Biopsychosocial assessments

Case Studies SWK5013 Choose one of the following case studies for your work in this course.

The Case of Ben Liu Ben Liu is a 7-year-old boy of Chinese descent who was referred for therapy due to problems at school. Ben’s mother Kim is present for the first session and is upset about the referral. She states the school principal informed her that Ben has caused too many disruptions in class for him to remain at the school unless the family is willing to take him for therapy. Kim states that Ben’s symptoms are due to a family problem and “should be handled within the family.” However, she feels pressure to take Ben to therapy to prevent him from being kicked out of school. Kim and Ben’s father Song divorced two years ago. Song remarried and has a one year old baby with his new wife. He does not approve of Ben attending therapy despite threats of expulsion from the school. Because Kim has defied his wishes, Song refuses to help pay the therapy bills. He has not paid child support for the past two months. Kim works as a nurse at the local hospital and has picked up additional shifts so she can keep up with the household bills. Kim’s mother assists with childcare. Song is a civil engineer at a large construction company. His wife, Ben’s stepmother, is a stay at home mother. Since the divorce, Ben spends alternating weeks with his mother and father. Kim reports that this was a difficult transition for Ben at first. When going back and forth between houses, he didn’t always have the right clothes and he would forget to complete his schoolwork. Ben had occasional episodes of bedwetting and he had frequent tummy aches after dinner. Kim states that Ben eventually adjusted to the changes but has occasional episodes of crying and yelling that are difficult to control. Ben does not have any medical problems other than seasonal allergies. During the session, Ben sits quietly in the chair with his hands folded in his lap. He is wearing cargo pants, a polo shirt, and new sneakers. His eye contact is limited, and his voice is quiet. When you ask him if he knows why he is there he replies, “I haven’t done anything wrong. No one likes me and that makes me sad.” Ben has told Kim on several occasions that his stepmother doesn’t like him. Ben states that the stepmother treats him differently than his baby sister, and he feels like everything he does is wrong. Ben cries when it’s time to go to his dad’s house and says, “they just ignore me.” Ben further reported that his dad does not hug him anymore; he only holds his baby sister. If his dad is not home, his stepmother sends him to his room to play by herself. Kim talked to Song about Ben’s concerns, and he stated, “Ben is the problem. Boys aren’t supposed to cry.” According to Song, Ben wants to stay in his room, and he does not want any contact with his stepmother or baby sister. When he tells him that it’s time for dinner, Ben says that he doesn’t feel good. “We almost have to force him to eat.” Ben is close to his grandmother. Ben states, “granny and I bake cookies together and play games. She loves me.” Ben also enjoys doing puzzles with his mom and playing soccer and board games with his next door neighbor. He says he doesn’t have any friends in his dad’s neighborhood. Ben and his dad used to go to the park together, but dad doesn’t take him anymore.

1

Ben demonstrated high intellectual abilities at a young age and started kindergarten at the age of 4. He is now in the 3rd grade. Ben was a straight A student until this academic year and is now barely passing his favorite subjects of science and math. Teachers report that Ben has difficulty paying attention in school, and that he is frequently seen staring out the window as if he is daydreaming. Two weeks ago, Ben was involved in an argument with another student while working on an art project. Kim was told that Ben dumped a full box of crayons on the floor and then began throwing them at other students. Ben was sent to the principal’s office, was crying “uncontrollably” for over an hour, and then refused to speak to the principal after he calmed down. Later that week, Ben’s teacher called Kim due to concern that Ben was drawing “dark images” in class. Ben said that he was drawing pictures of everyone that didn’t like him. Kim reports that Ben has had a few similar episodes at home. “If he doesn’t get his way, he throws a tantrum.” The tantrums last over an hour and occur at least three times a week. Ben has also had difficulty following rules at home. Last night, Kim asked Ben to turn off his tablet and go to bed. Ben refused and argued until “he got his own way.” Ben tells you that he often feels sad because no one loves him. He had friends at school, but they will not play with him since he has been getting into trouble in class. Ben states he does not want to go to school anymore because people are mean to him. He said, “I hate them.” Ben reported having nightmares about “bad men taking him away” and that this is the reason he argues with his mother about going to bed. “If I go to sleep, they’ll come get me again.” You ask Ben what types of activities he enjoys, and he shrugs his shoulders. Ben asks you, “what happens when you die?” Kim stated, “I just don’t know what to do anymore. I want my son back.” Kim denied having any social or formal support except for her mother. Kim and Song are practicing Buddhists, but they have not introduced Ben to any formal religion or spiritual practices. Ben is refusing to participate in any after school activities and Kim is worried that nothing will make Ben feel happy.

