Vignette Case Study and Analysis
Joan is a 26-year-old single female. She recently moved to the San Francisco Bay Area to work for a publishing business company. Joan’s presenting complaint is feeling unstable. During the process of moving to the Bay Area to start a new job, she discontinued her medication, Lithium, and lost contact with her prescribing psychiatrist. She described her condition as having difficulty sleeping, feeling “jittery”, being concerned about what other people are thinking, having difficulty focusing on work projects, and experiencing racing thoughts. She had sudden bursts of energy. She slept for 3 to 4 hours and worked long hours during the day. She felt elated, euphoric. Other times, she felt irritable toward people. She was partying, socializing, and preoccupied with sexual thoughts. She had bizarre behaviors such as talking to complete strangers. She had rapid speech and racing thoughts and news ideas but she was easily distracted and did not carry through. Joan also had inflated self-esteem and grandiosity. She believed that she was psychic and that she was able to read people’s minds. Joan has experienced psychotic episodes where she could hear voices telling her to use specific routes, or doing things in a certain order and that her apartment was haunted.
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Joan reported that, four years ago, she became depressed during a stressful period of final exams. During that depressive episode, she had difficulty sleeping and eating, lost about fifteen pounds and became socially isolated for the next two months. Her feeling of depression continued despite passing her final exam. She described her condition prior to this period as doing well in her studies, getting high grades, her social life was good, and that she had many friends. There is no information regarding genetics or physical illness. Additionally, there is no information about her family, socioeconomic or cultural factors except that she is a college graduate and a professional. Joan denies using drugs but admits to partying and socializing (AOU, 2014).
AXIS I: 296.44 Bipolar I Disorder, Most Recent Episode Manic, and Severe with Psychotic Features
AXIS II:V71.09 No diagnosis
AXIS IV:Problems with social environment: Euphoric or irritate with others
Occupational Problems: Difficulty focusing on project Stressful environment and situations
AXIS V:CURRENT: 60PAST: 33
Differential diagnosis considerations
Joan’s symptoms and behaviors meet the criteria of 296.44 Bipolar I Disorder, Most Recent Episode Manic, and Severe with Psychotic Features (APA, 2000). During her depressive episodes, she had difficulty sleeping, lost her appetite, lost weight loss, and was socially isolated. During her mania episode, she felt unstable. She had sudden bursts of energy. She slept for 3 to 4 hours and worked long hours during the day. She felt elated, euphoric. Other times, she felt irritable toward people. She was partying, socializing, and preoccupied with sexual thoughts. She had bizarre behaviors such as talking to complete strangers. She had rapid speech and racing thoughts and news ideas but she was easily distracted and did not carry through. Joan also had inflated self-esteem and grandiosity. She believed that she was psychic and that she was able to read people’s minds. Joan has experienced psychotic episodes where she could hear voices telling her to use specific routes, or doing things in a certain order and that her apartment was haunted. During this phase, her friends were concerned about her well-being and they took her to the emergency room and she was hospitalized and put on psychotropic medication. Moreover, she responded well to the treatment. Her symptoms decreased and she slowed down, was able to sleep, and got her appetite back (Brent & Pan, 2008).
Schizoaffective and schizophrenia disorders are excluded as diagnosis due to the following: in manic-depressive disorders, the psychotic symptoms are congruent with mania or depression. The individual has a period of normal mood while some of individuals with schizoaffective disorder may have psychotic symptoms in the absence of depression or mania. Schizophrenia has positive symptoms that may include hallucinations, delusions, and/or a thought disorder. In addition, people with schizophrenia have negative symptoms where they experience lack of interest in interacting with others or the pleasure in previously enjoyed activities. They talk less, and exhibit a demeanor that is rather flat or without much expressiveness (Seidman, et al., 2002).
Substance-induced mood disorder can have manic features, depressive features, or mixed features. The onset of this disorder occurs during intoxication or withdrawal from drugs. Therefore, it is ruled out do to Joan denied using drugs and she is not a heavy drinker.
Cyclothymia is a frequent and chronic mild form of bipolar disorder. Cyclothymia has several hypomanic episodes with episodes of depressed mood. These episodes of depressed mood are not severe enough to meet the criteria of manic or a major depressive episode. Joan‘s episodes are severe and do not meet the criteria of Cyclothymia (APA, 2000). It is difficult to determine whether there are any medical problems that causing her symptoms since there is no information that indicates any history of medical condition.
