Psychology homework help
\nMSW<\/p>\n
Suicide, stigma associated with accessing services, and substance abuse are real issues for the military. Although military social workers lead the field in these issues, there is always more work to be done. The civilian world is watching as the military works toward assuring access to services that will help their personnel. In fact, many programs developed within the military have been reproduced for a civilian environment. At the same time, there are programs outside of the military that could be tailored to help military personnel. In this Discussion, you consider other steps the military could take in the areas of suicide, stigma, or substance abuse.<\/p>\n
To prepare for this Discussion, read the case study, \u201cWorking With Clients With Suicidal Ideations: The Case of Denise,\u201d located in the Learning Resources.<\/p>\n
Post(2 to 3)<\/p>\n
Describe an approach you would take to help the military expand or better address either suicide, stigma, or substance abuse.
\nDescribe how the situation depicted in the case study could have been handled differently via your approach.<\/p>\n
Required Readings
\nRubin, A., Weiss, E. L., & Coll, J. E. (Eds.). (2013). Handbook of military social work. Hoboken, NJ: John Wiley & Sons.
\nChapter 12, \u201cAssessing, Preventing, and Treating Substance Abuse Disorders in Active Duty Military Settings\u201d (pp. 191\u2013208)
\nChapter 14, \u201cSuicide in the Military\u201d (pp. 225\u2013246)
\nPietrzak, R. H., Johnson, D. C., Goldstein, M. B., Malley, J. C., & Southwick, S. M. (2015). Perceived stigma and barriers to mental health care utilization among OEF-OIF veterans.\u202fPsychiatric Services, 60(8), 1118\u20131122. doi:10.1176\/appi.ps.60.8.11
\nDocument: Working With Clients With Suicidal Ideations: The Case of Denise (PDF)<\/p>\n
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\n\u00a9 2016 Laureate Education, Inc. 1
\nWorking With Clients With Suicidal Ideations: The Case of Denise
\nDenise is a 26-year-old, Caucasian, heterosexual female who initially presented to the
\noutpatient mental health clinic following a brief inpatient psychiatric facility admission for
\nhaving passive suicidal ideations and self-injurious behaviors, which included cutting
\nher upper thighs with a razor blade. A full biopsychosocial Assessment occurred on the
\nday of her release from the inpatient psychiatric facility. Denise presented to the clinic in
\na moderately agitated manner, voiced her dissatisfaction to the front desk staff that the
\nappointment was in the afternoon and was with a male therapist, and said that she
\nwanted to be seen the following morning and only by a female therapist. After
\ndiscussing the importance of establishing a solid safety plan and reviewing the clinic
\npolicy that would support her ongoing care with multiple appointments over the course
\nof the following six weeks, she agreed to be seen \u201cbriefly.\u201d This was the first indication
\nof Denise\u2019s manipulative quality and tendency to demand that others meet her needs.
\nOverall, Denise was in good physical health with no significant medical findings
\nor previous specialty care. She did not disclose at the initial intake session that she
\nreceived routine opiate prescriptions for a variety of broad-based aches and pains,
\nwhich had been prescribed intermittently since the age of 16. Upon review of her
\nelectronic medical record, the therapist discovered a long list of ongoing medical
\ncomplaints: chronic migraine headaches, lower back pain, and a host of other physical
\npain ailments that had no medical etiology.
\nFrom a mental health perspective, Denise revealed having multiple visits to local
\nemergency departments (EDs) beginning at the age of 15 and continuing to the current
\n\u00a9 2016 Laureate Education, Inc. 2
\nday. She explained that the primary reasons for the ED visits were \u201csuicide gestures,\u201d
\nwhich she explained typically followed an emotionally volatile breakup or argument with
\na boyfriend and resulted in engaging in some level of self-injurious behavior (e.g.,
\noverdosing on pills, cutting, crashing her car, or alcohol intoxication). However, despite
\nthe estimated half-dozen visits to various EDs and brief admissions to various inpatient
\npsychiatric facilities, Denise never followed through with the recommended outpatient
\ntherapy or psychopharmacology. As explanation for this lack of follow-up outpatient
\ncare, Denise said, \u201cthe crisis is over; things are back to normal, so why bring things
\nback up?\u201d This limited insight into the normalization of pathology appears to have begun
\nwithin her family of origin. Denise expressed that her mother was known for her
\n\u201cexplosive tempter\u201d and would display hysterical behaviors and extreme emotional
\nreactivity on a daily basis; she would then appear happy and cheerful once the crisis
\nwas averted or concluded.
\nDenise did acknowledge that she maintained a long pattern of alcohol misuse,
\nwhich appears to have begun during her early teen years. She reported having frequent
\nparties at her home when her mother would go out of town with a new boyfriend and
\nleave Denise with full access to alcohol and her mother\u2019s prescription medications.
\nDenise denied any pattern of misconduct with the law and offered no criminal
\nhistory and no documented or disclosed illegal behaviors.
\nDenise was raised in a large city in the northeastern United States, where she
\nmoved frequently with her mother and two older siblings. Denise\u2019s parents divorced
\nwhen she was 6 years old, stemming primarily from both parents having extramarital
\naffairs and frequent arguments regarding control of finances and overspending on
\n\u00a9 2016 Laureate Education, Inc. 3
\nluxury items they could not afford. Her socio-economic status could be categorized as
\nlower-middle class, but Denise\u2019s parents were known to purchase expensive clothing
\nand items for the kids so they would \u201cfeel important.\u201d Denise described her mother as
\n\u201cpretty cool,\u201d but upon further discussion it became evident that her mother was
\nemotionally distant and avoidant of setting appropriate limits and boundaries. Denise
\nlater described her mother as very \u201chypercritical and emotionally volatile.\u201d Following her
\nparents\u2019 divorce, Denise\u2019s biological father soon remarried and began a new family.
