the fashion industry and reported that she is very well liked by her peers and clientele. She is regularly chosen to train other staff members and comanage the store. However, she is often given a heavier workload to compensate for coworkers who are unable to perform at the expected level of her employer. Miranda stated that she has trouble saying no and feels increas- ingly irritable and frustrated with her increased workload.

Miranda has been married to her husband for 3 years, and they have no children. She reported that both her mother and father have a history of mental illness. Miranda’s parents are divorced, and when they separated, Miranda chose to live with her mother. Miranda’s mother remarried a man she described as “vicious and verbally abusive.” Miranda stated that her stepfather called her names and told her that she was worthless. She said he made her believe that she was sick with chronic health issues and many times forced her to take medicine that was either unnecessary or not prescribed by a doctor. Eventually he asked Miranda to leave her mother’s home. Miranda stated that her mother was well aware of her stepfather’s behavior but chose not to intervene, stating, “He is a sick man. Just do what he says.” She denied any physical or sexual abuse in the home.

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In order to treat Miranda’s symptoms, we first addressed the need for medication, and I provided a referral to a psychiatrist. The psychiatrist diagnosed her with panic disorder and major depres- sive disorder and prescribed appropriate medications to assist her with her symptoms. Miranda and I began weekly sessions to focus on managing her boundaries both at work and with her family. We discussed her behavior around boundary setting as well as the possibility of enlisting her husband as a support person to encourage and promote healthy boundaries. We also discussed unresolved issues from her childhood. This approach enabled Miranda to gain insight into the self and how her maltreatment as a child affected her functioning in the present time. This insight enabled Miranda to validate her feelings of anger, frustration, and sadness about her upbringing and further give herself permis- sion to set appropriate boundaries in her relationships. We also discussed the need for relaxation and stress management. Miranda was able to identify that she used to enjoy cycling and running but had not been engaging in them because of the demands at work. After discussing the importance of self-care, Miranda began to exercise again and set a goal to enter local running and cycling events to encourage herself to continue.

After 1 year of therapy, Miranda decided to taper down her medication, which was monitored by her psychiatrist. She has chosen to remain in therapy weekly to monitor her mood as she decreases her medication. Miranda’s overall presentation has improved greatly. With the use of medication, behavioral therapy, relaxation techniques, and psychodynamic therapy, Miranda’s affect presents as stable and her symptoms of depression are gone. Miranda is a client that is able to verbalize the benefits of treatment in helping her gain insight and empower herself to vali- date her own emotional needs. She has been a highly motivated patient who enjoys the safety of being able to express her thoughts and feelings without judgment.

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Reflection Questions The social worker in each of the cases answered select addi-

tional questions as follows.

Practice

Mental Health Diagnosis in Social Work: The Case of Miranda 1. What specific intervention strategies (skills, knowledge, etc.)

did you use to address this client situation? I referred the client to a psychiatrist. I used behavioral therapy,

relaxation and stress management techniques, and psychody- namic and structural family theories to address underlying issues from childhood.

2. Which theory or theories did you use to guide your practice? I used psychodynamic and structural family theories to address

adult survivors of child abuse in order to help Miranda connect to the effects of her stepfather’s maltreatment, regain her sense of self, and recognize the unhealthy functioning in her present relationships and daily living.

3. What were the identified strengths of the client(s)? Miranda was motivated, identified goals well, and had a supportive

husband. 4. What were the identified challenges faced by the client(s)? Miranda reported a mental health history. 5. What were the agreed-upon goals to be met to address the

concern? The initial goal was to decrease symptoms of anxiety and

depression. As therapy progressed, the greater goal became gaining insight into Miranda’s childhood to allow for more self- care and stress management.

6. How can evidence-based practice be integrated into this situation?

Miranda’s case is a great example of the benefit of a combina- tion of medication and talk therapy for overall improvement of emotional and mental health.

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7. Is there any additional information that is important to the case?

It is important to note that prior to seeing me for treatment, Miranda had been to several psychiatrists who misdiag- nosed her with borderline personality disorder and bipolar disorder specifically based on the fact that she was female and had a history of abuse. She had been given a series of medications that were ineffective due to misdiagnosis. When Miranda came in for the first session she was very distrusting of psychotherapy as well as medication. My ability to create a safe and trusting environment was of the upmost impor- tance in order for Miranda to get well and work with her underlying issues.

8. Describe any additional personal reflections about this case. Miranda’s case is a great example of the need for a thorough

mental health history, mental status exam, as well as family history of mental health issues and relationships. With individ- uals, it is important to ask critical questions that reflect mood and affect presentation as well as history of drug and alcohol use, family dynamics, and any past history of abuse. There is almost always a reason for a patient’s mood deregulation. A proper eval- uation session allows for accurate diagnosis and treatment plan- ning as well as letting you, the social worker, know if this is a case that will fit within your practice.

Social Work Supervision: Trauma Within Agencies 1. What specific intervention strategies (skills, knowledge,

etc.) did you use to address this client situation? This was a difficult tragedy to deal with, and it was difficult

to know how to proceed. I had contacted the county (who funded the agency) for help. The people I contacted at the county did not know what to do and were of little help because, as they stated, they had never dealt with death of a staff member. I turned to my senior staff, and we as a group came up with a plan to notify each client in the most sensitive way possible. In addition, the use of another agency and our