Executive Case Summary
Student Name: Cindy Morales
St. Elizabeth’s Health Center is a faith-based community health center that encourages the healthcare needs of the uninsured and underserved in Southern Arizona. The center commits to provide high-quality healthcare with respect and dignity by responding to individual needs and encouraging health and well-being. The clinical setting for this case is at the St. Elizabeth’s Health Center in the behavioral health unit. The interview took place in an office with the patient, Cindy. The room was small, had no windows, with only one lamp on. It had no decorations just a large Machu Picchu poster on one of the white walls. The unit is a locked unit in the medical area of the clinic. The unit has a lot of individual doctor rooms for patients. Cindy was seated outside of the unit in the lobby with her mother looking at brochures before the intake interview. Cindy and her mother were informed at the beginning of the session of the behavioral health intern’s role at the clinic. If they had any concerns with the treatment, they were receiving they had the right to consult with the intern’s supervisor. Patient and mother agreed and signed the appropriate consent forms.
Presenting Problems and Strengths:
Mother of the patient, Cindy, requested a consult with a behavioral health therapist to initiate care. The mother described Cindy was experiencing symptoms of depression, anxiety disorder (panic attacks) and self-harming (cutting). The patient reported feeling stressed a lot. Cindy is a 17-year-old Hispanic female living with her parents and two younger siblings. The patient says she feel high anxiety when she encounters social situations, for that reason patient reports she tries to avoid them. Some of Cindy’s strengths are being a good student at the school, having good grades most of the time. She enjoys writing and drawing. Patient denies any substance abuse. The patient also denies any history of past suicide ideation or prior attempt.
Mother reports that patient’s mood has been very depressed, she has lost her appetite; she speaks negatively about herself and has engaged in self-harming behaviors (physician noted superficial scars on left lower arm). The patient states that she has recently left one school and will be switching to another because her friends at the old school were engaged in cutting and other self-harm behaviors. She also stated some were unkind to her. She reports that she has not cut herself in several weeks, that the urge to do so vacillates, and seems to occur more often in the later part of the day. Mother of the patient believes patient was being bullied at the school she was attending before, but patient denies.
Diagnosis according to DSM 5:
Generalized Anxiety disorder (ICD-300.02) (ICD10-F41.1): The patient complains of excessive worry for more than six months, inability to control fear, easily fatigued, weak concentration/ mind goes blank, irritability, and sleep disturbance.
Patient’s anxiety revolves mostly at school or in any. She has recently moved to a new school. The patient expressed her concerns about starting the new school in a couple of weeks, particularly the social environment in the new school setting. However, she states she feels comfortable setting boundaries with unpleasant or bullying kids. Patient reports experiencing high anxiety in social situations frequently. The patient finds it hard to participate in new things because she is mostly shy, and because of that, she also sometimes avoids speaking to people when she can. The patient reported one of her main reasons she is afraid to talk to people or have relationships is because she is worried that people will think poorly of her. Social situations feel “threatening” to her. The patient describes, “I am unlikeable, or I’m not good enough.” She does not have a good support system. She also finds it hard to speak to her parents, especially her father. Patient reports their communication is weak and it makes it hard for her to open up to them.
Major depressive disorder, single episode, and moderate degree (ICD-296.22) (ICD10-F32.1): The patient complains of depressed mood, decreased interest, significant weight loss/ reduced appetite, reduced energy, extreme worthlessness, poor concentration, and patient admits to self-harming behavior when feeling depressed (cutting on forearm).
Patient reports that she spends a lot of time at home locked in her room. She doesn’t have many friends. Patient’s mother said patient never wants to do anything outside the home or at home, household chores. Patient’s mother reported patient has been lacking interest in getting ready for school or family events. “She doesn’t even do her makeup anymore.” The patient reported that at her former school she didn’t get along with a few people. She stated it would make her feel very “sad” that she didn’t have many friends. The patient was asked if she was being bullied, and she responded no. Patient’s mother stated that patient had lost weight since she was at her last school, one year ago. The patient stated her parent’s relationship overwhelms her and gets her sad most days as they argue on a daily basis. Her parents are having problems right now, and she wishes not to have to hear them “fighting” all the time. She is the eldest of three siblings, and she feels like she plays a more prominent role than an older sister, cooking for them, taking them and picking them up at school, and sometimes doing laundry every week. The patient stated that she is most content when her grandparents come to town and visit from Mexico.