It is important to receive the appropriate diagnosis and treatment to successfully manage bipolar disorder. There are no known cure. The treatment plans must focus on managing symptoms and preventing mood episodes by using a combination of medication and psychotherapy. Medications may include mood stabilizers such as valproic acid, lithium, and carbamazepine are effective in treating manic and depressive phases of bipolar disorder and help in preventing future symptoms. Antidepressant can be used during the depressive phase. However, they have to be used in conjunction with mood stabilizer. Using antidepressants alone may cause mania in persons with bipolar disorder. Additionally, regulating sleep is very essential for people with bipolar disorder and helpful in stabilizing moods.
Cognitive-behavioral therapy, or CBT, is used to treat bipolar disorder. It can help patients identify negative thoughts and behaviors and learn how to modify them to create positive change. Other mental health services may involve family members, which helps to manage the patient’s symptoms and needs (NIMH, 2008; Hirschfield, 2005; Akiskal, 2009).
Agitation or euphoria
Flight of thoughts
Difficulty following instructions
Rapid pace of speech
Talking excessively Interruption of others
Decreased need for sleep
Altered sense of self-importance
Delusional thought content
High-risk seeking behaviors
Joan will take psychotropic medication as prescribed
Identify causes of stress that may increase the risk of relapse
Develop a relapse drill for friends and family, which include the role of individuals, responsibilities and course of action to carry out in case of relapse.
Work on extinguishing self-destructive behavior, i.e. promiscuity, hostility etc.
Joan will collaborate with medical treatment and ensure adherence to mediation
Joan will work with the therapist to pinpoint triggers and causes of relapse.
Joan will be part of the process of developing the drill and work with family and therapist to be fully involved in the process.
Joan will recongnize negative consequence of her destructive behavior
Joan will work on homework assignment to track thoughts and urges between sessions.
Joan will participate in role-playing to understand the consequences of the behaviors
Joan will respect boundaries and limits
Monitor Joan’s reaction, compliances, side effect and success of the medication
Ensure that psychiatric evaluation is in place to arrange for hospitization if Joan presented any sign of homicidal or suicidal ideation
Identify the causes of stress that may potentially causes relapse such as bad communication with family, sleep pattern, medication noncompliance. Use this information as a part of the target treatment.
Educate Joan and family about the signs and symptoms of relapse.
Help client and family to develop detailed relapse drill, which include problem-solving ideas, contacting physician, calling emergency if needed.
Explain negative consequence of behavior
Assign homework to track thoughts and urges
Practice role-playing and role-play reversal to increase sensitivity to consequence of behaviors
Listen to client expression of emotions but set limit to hostile behaviors
Setting boundaries and limits to clients manipulation and breaking of the rules.
Potential Ethical Issues
Kitchener (1984) has identified five moral principles to help in ethical decision-making. These principles include autonomy, beneficence, Non-maleficence, justice and fidelity.
The first principle is respect for autonomy of the individual. Therapist should help Joan make her own decision by providing her with complete information. Her decision must be validated regardless whether it seems erroneous in the eye of professionals. The second principle is Beneficence which looking out for what is best for Joan. Therapists have the responsibility to contribute to of Joan (Forester-Miller & Rubenstein, 1992). Nonmaleficence is a critical principle, which cautions professionals to do no harm (Kitchener, 1984; Rosenbaum, 1982; Stadler, 1986). For Joan, may there be harmful consequences of diagnose he with bipolar? Do the benefit compensate for the potential harm?
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When considering justice for Joan, I have to ensure that other people in her situation have access to a similar care. I treating Joan, the therapist has to think about family and friends in her circle that may be affected by the decision of the therapist and explain why Joan is receiving such treatment. Kitchener (1984) stated that “treating equals equally and unequals unequally but in proportion to their relevant differences” (p.49). Fidelity includes the ideas of loyalty toward the client. Trust between client and therapist is essential in building the relationship. Thus, the therapist has to walk a fine line to fulfill his or her duties.
The American Counseling Association (ACA) has established a guideline to assist professionals to make solid ethical decisions and meet challenges (2014). Due to Joan mood disturbance and tendency to interpret events in sexual lenses, the therapist has to ensure that he or she on guard to avoid any ethical problems. The ACA, A.5.a., states “Sexual and/or Romantic Relationships Prohibited Sexual and/or romantic counselor–client interactions or relationships with current clients, their romantic partners, or their family members are prohibited. This prohibition applies to both in person and electronic interactions or relationships (p.5).
