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 inconsistent. She reported an increase in alcohol consumption, although clarified it was only when she felt anxious. She denied any blackouts 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 increasingly 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. SOCIAL WORK CASE STUDIES: CONCENTRATION YEAR 6 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 depressive 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 permission 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 validate 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. APPENDIX 95 Reflection Questions The social worker in each of the cases answered select additional 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 psychodynamic 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 selfcare 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 combination of medication and talk therapy for overall improvement of emotional and mental health. SOCIAL WORK CASE STUDIES: CONCENTRATION YEAR 96 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 misdiagnosed 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 importance 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 individuals, 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 evaluation session allows for accurate diagnosis and treatment planning 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 ou
The Cortez Family
Paula is a 43-year-old HIV-positive Latina woman originally from Colombia. She is bilingual, fluent in both Spanish and English. Paula lives alone in an apartment in Queens, NY. She is divorced and has one son, Miguel, who is 20 years old. Paula maintains a relationship with her son and her ex-husband, David (46). Paula raised Miguel until he was 8 years old, at which time she was forced to relinquish custody due to her medical condition. Paula is severely socially isolated as she has limited contact with her family in Colombia and lacks a peer network of any kind in her neighborhood. Paula identifies as Catholic, but she does not consider religion to be a big part of her life.
Paula came from a moderately well-to-do family. She reports suffering physical and emotional abuse at the hands of both her parents, who are alive and reside in Colombia with Paula’s two siblings. Paula completed high school in Colombia, but ran away when she was 17 years old because she could no longer tolerate the abuse at home. Paula became an intravenous drug user (IVDU), particularly of cocaine and heroin. David, who was originally from New York City, was one of Paula’s “drug buddies.” The two eloped, and Paula followed David to the United States. Paula continued to use drugs in the United States for several years; however, she stopped when she got pregnant with Miguel. David continued to use drugs, which led to the failure of their marriage.
Once she stopped using drugs, Paula attended the Fashion Institute of Technology (FIT) in New York City. Upon completing her BA, Paula worked for a clothing designer, but realized her true passion was painting. She has a collection of more than 100 drawings and paintings, many of which track the course of her personal and emotional journey. Paula held a full-time job for a number of years before her health prevented her from working. She is now unemployed and receives Supplemental Security Insurance (SSI) and Medicaid.
Paula was diagnosed with bipolar disorder. She experiences rapid cycles of mania and depression when not properly medicated, and she also has a tendency toward paranoia. Paula has a history of not complying with her psychiatric medication treatment because she does not like the way it makes her feel. She often discontinues it without telling her psychiatrist. Paula has had multiple psychiatric hospitalizations but has remained out of the hospital for at least five years. Paula accepts her bipolar diagnosis, but demonstrates limited insight into the relationship between her symptoms and her medication.
Paula was diagnosed HIV positive in 1987. Paula acquired AIDS several years later when she was diagnosed with a severe brain infection and a T-cell count less than 200. Paula’s brain infection left her completely paralyzed on the right side. She lost function of her right arm and hand, as well as the ability to walk. After a long stay in an acute care hospital in New York City, Paula was transferred to a skilled nursing facility (SNF) where she thought she would die. It is at this time that Paula gave up custody of her son. However, Paula’s condition improved gradually. After being in the SNF for more than a year, Paula regained the ability to walk, although she does so with a severe limp. She also regained some function in her right arm. Her right hand (her dominant hand) remains semiparalyzed and limp. Over the course of several years, Paula taught herself to paint with her left hand and was able to return to her beloved art. In 1996, when highly active antiretroviral therapy (HAART) became available, Paula began treatment. She responded well to HAART and her HIV/AIDS was well controlled.
In addition to her HIV/AIDS disease, Paula is diagnosed with hepatitis C (Hep C). While this condition was controlled, it has reached a point where Paula’s doctor is recommending she begin treatment. Paula also has significant circulatory problems, which cause her severe pain in her lower extremities. She uses prescribed narcotic pain medication to control her symptoms. Paula’s circulatory problems have also led to chronic ulcers on her feet that will not heal. Treatment for her foot ulcers demands frequent visits to a wound care clinic. Paula’s pain paired with the foot ulcers make it difficult for her to ambulate and leave her home. As with her psychiatric medication, Paula has a tendency not to comply with her medical treatment. She often disregards instructions from her doctors and resorts to holistic treatments like treating her ulcers with chamomile tea. Working with Paula can be very frustrating because she is often doing very well medically and psychiatrically. Then, out of the blue, she stops her treatment and deteriorates quickly.