Emily Jones Emily Jones comes to your office with her husband Jack, and states, “I’m only here because he made me come.” Jack has threatened to divorce Emily if she does not get help. Jack reports that Emily has exhibited several erratic behaviors. He states, “I can’t keep up with her. She stays up working all night and rarely sleeps.” Jack states, “I don’t understand how anybody can keep going several days in a row without sleeping. It’s not normal.” Emily tells you that she feels great, and she has never felt so productive in her life. In the past two weeks she read the Bible from cover to cover, she completed a large project for work that should have taken months, and she cleaned the house from top to bottom. Jack reports that Emily gets angry with him because he isn’t helping her and he “moves too slow.” Emily is 35 years old and has two children ages 8 and 10. She is White and identifies as Christian. Emily states that she “had a lot of problems” growing up. She was bullied in school, didn’t get along with her parents, and struggled academically. She had a few friends but had difficulty maintaining stable relationships. She said, “people are either for you or against you, and a lot of people let me down.” Emily reports that she has never been able to maintain a friendship for more than a year because “people leave.”

2

Jack stated that their children are also concerned. Their 8-year=old son Pete stays in his room because Emily “yells too much.” Their 10-year-old daughter Taylor told Jack that “mommy always wants to play dress up and I’m too old for that.” Both children are involved in extracurricular activities, and there have been a few times recently when Emily forgot to pick them up from school or take them to their extracurricular activities. The family has been heavily involved in church. Jack states that church involvement has become a source of distress because clergy has discouraged Emily from seeking mental health treatment. Emily states, “God can get me through anything and there is really nothing wrong with me.” At the age of 15, Emily was hospitalized for an episode of depression. Her parents thought she was trying to kill herself when they found several cuts on her arms and legs. Emily states that her life was so stressful, that the only way to cope was to turn emotional pain into physical pain. She used a razor to cut, but after her parents saw what she was doing, they removed all sharp objects from her reach. Emily was prescribed Prozac during the hospitalization. She said the medication made her feel worse, but her mother forced her to take it. Emily stated that she stopped taking the medication when she went away to college and her parents could no longer control her. Emily stated that she would never kill herself because suicide is against her religious beliefs, and she would not want to leave her children without a mother. She reported that she still cuts on occasion to relieve stress or when she has suicidal thoughts, but mostly on her upper arms and legs where she can hide the cuts from her family. Emily has one younger sister who she is not close with. Emily states, “my parents thought she was the golden child and she got away with everything.” Emily last spoke with her sister a month ago. Her sister told her that she needed to seek professional help and Emily has not spoken with her since. Emily’s mother is of German descent and was a strict disciplinarian. She was employed as a teacher and worked where Emily attended elementary school. Emily stated that her mother was embarrassed by her because she wasn’t good in school. Her dad is also of German descent. He worked long hours at a local factory and did not participate in disciplining the children. Emily stated that the best times with her dad were when they went fishing together because her mom didn’t come. Emily has a master’s degree and works as an accountant part-time. She stated that she can’t trust her coworkers because “they’re all trying to get over or get ahead.” Emily has a history of hypothyroidism, is prescribed medication, and takes the medication as prescribed. Jack reports that prior to Emily’s burst of energy, she “was down” for about two weeks. She didn’t want to get out of bed, shower, or eat. He encouraged Emily to see a psychiatrist or her medical doctor, but she refused stating “they’re all quacks.” Jack states that Emily only came to counseling today because he told her he would have to separate from her if she didn’t. He is concerned that her recent behavior is having a negative impact on their children, and this has led to frequent arguments. Jack states that this is not the first time he thought that Emily needed help, and that “episodes” like this have become more frequent. Jack states that he makes plenty of money, and he has encouraged Emily to stop working for a while until “she’s herself again.”