Joan’s friends at certain points, when her condition worsen, felt obligated to admit her to a hospital. The therapist has to take all the right decisions to ensure her safety and that her rights are not violated. ACA, B.2.a. Serious and Foreseeable Harm and Legal Requirements states that “The general requirement that counselors keep information confidential does not apply when disclosure is required to protect clients or identified others from serious and foreseeable harm or when legal requirements demand that confidential information must be revealed.
Counselors consult with other professionals when in doubt as to the validity of an exception. Additional considerations apply when addressing end-of-life issues (p.7).
Due to the nature of her bipolar disorder, Joan may discontinue her treatment as she did in the past when she moved to the Bay area. Regardless, how strongly the therapist feels about the course of treatment, Joan has the right to make her own decision. ACA Sec. A.1.c. Counseling Plans states that “Counselors and their clients work jointly in devising counseling plans that offer reasonable promise of success and are consistent with the abilities, temperament, developmental level, and circumstances of clients. Counselors and clients regularly review and revise counseling plans to assess their continued viability and effectiveness, respecting clients’ freedom of choice (p.4).
Role of Diversity Related Factors in Diagnosing and Treatment Planning
While bipolar is recognized mental illness and exists in all cultures and countries, the field of psychology although came a long way, is still in need of more understanding of cultural
short on cultural considerations. Although we know that Joan has bipolar, we do not know what is her cultural background and what are the beliefs and sociocentricity about mental illness in her particular culture. Additionally, health professionals may have different approaches when diagnosing and treating bipolar. A more comprehensive research is needed to understand the multicultural variability and its effects on diagnosing and treating mental illness. Moreover, cultural awareness a multicultural dialogue should be among mental health professional should be in place. There are vast individual differences within each cultural group. Stereotyping all a group members as are alike is a disservice and an obstacle to the healing process.
There are a number of factors that are must be acknowledge in order to meet the client’s needs. Some of these factors include: acculturation, poverty, language, transportation, housing and children, educational background, beliefs, physical characteristics, social history and existing support. It is useful to know if Joan was born in the U.S and what is her level of proficiency an acculturation in this culture. Joan is a professional and poverty aspects does not seem to apply to her. She seems to be aware of “culture of poverty” concept and know the various established practical practices to deal with her issues by using mental health interventions.
Joan’s native language is English. She is a college graduate from an American university. Educational background and reading abilities plays and important part in understanding the concept of treatment and academic experience varies among different ethnic groups. The neighboring country of Mexico has many regional dialects and each has a distinctive culture and a unique oral history.
Several characteristics of the therapist are important in shaping the therapeutic relationship. It is important for Joan to work with a counselor who is capable of serving her and help her to understand herself in order to move on to the next level. As a therapist, it is important to provide a safe and warm environment. It is unclear if Joan would have any issues regarding the cultural difference between her and her therapist. This therapist believes that cultural self-awareness and sensitivity to the client heritage is important since it influences the attitudes, values and biases in the therapeutic processes.
Transportation and housing is also essential in treatment. Lack of basic needs and transportation makes it difficult for the individual to continue with treatment. Joan is a middle class member and this does not apply to her. However, therapists have to address these issues and base the treatment plan on how the individual is going to be able to work on the treatment while facing all these daily issues of even getting to clinics.
Individuals from different ethnic and cultural groups differ in their beliefs about mental illness, causes, and treatment. They also differ on their expectations of the outcome of the treatment and the therapist roles in the process of healing. Joan came to therapy and seemed to understand the process and what needed from her.
People from different races and ethnic background differ in their appearance. Nevertheless, appearance in this therapist opinion does not make any difference. It is the belief and social and community support of the group that matters. Previous life experiences and history effect the client’s response to treatment. Religious belief may pose an issue depending on the kind of he treatment and whether it is allowed within that religious paradigm, If there is a stigma attached to mental illnesses within particular groups, asking for help may face many obstacles such as cultural belief in endurance, privacy, and legal issues. Additionally, some clients are not aware of resources within their communities. Therapists have to provide clients with information that will help them utilize supports, which include legal, referral, religious and other kind of assistance to help them become part of their own healing and prevision of relapses.
about culturally relevant and responsive networks of supports that include legal, religious, and civic components. Referral and assistance can often become a vital part of empowering the future capacity to prevent or intervene early in a remission.
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