assignment focuses on vignette analysis and direct application of course
concepts to the persons and situations presented in the vignette for
each question. All discussions must take into account the legal and
ethical considerations, as well as issues of culture and human
diversity that may pertain to the situation presented below.
Culture and Legal/Ethical issues can be found in the course text, but
you are encouraged to use outside sources in culture and ethics to
enhance your work.
Please keep your responses focused on what
is presented in the vignette. Do not add information but use your
creativity to support what you see in the vignette as written.
assignments MUST be typed, double-spaced, in APA style and must be
written at university level English. The content, conciseness and clarity
of your answers will be considered in the evaluation of your work.
You must integrate the material presented in the entire text and DSM-5. You are encouraged to use outside research to enhance the text material, but not to replace the text. Please cite all work according to APA format.
Your response to each case should be approx. 3-4 pages per case.
Your entire assignment should be 6-8 pages total
Case of Meredith
Meredith is a 17-year-old Latino high school junior who just
experienced a school shooting that resulted in the death of 2
classmates. She was referred to you by her family physician. Meredith
has been diagnosed with major depressive disorder, recurrent (moderate)
previous to this recent incident. Meredith has a history of two recent
suicide attempts. Her previous treatment has included inpatient, partial
hospitalization, and intensive outpatient phases of mental health care.
Meredith discloses that for over the past few months, she has been
drinking alcohol (whiskey, vodka, and beer) and snorting
crushed Adderall tablets. She states that both the alcohol
and Adderall help her cope with the depression, just in different ways.
Meredith says “drunk or high on Adderall beats depressed or dead” and
she refuses to cease either substance.
Major Depressive Disorder and Suicide History
Meredith reports that around age 13, she experienced her first serious
and long-lasting depressive episode where she recalls nearly one month
of increasingly worsening depressed mood, feeling “worthless and ugly,”
and an inability to sleep, eat, or do her schoolwork. At age 14, she
first attempted suicide by taking a large amount of acetaminophen.
Meredith recalled being angry that the Tylenol did not kill her.
However, she never informed her parents and it was not discovered until
Meredith was admitted to an inpatient mental health facility following
her second suicide attempt about 18 months later where she swallowed a
handful of Zoloft that her family physician prescribed. The attempt was
uncovered by her parents when she was found vomiting and shaking while
reporting being dizzy. Again, Meredith reported feeling “overwhelming”
depressed mood in the weeks leading up to her second suicide attempt.
The attempt was not planned. Meredith stated to you that she “did not go
into the bathroom to kill myself, it just sort of overtook me all of a
Meredith currently reports feeling moderate
depressive symptoms that can sometimes border on severe. Meredith is
currently in a depressive episode that seems to have lasted for
approximately the past three weeks. She reports still having suicidal
thoughts, but lacks any plan or intent. She is currently under the care
of a psychiatrist who has her on a low dose of Lithium daily.
Alcohol Use History
Meredith reported two “types” of drinking. One drinking “type” is a
typical pattern of alcohol use for a high school student where she
reports drinking at parties and sometimes getting drunk. The other
“type” of drinking that has you concerned is her use of alcohol as a
coping mechanism for the depression and suicidal thoughts
Meredith reports drinking alone in her room 3–4 times per week when she
is experiencing depressed mood and/or suicidal thoughts. Over the past
four months, Meredith was able to identify that it seems she now needs
“a little more” alcohol to achieve her same desired effect. She also
states that over the past two weeks, she experienced her first instance
of going to school with a “major hangover.”
Adderall Use History
Approximately two months ago, her friend turned Meredith onto
snorting Adderall. Meredith states she would snort Adderall almost once
daily (usually in the morning) over the past several weeks. She stated
it helped her to “focus” and be able to do well in school. “The
depression makes me drag. I can’t think well. Plus, I get wrapped-up in
my own pity party in my head. I snort some Adderall and I feel a buzz in
just a few moments. I’m up. I see it as a counter to the depression.
Please respond to the following questions:
1. Drinking
and snorting Adderall are clearly not healthy coping skills, but they
are the only coping skills Meredith seems to believe in due to their
effectiveness of removing her negative affect/mood/thought (even though
it is only temporary). Considering her recent exposure to school
violence, her poor perception of typical coping skills and her
reluctance to see counseling as a helpful strategy, how would you work
with Meredith to engage her in treatment?