3

Margaret Jenkins Margaret is a 78-year-old Black female who presents to your office with her daughter Sasha. Sasha reports that Margaret had a stroke a year ago, and “hasn’t been the same since.” Margaret worked for the local electric company for 40 years and retired at the age of 65. When she retired, she became a volunteer driver for the local Meals on Wheels program two days a week. She also volunteered as a driver for the American Cancer Society by helping patients with transportation to their medical appointments. Margaret’s friends have described her as a “pillar of the community.” Margaret had almost a 100 percent physical recovery from the stroke. She still has some weakness in the left side of her body, and it is unknown if she will regain her full strength. Since the stroke, Margaret is not allowed to drive, and she is dependent on Sasha and friends for transportation. Sasha is worried that Margaret has a high risk of falling. She assists Margaret with grocery shopping, housekeeping, bathing, and transportation to medical appointments. Sasha states she feels overwhelmed caring for her mother because she works full time and has three children. Margaret also has a son, Derrick, who is willing to help with Margaret’s personal needs. However, Margaret has told Sasha, “You are my daughter, and it’s your job to take care of me the same way I took care of my mother. Men aren’t supposed to do this.” Recently, Margaret has experienced forgetfulness. She cannot remember to take her medication, and she has difficulty remembering the date or day of the week, even when she uses a calendar for reference. Last week, the fire department responded to a small grease fire that was caused due to the stove being left on. On two occasions in the past month, Margaret forgot her keys and accidentally locked herself out of the house. Sasha and Derrick suggested that Margaret move into an assisted living facility, or at least find a personal aid to help Margaret at home. Margaret has refused both options stating, “I can manage on my own.” Margaret married Tom, her high school sweetheart when she was 18. She said, “it was a true love story.” Tom worked as a postal carrier for over 30 years, and he enjoyed getting to know people in the community throughout his workday. Margaret stated, “we always had a new adventure to look forward to.” Tom died of lung cancer three years ago. Margaret states “I’m lost without him.” Sasha states that not being able to drive has been very hard on Margaret, because volunteer work kept her busy. Now, she spends much of her time thinking about how much she misses Tom. She turns down most invitations from friends and family and prefers to be alone at home. Margaret states that she still enjoys spending time with her grandchildren, but she feels guilty that she cannot take them out of the house to go to the park or the neighborhood playground. Margaret admitted that she forgot her granddaughter’s name the last time she visited, but her grandson quickly reminded her. Margaret grew up in a lower middle class family in Georgia. She said her parents stressed the importance of family values, education, and a hard work ethic. She had five siblings; three are deceased and two sisters are still living. Margaret stated, “I had to bury my husband, my parents, and three of my siblings. After a while you start to question if you’ll be the last one and who will take care of you.” Margaret’s two living sisters live out of state, but they speak on the phone several times per week. Margaret completed high school and took some college courses in business. She is proud to have worked for the same company for 40 years. She earns social security income and a small pension from the electric company.

4

Margaret is diagnosed with hypertension, atrial fibrillation, and rheumatoid arthritis. She had one hospitalization after the stroke last year, but no prior medical conditions. Margaret has never seen a mental health professional, and she cannot understand why her medical doctor recommended that she see a therapist. You ask Margaret what would make her life better, and she replied, “If I could drive again, I would be fine.”