I met Paula as a social worker employed at an outpatient comprehensive care clinic located in an acute care hospital in New York City. The clinic functions as an interdisciplinary operation and follows a continuity of care model. As a result, clinic patients are followed by their physician and social worker on an outpatient basis and on an inpatient basis when admitted to the hospital. Thus, social workers interact not only with doctors from the clinic, but also with doctors from all services throughout the hospital.
After working with Paula for almost six months, she called to inform me that she was pregnant. Her news was shocking because she did not have a boyfriend and never spoke of dating. Paula explained that she met a man at a flower shop, they spoke several times, he visited her at her apartment, and they had sex. Paula thought he was a “stand up guy,” but recently everything had changed. Paula began to suspect that he was using drugs because he had started to become controlling and demanding. He showed up at her apartment at all times of the night demanding to be let in. He called her relentlessly, and when she did not pick up the phone, he left her mean and threatening messages. Paula was fearful for her safety.
The Cortez Family
David Cortez: father, 46
Paula Cortez: mother, 43
Miguel Cortez: son, 20
Given Paula’s complex medical profile and her psychiatric diagnosis, her doctor, psychiatrist, and I were concerned about Paula maintaining the pregnancy. We not only feared for Paula’s and the baby’s health, but also for how Paula would manage caring for a baby. Paula also struggled with what she should do about her pregnancy. She seriously considered having an abortion. However, her Catholic roots paired with seeing an ultrasound of the baby reinforced her desire to go through with the pregnancy.
The primary focus of treatment quickly became dealing with Paula’s relationship with the baby’s father. During sessions with her psychiatrist and me, Paula reported feeling fearful for her safety. The father’s relentless phone calls and voicemails rattled Paula. She became scared, slept poorly, and her paranoia increased significantly. During a particular session, Paula reported that she had started smoking to cope with the stress she was feeling. She also stated that she had stopped her psychiatric medication and was not always taking her HAART. When we explored the dangers of Paula’s actions, both to herself and the baby, she indicated that she knew what she was doing was harmful but she did not care. After completing a suicide assessment, I was convinced that Paula was decompensating quickly and at risk of harming herself and/or her baby. I consulted with her psychiatrist, and Paula was involuntarily admitted to the psychiatric unit of the hospital. Paula was extremely angry at me for the admission. She blamed me for “locking her up” and not helping her. Paula remained on the unit for 2 weeks. During this stay she restarted her medications and was stabilized. I tried to visit Paula on the unit, but the first two times I showed up she refused to see me. Eventually, Paula did agree to see me. She was still angry, but she was able to see that I had acted with her best interest in mind, and we were able to repair our relationship. As Paula prepared for discharge, she spoke more about the father and the stress that had driven her to the admission in the first place. Paula agreed that despite her fears she had to do something about the situation. I helped Paula develop a safety plan, educated her about filing for a restraining order, and referred her to the AIDS Law Project, a not-for-profit organization that helps individuals with HIV handle legal issues. With my support and that of her lawyer, Paula filed a police report and successfully got the restraining order. Once the order was served, the phone calls and visits stopped, and Paula regained a sense of control over her life.
From a medical perspective, Paula’s pregnancy was considered “high risk” due to her complicated medical situation. Throughout her pregnancy, Paula remained on HAART, pain, and psychiatric medication, and treatment for her Hep C was postponed. During the pregnancy the ulcers on Paula’s feet worsened and she developed a severe bone infection, ostemeylitis, in two of her toes. Without treatment the infection was extremely dangerous to both Paula and her baby. Paula was admitted to a medical unit in the hospital where she started a 2-week course of intravenous (IV) antibiotics. Unfortunately, the antibiotics did not work, and Paula had to have portions of two of her toes amputated with limited anesthesia due to the pregnancy, extending her hospital stay to nearly a month.
The condition of Paula’s feet heightened my concern and the treatment team’s concerns about Paula’s ability to care for her baby. There were multiple factors to consider. In the immediate term, Paula was barely able to walk and was therefore unable to do anything to prepare for the baby’s arrival (e.g., gather supplies, take parenting class, etc.). In the medium term, we needed to address how Paula was going to care for the baby day-to-day, and we needed to think about how she would care for the baby at home given her physical limitations (i.e., limited ability to ambulate and limited use of her right hand) and her current medical status. In addition, we had to consider what she would do with the baby if she required another hospitalization. In the long term, we needed to think about permanency planning for the baby or for what would happen to the baby if Paula died. While Paula recognized the importance of all of these issues, her anxiety level was much lower than mine and that of her treatment team. Perhaps she did not see the whole picture as we did, or perhaps she was in denial. She repeatedly told me, “I know, I know. I’m just going to do it. I raised my son and I am going to take care of this baby too.” We really did not have an answer for her limited emotional response, we just needed to meet her where she was and move on. One of the things that amazed me most about Paula was that she had a great ability to rally people around her. Nurses, doctors, social workers: we all wanted to help her even when she tried to push us away.