The strengths perspective will be the best theoretical framework for this case study because it will help the patient will understand her feelings and meaningfulness behind the symptoms anxiety and depression. The patient will learn how those feelings can lead to self-harm. This framework will help identify her needs and developing skills. Also, it can facilitate interpersonal communication (family), and build a better social environment. The patient is triggered by different things, such as shame, anger, social situations, or high- stress situations (parent’s relationship). The act of self-harm serves as an emotional release and helps her feel as if she was in control of herself, or sometimes serves as a distraction from stress in her daily life. This has eventually prevented the patient to develop other coping mechanisms. With this framework, the therapist and patient will develop new coping mechanisms.
Patient and mother were provided intake information and agreed to begin psychotherapy on a weekly basis to address depressive and anxiety symptoms through the use of Cognitive Behavioral Therapy. Father and siblings will likely attend some future sessions. Treatment goals will be: enhancing communication skills within the family system, building emotional literacy and resilience, intervening on the patient’s self-harming behaviors and developing alternative coping tools.
With this case, I will be using Cognitive behavioral therapy (CBT). CBT is a form of psychotherapy that aims to change thought patterns to change moods and behaviors. It’s grounded in the idea that harmful actions or feelings are the outcomes of current distorted beliefs or thoughts. With CBT, the therapist will help the patient develop a more balanced and positive way to respond to stressors. If possible, these new responses will improve the patient decrease or eliminate the concerning behavior.
The presentation of a critical psychiatric disorder such as major depression is among the most influential predictors of self-harm. Anxiety, especially if acute and intense, also has an important role. It is highly essential that the therapist considers this to help reduce any intentions of self-harm. CBT will help the patient decrease symptoms of anxiety and depression and improve the patient’s self-esteem and problem-solving ability. Empirical evidence indicates that individual and group CBT are efficacious and effective treatments for depression and anxiety (Hofmann, Asnaani, Vonk, Sawyer, & Fang, pg. 427, 2012)
This intervention best fits my patient as she is having frequent negative-self thoughts. These lead her to not trusting herself and to think she is not “good enough.” I also decided to use this intervention because of her social anxiety. A tool we will be using is the Dysfunctional Thought Record Worksheet. We will be challenging some of her core beliefs, “I am unlikeable,” “I am not good enough” as they tend to drive the expression of socially anxious symptoms. A study found that decreases in negative automatic thoughts predicted treatment gains in CBT for highly anxious children (Kendall and Treadwell, pg. 381, 2007). Another study concludes that changes in negative thinking are associated with decreases in anxiety and appear to predict improvement in symptoms (Normann, Ronfeldt, Reinholdt-Dunne, and Esbjorn, pg. 188, 2016).
There are a few long-term emotional risks with CBT that the therapist must be aware of. Analyzing painful feelings and experiences can be stressful for the patient, especially at a young age. The treatment may involve facing situations the patient may have tried to avoid for some time.
The therapist will evaluate this intervention as the patient shows the reduced amount of harmful self-thoughts and core beliefs. The patient will be aware of her maladaptive thoughts and know how to use different tools to cope with them. The patient will have no behaviors toward self-harm. The patient will improve communication skills within the family system.
Relevant Policies or other Macro Issues:
A macro issue affecting the paient and the family are the effects of immigration legislation on Mexican immigrant families’ health and mental health. The patient’s parents are immigrants and have been here for more than ten years. They have a low-income because of their inability to work and have a good-paying job. The family, as a whole, live under risky conditions in their everyday life; feelings of isolation and powerlessness by the father, frustration, living with the fear that they will be deported, stress, etc. Even though the family has been in Arizona for more than a decade the state of Arizona has passed many policies that negatively affect this community. Most recently, Arizona legislation has put an end to bilingual education and prevents undocumented immigrants from receiving state public benefits. Without these benefits, the family will remain with a low income and continue to suffer from high costs of medical care.
What other theoretical framework could be best used with self-harm patients?
Are there any other concerns you would have addressed in this case?