Alcohol is a depressant whereas Adderall is a stimulant. How and why
do you think each of these substance classes assist Meredith in coping
with her depression and life in general? Why do you think her
psychiatrist is treating her with Lithium?
Based on your thinking in answering question #2, what would be the
appropriate level(s) of care for Meredith? Discuss the complexity of
Meredith’s treatment in consideration of the recent school shooting,
her major depressive disorder and substance use.
4. How would you use family counseling in your treatment of Meredith?
Case of Richard
Richard is a 22-year-old gay college senior who presents with a
five-year history of alcohol use disorder and a little over one-year
history of sedative, hypnotic, and anxiolytic use disorder
(i.e., Xanax). In addition, Richard presents with a long-term history of
generalized anxiety disorder and panic disorder. He discloses that he
has been in therapy for anxiety, but has never been in any form of
substance use treatment before. He was referred by his partner, who grew
concerned regarding Richard’s recent increase in anxiety over the past
few days. His partner does not know of Richard’s Xanax use.
Richard reports having “anxiety issues” for as far back as he can
recall. He vividly remembers the phone call he received from his aunt at
age 8, informing him that his parents had been killed in a car
accident. He was then raised by his aunt and uncle. Relevant to his
adulthood (since approximately age 18), Richard can recall numerous
instances in college where he experienced anxiety that he could not
understand. I would wake-up and just feel anxious. “It was ridiculous. I
am a great student with a 3.7 GPA but it took so much work. And not the
normal work others do. I would get so worried”. Richard also discussed
having multiple panic attacks that were entirely unexpected.
Alcohol Use History
Richard reported a frequent use of alcohol that started in his latter
high school years and progressed throughout college. Richard noted that
at first drinking was only a “social thing” but he slowly realized that
his drinking would help him “calm down.” He tells you how alcohol solved
his social anxiety, especially when having to speak in front of
classmates. “I felt so much better about 30 minutes later when it was my
turn to talk. I can still remember doing the talk while thinking to
myself wow I’m not anxious!
Richard reviewed a
drinking history in college that consisted of beer and hard liquor
consumption approximately 4-5 days per week. On any given day over the
past 12 months, Richard was unable to quantify his exact usage.
Xanax Use History
Approximately, 14 months ago, Richard started taking Xanax that he
obtained illegally. He began when his friend at college, who also
experiences anxiety, offered two of his Xanax prescribed by a physician.
Richard found the Xanax just as beneficial for his anxiety as the
alcohol, but he was able to take these “out in plain sight.” Richard
discussed he would typically consume the Xanax and drink alcohol within
the same 24-hour period.
Richard’s Presentation
Richard reported that he read an online article about the dangers
of Xanax. Approximately three days ago, stopped taking the Xanax “cold
turkey.” He reports that he stopped drinking as well because he “read
about how alcohol is a bad thing mixed with Xanax.” Richard does present
in session as very jittery, with rapid speech, an inability to stay on
task, and an increased degree of reported anxiety. Richard also reports
he “sometimes hear footsteps or whispering” over the past 2-3 days. He
reports difficulty sleeping the past few nights and he demonstrates
moderate hand tremors when filling out intake paperwork. Richard reports
he feels “overwhelming” anxiety and fears another panic attack is
imminent. When pressed regarding any context for his anxiety, Richard
cannot clarify why he feels such overwhelming anxiety.
Please respond to the following questions:
Richard clearly presented to counseling ONLY for anxiety issues.
Consequently, how do you educate Richard on his appropriate immediate
level of care? Where do you see the levels of care progressing following
the initial treatment level?
2. Even though
Richard does present with a clear co-occurring non-substance-related
history of anxiety disorders, how do you conceptualize his current
anxiety symptoms in the context of his rapid “cold-turkey” cessation
of Xanax and alcohol?
3. In consideration of
Richard’s history of trauma, and current clinical and substance-related
presentation, what are your diagnostic impressions?
Given the models if intervention and levels of care discussed in the
course, how might you treat Richard? How might couple counseling be a
supportive adjunct to Richard’s treatment?
Activity Outcomes
Identify legal and ethical issues in diagnosis and treatment
Recognize relevance of age, cultural diversity and special populations in diagnosis and treatment

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