Case 1: Jack

Jack Krull is a 26-year-old white male presenting with a shy demeanor. He made only fleeting eye contact and did not smile as he told the therapist in his first session that he knew he was overdue for getting help, mentioning that one of his problems is procrastination. He identifies that he has a lot of anxiety, which has worsened lately.

Jack has a degree in engineering and has held a job as a government patent examiner for the past 3 years since finishing college. He said that he gets very little work done, frustrated by the fact that each patent is different in scope and to find out how to approach it, he has to get information from others. Jack described how difficult it is to call people to do this. He does not know what to say and is afraid of stumbling over his words and sounding “stupid.” He also thought he would be judged for not knowing more.

Jack said he could not concentrate at work, spending most of his time procrastinating. He has received a warning from his supervisor for not meeting his quota. His job is solitary, and he does not interact with others at work, although everyone else there are “nerds” like him. However, some of them go to lunch with each other. He wonders whether it would be nice to join them rather than eating alone at his desk, but he does not feel he can do this since he is always so behind.

Jack is the product of a dating relationship between his mother and father, who had just come out of a divorce. His father indicated that Jack was a “mistake,” and Jack has had very little contact with him throughout the years and no monetary support. From his mother’s previous marriage, Jack has a half-sister, who is 3 years older. From his father, he has a half-brother from the previous marriage, and another half-brother from a subsequent marriage.

Jack said that his mother remarried when he was about 7 to a critical stepfather to whom he did not feel close. His stepfather was physically abusive to Jack’s mother. During these sporadic abusive episodes, Jack would remain in his room, feeling guilty for being unable to help. His mother left this man when Jack was 12.

Jack described his mother as overprotective growing up, exhorting him to do well in school and disallowing his attending social events because she did not want him getting into trouble. They lived in an isolated, rural setting.

Currently, Jack speaks to his mother about once a month on the phone, and he says they are not close. He tends to avoid her as much as possible and dreads talking to her. He says that he does not feel connected to any of his half siblings either.

Jack was diagnosed with ADHD as a child but could not describe any behaviors that warranted the diagnosis. He took stimulants for years but could not tell whether they helped or not. He is currently not on any medication. He says that he does not remember much about his childhood, but that, in general, he has a terrible memory. He has one memory of speaking in front of the class for a presentation when he was about 11 and starting to cry because he became so anxious.

 

Jack is currently living with his ex-girlfriend. They broke up after dating for 4 years, primarily because he was not interested in her sexually. She has been diagnosed with bipolar disorder, but from what he reports, she is stable on her medication and high functioning. (She is in a graduate studies program.)

Their lease will soon be up and Jack agonizes whether to get an apartment on his own or move with her to another place. On one hand, he feels very dependent on her but he also would not mind exploring what it would be like to be on his own. He has been with her since his senior year of college. However, he has a long-time fear of cockroaches and is afraid of choosing a place that has cockroaches.

Jack says he has some friends in the area to socialize with, but he does not feel close to them. He says he starts stammering, blushing, and shaking if he talks to more than one of his friends at a time. He does not know what to say or where to put his hands, and he focuses heavily on how he walks, believing he is doing it “wrong.” He also worries about what he will say and how he will handle interactions with clerks and shopkeepers. He goes to social events at times but usually “talks himself out” of going or leaves after a short time. He does not try to approach any women because he is afraid they would think he is being “obnoxious” and “hitting on them.” His self-talk is negative in that he calls himself “stupid” and that no one would like him. He is suspicious of people, thinking they are “fake” and “trying to get something.” Although Jack does not feel close to anyone except his ex-girlfriend, he says he feels more comfortable around women. He admits to feeling afraid of men, that they will yell at him or try to physically threaten him.

Jack says his appetite is fine, and he usually has three meals a day, but he does not eat as healthily as he should. He has a hard time sleeping at night and then has a difficult time waking up in the morning. He reports sporadic feelings of suicidality although he does not have an active plan and has never attempted suicide. He finds work so stressful that he is glad to retreat to his apartment in the evening. Still, he does not enjoy what he is doing there and constantly beats himself up about why he is not more productive at work so he can be rewarded with a more flexible schedule.

Case 2: Monica

Monica Moreno is a 20-year-old woman who was born in the U. S. Her parents at the time were recent immigrants, her mother Claudia from El Salvador and her father Enrique from Mexico. Monica said she heard her father had raped her mother (the families knew each other) and that Estelle had become pregnant as a result. They then married and bore two other children, Monica’s sister who is now 18 and a brother who is 12. Monica’s parents both worked long hours in food service when she was growing up. Her father worked his way up to a chef at this point in life, but Claudia is still stuck in minimum-wage positions.

