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Single System Design (Case Study)
Transcript of Single System Design (Case Study)
Client Case Presentation
Indiana University School of Social Work
Present Psychiatric Illness/Symptoms
39 year old female.
Attorney and adjunct professor.
No children and no history of pregnancy.
Initially referred to JLAP back as a bar applicant for a review of information contained in her bar application (regarding mental health treatment). However, she has been a voluntary client since
Referred to JLAP intern in July 2015 to address current (severe) anxiety issues in professional and social interactions.
Client described herself as a "constant worrier" and could not recall a time when she had not experienced some degree of anxiety.
She reported that she tends to overanalyze everything to the point of obsession - resulting in tension and headaches.
This problem was particularly bad during her tenure in law school. Despite possessing exceptional intelligence, she said she has always had trouble making decisions for fear of making mistakes and not trusting others.
Client gets very anxious about engaging in unfamiliar social situations.
For the past several weeks she has begun to experience severe bouts of depression. She admits having brief sucidial ideations without a specific plan, but believes these ideations were prompted by her medication(s).
She has become very agitated with her clients and people in general.
She finds it difficult to concentrate on her work due to her thoughts being "like a broken record" - thoughts from which she has difficulty distracting herself.
Her sleep patterns are abnormal. She has trouble initating and maintaining sleep.
She avoids any romantic situations with men.
Prefers female mental health practitioners, etc.
Client was raised in a two parent household in Indiana. Father is deceased and mother is still living.
She reports that she had a tense relationship with her parents, who were capable of being rather emotionally and verbally abusive to her in the past.
Client reports that father was an alcoholic. Mother constantly berated her father about his addiction and low intellect.
She is the youngest of five children - three brothers and one sister. The eldest sibling (brother) died of heart complications in 2002.
Client states that as a child she generally got along with her sibilings. However, she was closest to her deceased brother (who also possessed above average intelligence).
Client reports that she is currently not close to any of her siblings and has limited contact with them. Amongst her sibilings, she predominately maintains contact with her sister.
Client reports a family history of alcoholism, diabetes, and heart complications.
Academic and Intellectual History
Client has been placed in academically gifted courses, beginning in elementary school thru college.
Gathered numerous awards and accolades for superior academic achievement, including "Who's Who Amongst American Hight School Students", etc.
Has received a J.D. and M.B.A.
Client has a long psychiatric history. She has been pro-active in purusing counseling/treatment for her mood disorder throughout her life time (Agency records highlight client's medical treatment since 2003).
Clients current treatment plan - mental health therapy and periodic antidepressant medication - is appropriate due to the nature of her Dysthymic Disorder.
This disorder is characterized by depressed mood, more days than not, and can include major episodes of depression.
Client currently works as an attorney and a part-time adjunct professor at a local college.
She reports having financial stressors and admits to being overwhelmed by her bills - resulting from outstanding balances for her legal services.
When discussing her financial hardships, client claims:
I invest all my time trying to secure the most optimal outcome(s) for my client(s). They don't appreciate my efforts. In fact, trying to get my clients to pay for my services is very difficult! [Oustanding balances] make me very upset. It causes me a great deal of stress and anxiet
Interpersonal & Role Functions
The client does not identify as having any close friends.
She reports having very few friends and colleagues whom garner her respect (including JLAP volunteer(s)).
Client repeatedly states that "
people only stab you in the back
" and "
no one can be trusted
" -- evident by her ex-boyfriend (who is currently suing her).
Client tends to be isolative to her home and has limited interactions with people.
She becomes extremely anxious when encountering new people and unfamiliar social settings.
Specific person-in-environment factors
During the intervention period, client was under the following stressors:
Family issues with mother;
Lawsuit from ex-boyfriend of 2.5 years;
Financial problems due to non-paying clients;
Juggling clients and adjunct teaching duties;
Depression and suicidal thoughts during a short period;
Fender bender, causing the return of back problems (pending litigation); and
Trying to be all things to people with little time for
Strengths & Resilence
Client is very intelligent and resourceful.
Has made great strides in learning about her mental health disorder(s).
Client continously seeks out advice and support from her therapist, psychiatrist, and the JLAP Staff.
Goals, & Interventions
The client willingly completed the State Trait Anxiety Inventory for Adults (STAI - AD) on weekly basis.
STAI-AD is an introspective psychological inventory consisting of 40 self-reporting items.