While Paula was in the hospital unit, we were able to talk about the baby’s care and permanency planning. Through these discussions, Paula’s social isolation became more and more evident. Paula had not told her parents in Colombia that she was having a baby. She feared their disapproval and she stated, “I can’t stand to hear my mother’s negativity.” Miguel and David were aware of the pregnancy, but they each had their own lives. David was remarried with children, and Miguel was working and in school full-time. The idea of burdening him with her needs was something Paula would not consider. There was no one else in Paula’s life. Therefore, we were forced to look at options outside of Paula’s limited social network.
Key to Acronyms
|AIDS:||Acquired Immunodeficiency Syndrome|
|HAART:||Highly Active Antiretroviral Therapy|
|HIV:||Human Immunodeficiency Virus|
|IVDU:||Intravenous Drug User|
|SNF:||Skilled Nursing Facility|
|SSI:||Supplemental Security Insurance|
|WIC:||Supplemental Nutrition Program for Women, Infants, and Children|
After a month in the hospital, Paula went home with a surgical boot, instructions to limit bearing weight on her foot, and a list of referrals from me. Paula and I agreed to check in every other day by telephone. My intention was to monitor how she was feeling, as well as her progress with the referrals I had given her. I also wanted to provide her with support and encouragement that she was not getting from anywhere else. On many occasions, I hung up the phone frustrated with Paula because of her procrastination and lack of follow-through. But ultimately she completed what she needed to for the baby’s arrival. Paula successfully applied for WIC, the federal Supplemental Nutrition Program for Women, Infants, and Children, and was also able to secure a crib and other baby essentials.
Paula delivered a healthy baby girl. The baby was born HIV negative and received the appropriate HAART treatment after birth. The baby spent a week in the neonatal intensive care unit, as she had to detox from the effects of the pain medication Paula took throughout her pregnancy. Given Paula’s low income, health, and Medicaid status, Paula was able to apply for and receive 24/7 in-home child care assistance through New York’s public assistance program. Depending on Paula’s health and her need for help, this arrangement can be modified as deemed appropriate. Miguel did take a part in caring for his half sister, but his assistance was limited. Ultimately, Paula completed the appropriate permanency planning paperwork with the assistance of the organization The Family Center. She named Miguel the baby’s guardian should something happen to her.
The Cortez Family
1. What specific intervention strategies (skills, knowledge, etc.) did you use to address this client situation?
Skills I used included engagement and repairing relationship, assessment, asking open-ended questions, gathering information, identifying presenting problems and treatment planning, coordination of and collaboration with an interdisciplinary team, and coordination of and collaboration with community resources. Interventions I used included providing support, partializing problems, setting small achievable goals, suicide assessment, and case management. I had knowledge of the hospital system, Medicaid and public assistance, and HIV/AIDS.
2. Which theory or theories did you use to guide your practice?
My practice was guided by strengths perspective, motivational interviewing, psychodynamic theory, and goal-oriented practice.
3. What were the identified strengths of the client(s)?
Paula had many strengths. She was intelligent, completing both high school and college. She was able to create relationships with helping professionals. She was able to rally people around her. Paula was also a survivor and drew on her life experience. She taught herself how to use her nondominant hand to paint. Even though it took a lot of effort and convincing, Paula was able to get things done.
4. What were the identified challenges faced by the client(s)?
Paula’s challenges included social isolation, physical illness, mental illness, and limited financial resources.
5. What were the agreed-upon goals to be met to address the concern?
We agreed that we would address Paula’s domestic violence relationship by creating a safety plan and obtaining a restraining order. I would assist Paula in making a decision about keeping or ending her pregnancy. We would monitor Paula’s mental and physical health. I would help Paula prepare for her baby’s arrival by helping her get baby supplies; arrange for appropriate services such as in-home child care assistance, WIC benefits, baby’s Medicaid; emotionally prepare for how life will change with a baby; and arrange for permanency planning.
6. Did you have to address any issues around cultural competence? Did you have to learn about this population/group prior to beginning your work with this client system? If so, what type of research did you do to prepare?