George Gomez George is a 48-year-old Hispanic male who presents to your office alone. He is wearing a work uniform, his hair is unkempt, and he appears sweaty. He apologizes for his appearance, telling you that he did not have time to shower before the appointment. George served in the military for 20 years and was deployed to Afghanistan on three tours during his military career. He earns military retirement income and is employed as a forklift operator at a local warehouse. George informs you that he tested positive for alcohol and marijuana on a random drug screen at work. Because George has been a good employee for almost ten years, his boss referred him for mandatory employee assistance counseling rather than terminating George from his position. George has been married to his wife Bianca for 28 years. Bianca is a manager at a local bank. George describes Bianca as a good wife, an excellent cook, and a dedicated mother. George’s 16 year old daughter Selina excels in gymnastics and is on the cheer team at school. George recently found marijuana in her room. George’s 15 year old son Mateo is a good student, but he has been getting bullied at school since he came out as bisexual. He doesn’t want to go to school anymore because he doesn’t feel safe. When asked about his military service, George responded, “It was the same as everybody else. I watched a lot of friends die, and I don’t know how I got out of there alive.” George reported that he sometimes has nightmares about a fellow servicemember stepping on an IED. “I had to recover his body’ every piece of it.” George states that he does not think about things he saw in the war when he is awake, only in his nightmares. However, he startles when hearing loud noises and has difficulty watching movies that involve guns. He is also bothered by scents that remind him of death, such as mold or rotting food. George tells you, “All the stress has been getting to me, so I smoke a little weed. It’s legal now anyway.” George uses marijuana daily before and after work. George does not feel that marijuana use has been a problem, but he is aware that his place of employment has a no tolerance policy about drug use. Bianca found out that George was using marijuana six months ago. “She could smell it on me, and she asked me to stop.” George states that he wants to stop, but there is no other way to cope with stress that works for him. Bianca blames George for the marijuana in Selina’s room. “Bianca thinks Selina got it from me. Maybe she did.” On the day of the drug test, George reported “having a swig” of vodka before his shift. He said he has used alcohol before work on only two occasions, because sometimes marijuana isn’t enough to calm his nerves. George states that he is not “bothered” by Mateo’s sexuality, but it makes him angry that Mateo is being bullied at school. “My son comes home from school crying. My daughter is smoking weed. My wife and I are working long hours and argue a lot. It’s too much.” George states that he and Bianca make more than enough money to support the family, but he wants to keep

5

working full time to stay busy and teach his children a strong work ethic. George was raised by his mother and father in Brownsville, Texas. George’s mother was a stay- at-home mom and his father worked on a cattle ranch. George stated, “My dad was a drunk. He drank all day, every day, he wouldn’t get any help, and he died drunk.” George’s mother is still living, and George visits her at least three times a week. George’s parents frequently had difficulty paying the household bills. They received assistance from their church, local food banks, and clothing donation programs at school. George stated that his teachers called social services after his dad tried to pick him up from school while intoxicated, but “nothing ever came of it.” George is closest to his sister Zaida. Her children are the same age as George’s children. The families have dinner together every day after church. George’s brother Luis is currently undergoing treatment in a residential substance abuse program. George stated that when he was growing up, all he wanted to do was get out of the house to be away from his father. He dropped out of school at the age of 16, earned a GED at 17, and enlisted in the army at 18. George stated that despite military service being the hardest thing he has ever done in his life, the army taught him structure and gave him a sense of purpose. George goes to the local VA medical clinic for annual checkups. He is diagnosed with hypertension and borderline diabetes. George is not taking any medication currently, and he tries to maintain a low sugar diet. Nightmares disturb George’s sleep; he states that a normal night of sleep lasts 5 to 6 hours. George tells you that he loves his kids and his wife, but he knows that he’s changed. “I feel like I have difficulty connecting with my family. My kids are getting older, and they have to deal with things that I didn’t have to deal with. I’m letting them down. I just want to be myself again.” George considered getting a medical marijuana card, but his employer has informed him that the no tolerance policy at work will be upheld due to job safety reasons.

6