Monica said that her mother was physically abusive, hitting Monica, sometimes with objects such as brooms, and berating her on a frequent basis as a child and teenager. Monica claimed to have been treated more harshly than her brother and sister. When Monica was about 7, she was sexually abused by her babysitter’s uncle. She said she remembers her mother examining her vagina with a flashlight to see if there was “damage” (it was a one-time incident of digital penetration). Monica said that she remembers leading her younger female cousins in watching pornography and touching each other when she was about 11. Her mother scolded her for being a “lez” for this incident. Monica said she was also sexually abused by a male cousin who was 2 years older from about 12–14 years. None of these incidents were reported, and she said no one in her family was aware of the last one.

She said that her father reportedly had sexually abused Monica’s mother’s younger sister but she said her father had always been appropriate with her and her sister, describing herself as a “Daddy’s girl.” She said that she now realizes her father is “manipulative” and a “pathological liar” and got Monica to side against her mother in the long period of their separation and divorce, (which was final when Monica was about 15). Her father was jealous and violent with her mother during this period of time. He, however, was a chronic “cheater” during the marriage. Monica said there were a few incidents that she and her siblings witnessed, the most memorable of which was when he threatened Estelle with a gun.

Monica discovered later that her mother was involved with a family friend from Mexico, and once she was divorced, she married him. Currently, Monica, lives with her mother, brother, stepfather, and Estelle’s new baby in a two-bedroom apartment. Monica said that she is sad that her brother, whom she cares for very much, is being neglected in favor of the new baby. She said he is withdrawn and gets poor grades, and she is worried for him. Her sister currently lives with her father about 2 hours away, and she has been in and out of residential treatment programs for the last year because of being suicidal. Monica said to her knowledge her sister had not been sexually abused.

When Monica was 14, she became involved with her boyfriend who is 4 years older. She said she loves him but is racked by insecurity. She said when she was 14, she flirted and kissed a couple of boys who were interested in her and still replays those incidents in her mind, castigating herself, and worrying that she has not confessed these incidents sufficiently to her boyfriend. She also constantly scrutinizes her behavior when she is not with her boyfriend, worried that she is not going to be able to control her flirting and perhaps even do something physically with them, especially when she has been drinking. She is also worried that her boyfriend will cheat on her and gets on his social media accounts, looking for clues. She said she constantly feels insecure and that her anxiety is almost unbearable, her thoughts racing in a near-constant loop on this subject. She denied any physical abuse by him but says that he has a problem with alcohol. He currently is unable to drive due to a DWI.

Monica said that she did poorly in school but well enough to get passed along. Although English is not her first language, she is well able to express herself, indeed, speaking rapidly and almost without stopping for the first session. She has taken classes this past year at the local community college and fails all her classes each semester. She is not sure what she would like to do but considers being a nurse’s aide. She admits to frequently not attending classes, forgetting about assignments, and being unable to concentrate when studying.

Monica holds a part-time job at a doctor’s office that her cousin, the office manager, got for her. She said she has a hard time remembering her duties at the job, and one of her coworkers is frequently irritated with her for not learning quickly enough and not working fast enough to keep up with the practice.

Monica said that she feels depressed sometimes when she wakes up but she mainly struggles with anxiety. She denies flashbacks and nightmares but has problems falling asleep and then cannot wake up in the morning for classes and work. She says she is late for work almost every day. She denies any problems with drugs and alcohol though says that she has about five drinks when she goes out with her friends and/or boyfriends to bars and parties on mostly weekend nights. She said that she is close to her sister, her female cousins, and a couple of girlfriends she has known since middle-school.

Appendix C: Directions and Template for “Reflect and Reply” Cases

 

Case

Directions Part I, Diagnosis

Given the case information, prepare the following: a diagnosis, the rationale for the diagnosis, and additional information you would have wanted to know in order to make a more accurate diagnosis.

Directions Part II, Biopsychosocial Risk and Resilience Assessment

 

Formulate a risk and resilience assessment, both for the onset of the disorder and for the course of the disorder, including the strengths that you see for this individual. What techniques could you use to elicit additional strengths in the client?

Biopsychosocial Risk and Resilience Assessment for Onset of the Disorder

 

Risk Influences

 

 

Resilience Influences

 

Biological

 

 

Psychological

 

 

Social

 

Biopsychosocial Risk and Resilience Assessment for Course of the Disorder

 

Risk Influences

 

 

Resilience Influences

 

Biological

 

 

Psychological

Social

Directions Part III, Goal Setting and Treatment Planning

Given your risk and resilience assessment of the individual, your knowledge of the disorder, and evidence-based practice guidelines, formulate goals and a possible treatment plan for this individual.

Directions Part IV, Critical Perspective

Formulate a critique of the diagnosis as it relates to this case example. Questions to consider include the following: Does this diagnosis represent a valid mental disorder from the social work perspective? Is this diagnosis significantly different from other possible diagnoses? Your critique should be based on the values of the social work profession (which are incongruent in some ways with the medical model) and the validity of the specific diagnostic criteria applied to this case.