This tool is the definitive instrument for measuring anxiety in adults.
It clearly differentiates between the temporary condition of "state anxiety" and the more general, long standing quality of "trait anxiety".
It helps professionals distinguish between a client's feelings of anxiety and depression.
Access to Medical Care
Client has no issues in accessing medical care.
Twenty items assess “
how you feel right now, at this moment
,” and twenty items measure “
how you generally feel
,” with the intention to differentiate between anxiety states and traits.
Both scales have a good internal constancy with a Cronbach alpha > 0.90 (
Cronbach's alpha was 0.93 for the State and 0.92 for the Trait subscale
Both STAI scales show a high correlation to depression scales, as the majority of items capture a “negative mood” or “general distress” aspect (e.g., feeling tense, upset, frightened, indecisive, strained, etc) which is also assessed by typical depression scales.
Assessmental Tool (Cont'd)
The STAI inventory was used to measure client's state and trait anxiety levels at the baseline, during, and post-writing intervention for 13 weeks.
Writing intervention objectives:
Identify anxiety triggers;
Reduce client's level of anxiety;
Explore cognitive restructuring of maladaptive thoughts; and
Encourage positive coping technqiues for anxiety and stress.
Goal(s) & Intervention
Mean"state" anxiety was 80 (R =41-67, SD = 10.88)
Mean "trait" anxiety was 54.4 (R = 47-66, SD = 4.68)
During the course of the intervention, various factors influenced client's state and trait anxiety. Including, but not limited to, the following:
Week 5 - Client changed medication
Wellbutrin and Effexor (for depression) did not work. Wellbutrin gave client terrible insomnia and affected her functioning in general. Effexor made her very sick. Both of these medications impacted her anxiety and mood levels.
Week 6 - Scheduling issues
Client did not recieve adjunct teaching schedule until week 5, causing her a great deal of stress.
Week 7 - Classes begin
Semester begins at local college. Client cites scheduling and location difficulties for her course as a continued source of stress and anxiety.
Client completed her journal entries on a daily basis, typically at night before bed.
Reports that daily writing helped her calm down and get rest.
Client found the writing intervention helpful because it allowed her to gain a clearer perspective on certain situations (e.g., needing to switch medication(s) due to increased mood swings) and identified anxiety triggers (e.g., dealing with non paying clients).
Client still has difficulty responding to cognitive restructuring aimed at increasing her self-esteem.
Client still has difficultly engaging in unfamiliar social situations and with new people due to a pervasive distrust of people.
The intervention has encouraged client to attempt and implement anxiety reducing techniques (e.g., going on neigborhood walks, making positive self-affirmations each morning, etc.)
Ethical Issues, Social Justice Issues, & NASW
During the course of the intervention, no ethical or social issues (tied to the NASW Code of Ethics) arose.
Writing intervention was informed by the theory of "Transformative Learning".
The theory of adult transformational learning is grounded in the concept of individual, personal learning, and growth.
Its foundations do not analyze or interpret individual behavior from a systems perspective but rather require the individual to spend time reflecting . It is aimed to make to the individual become aware of their own emotions , critical of their own assumptions, and critical of their own judgments.
The individual must then use that information to change their frames of reference in order to work more collaboratively and
effectively with others.
The idea of reframing is critical to adult learning and it is necessary to break down the barriers our unconscious habits of mind have forced upon us.
(Source: Gloss, 2012)
Theory Informing Intervention : Transformative Learning
Theory Informing Intervention cont'd
The act of journaling allowed client to carve out time to connect with herself emotionally - letting her thoughts flow from the unconscious to see what images, memories and realizations or conclusions come about.
Gloss, E. (2013). A Hint of This and a Pinch of That: Theories that Inform Coaching and Counseling.
Journal of Organizational Dynamics
(1), 1 - 13.
National Institutes of Health (2011).
Measures of Anxiety
. Retrieved from, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3879951/
(Source: National Institutes of Health, 2o11)
(Source: National Institutes of Health, 2011)
Determining whether or not the client, in light of her mental health status, should continue to practice law.
Should agency inform appropriate authorities about client's current mental health status?
Professionalism and Self-Care
As a social worker, I :
Met the client where she was at; and
Used MI techniques.
Regarding self-care (while working with the client), I:
Continued to exercise; and
Cooked (relatively) healthy meals.