Some cultural competence issues were addressed. It was important for me to understand Paula’s Catholic background. While Paula claimed that religion was not a big part of her life, her Catholic views did affect her decision to keep her pregnancy. They were also intertwined in her thoughts and feelings about death and dying.
There were also aspects of Paula’s Latino culture that played out in her case. For example, her tendency to give up on mainstream medical interventions and resort to more holistic and home remedies is consistent with Latino culture. In addition, Paula was always resistant to involving outsiders (i.e., community resources, friends, aides, etc.) in her care/life. She held onto the cultural belief that family issues should be dealt with from within. What made this difficult for Paula was the fact that her family was not involved in her life. She did not want to rely on outsiders, but she was alone and really had no choice.
7. What local, state, or federal policies could (or did) affect this case?
The local and state policies that affected this case include Medicaid, WIC, New York State public assistance, New York City court system, and hospital policies such as length of stay, the Health Insurance Portability and Accountability Act of 1996 (HIPPA), coordination of care across disciplines, etc.
8. How would you advocate for social change to positively affect this case?
This does not apply to this case.
9. Were there any legal or ethical issues present in the case? If so, what were they and how were they addressed?
The big ethical issue that was present in this case was Paula’s decision to keep her baby. Several of Paula’s doctors held strong feelings that Paula should abort her pregnancy. They felt she was too ill to care for an infant and a child at all. As her social worker, I was not sure what the right answer was. It really did not matter because the decision was hers. My role was to support whatever decision she made and help her reach the best outcome given either scenario.
With regard to legal issues, Paula did obtain a restraining order for the baby’s father. Throughout the course of treatment, the father violated the order once. I helped Paula file a report with the police regarding the violation. We also made sure that Paula’s advance directives were in order and helped Paula file permanency planning paperwork with the courts. When working in a hospital setting, one must always deal with HIPPA and protected health information.
10. How can evidence-based practice be integrated into this situation?
Evidence-based practice can be integrated into the situation by using appropriate scales to measure depression, such as the Beck Depression Inventory-II, and by using formal suicide assessment, such as the Beck Scale for Suicide Ideation.
11. Is there any additional information that is important to the case?
There is no additional information.
12. Describe any additional personal reflections about this case.
Paula’s case is one of the most difficult cases I have encountered in my career. I worked with Paula for a little bit over a year. We terminated because I left my position at the hospital. Paula not only challenged my social work skills, but she also drew me into her case emotionally. Yes, I was Paula’s social worker, but at times I felt like I was her only friend and her caregiver. At the beginning, I felt an enormous sense of responsibility for the outcome of her situation. Paula consumed a lot of my time. She called me often and required a great deal of hand-holding. The irony is that when I did not hear from her, I worried. When I did hear from her, I felt like she was demanding and she drew me right into the chaos of her life and her situation. Eventually, when I realized the extent of my emotional involvement in this case, I had to set boundaries for Paula and myself. This became crucial to our work together. I ultimately realized that the boundaries were actually good for Paula as they demonstrated structure and the limitations of others’ involvement in her life. They forced Paula to take personal responsibility for her situation and take an active role in dealing with it. For me, the boundaries kept me sane. They allowed me to realize my own limitations. Many times, I reminded myself, “You can lead a horse to water, but you can’t make them drink.”
I feel very fortunate that I was able to work with Paula as part of an interdisciplinary team. Working on a team allowed me to consult with colleagues about the direction we should take with Paula. It also helped me cope with the stress and challenges of Paula’s case. My colleagues and I often found ourselves venting our frustrations, concerns, and fears with each other. I truly do not think I would have been as successful as I was in helping Paula if I had been on my own.
Mental Health Diagnosis in Social Work: The Case of Miranda Miranda is a 35
old, Scottish female
who sought counseling for increased feelings of depression and anxiety. Her symptoms inclu
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
inconsistent. She reported an increase in alcohol consumption, although clarified it was only when she
felt anxious. She denied any blackouts or reckless/illegal behavior while drinking. She denied a
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 com
pensate for coworkers who are unable to perform at the
expected level of her employer. Miranda stated that she has trouble saying no and feels increasingly
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
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.” Sh
e denied any physical or sexual
abuse in the home. SOCIAL WORK CASE STUDIES: CONCENTRATION YEAR 6 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 depressive 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 ar
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 a
nd 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 permission to set appropriate
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 importanc
e of self
care, Miranda began to
exercise again and set a goal to enter local running and cycling events to encourage herself to continue.