\nDenise reported having very little contact with her biological father, and she did not
\nconsider him a source of support or parental guidance. Denise\u2019s mother moved the
\nfamily moved several times over the course of her middle and high school years, usually
\ndue to financial problems, including the inability to pay rent or bills.
\nDenise\u2019s two older siblings were aged 3 (brother) and 5 (sister) years older than
\nDenise, and they did not interact or provide much oversight into her life. Both older
\nsister and brother played a minimal part in her childhood and adolescent development,
\nwith each having a different biological father. Both Denise\u2019s brother and sister were
\ninvolved in drugs and had considerable legal problems, which took considerable time
\naway from attending to Denise\u2019s emotional and social needs. Denise reported on
\nseveral occasions that she learned to get her needs met by friends and others and that
\nshe could attract attention from prospective boyfriends by \u201cacting flirtatious and getting
\nthem to buy her things.\u201d
\nDenise recalled that at age 12 she experienced the first of several sexual
\nmolestations and abuses at the hands of her mother\u2019s boyfriend, who lived occasionally
\nat their residence. She stated that her mother and boyfriend would come home
\n\u00a9 2016 Laureate Education, Inc. 4
\nintoxicated from a party or elsewhere and that he would sexually molest her at night. He
\nwould then return to the mother\u2019s bedroom and the next morning, would act like nothing
\noccurred. This reportedly occurred over the course of the next 2\u20133 years, until there
\nwas a domestic violence incident between the mother and boyfriend that resulted in his
\nbeing arrested and the family subsequently obtaining a protection order.
\nDenise was able to make friends easily, and reportedly was considered popular
\nby most people. Her relationships were filled with interpersonal chaos, and she focused
\nmost of her time on boyfriends to feel a sense of belonging and self-worth. Intimate
\nrelationships began in her early teen years; these relationships often ended with an
\nimpulsive and emotionally reactive behavior. Female friends were superficially friendly,
\nand the relationships were often described as a \u201csoap opera.\u201d She described getting
\ninto physical altercations with other female students in her high school due to people
\n\u201cdisrespecting her or trying to take her boyfriend.\u201d
\nDenise began to engage in self-injurious behaviors at age 13 by cutting her
\nupper thighs with a razor blade. The cutting began to \u201cnumb away\u201d the emotional pain of
\nbeing sexually abused by her mother\u2019s boyfriend. Denise stated that she attempted to
\nreport the abuse to her older sister, but she stated that she was rejected and told to \u201cnot
\nmake waves,\u201d as the boyfriend financially supported the family. She soon began to
\ndescribe the cutting behavior as a \u201cbadge of honor\u201d to repress and control her emotional
\npain. In addition, Denise stated that she often took pride in being able to \u201cshow off her
\npain tolerance\u201d and made comments such as, \u201cI wanted to feel my emotional pain
\nphysically.\u201d
\n\u00a9 2016 Laureate Education, Inc. 5
\nOver the course of several clinical sessions, it became more evident that
\nDenise\u2019s primary expression of emotions was in the form of extreme volatility of rage
\nand anger, often followed by a sense of desperation and hopelessness. She reported
\ndifficulties with coworkers and complained about others commenting that she was
\n\u201coverconfident and cocky.\u201d She also appeared to have minimal insight into fantasy-like
\nbeliefs that bordered on narcissism. Denise often presented to the outpatient clinic in
\nemotional crisis, usually due to a problem with a personal or intimate relationship. Initial
\ndiagnosis was adjustment disorder with depressed mood, but notably had several key
\ntraits of borderline and histrionic personality disorder. Initially, she refused to comply
\nwith assigned clinical homework and had difficulty establishing clear therapeutic goals.
\nDenise had \u201cfired\u201d three different therapists and two psychiatrists over a ten-month
\nperiod, often lamenting that the therapist didn\u2019t agree or \u201cdidn\u2019t understand my situation
\nwell enough.\u201d
\nFrom a clinical perspective, Denise was superficially charming and likeable. She
\nwould initially provide praise and gratitude for helping her, but over time she became
\ncontentious and frustrated when challenged to consider altering her own behavior or
\nthought processes. External attributions for every presenting problem was consistently a
\nsource of clinical concern, but eventually would fracture the therapeutic relationship as
\nthe therapist would attempt to engage in some limit setting or challenging perspective.
\nDenise seemed to enjoy being a \u201cpatient at the mental health clinic,\u201d and she would
\noften disclose her mental health treatment to supervisors during times of emotional
\ncrisis as a way of avoiding her job duties or responsibilities. Her ego-syntonic
\nmaladaptive behaviors were the primary focus of treatment for the therapist, but Denise
\n\u00a9 2016 Laureate Education, Inc. 6
\nwanted to maintain focus on the perceived external slights from others and distress from
\nintimate relationships. After several months of unsuccessful therapy, Denise had again
\nengaged in another episode of self-injurious behaviors of cutting, combined with an
\nopiate overdose and alcohol intoxication following a volatile breakup with a boyfriend.
\nThe overdose and self-injurious cutting behavior was discovered by her female
\nroommate, who took her to the ED, and Denise was subsequently admitted to a local
\ninpatient psychiatric hospital for three days. Denise returned to the outpatient clinic and
\nonce again requested a change in primary therapist. A critical therapeutic breakthrough
\noccurred when the new therapist quickly established clinical boundaries and worked
\ncollaboratively to focus on gaining insight to understand the long-standing pattern of
\nself-destructive behavior. Denise was introduced to several key empirically supported
\ntreatments for borderline personality disorder, and she was provided consistent clinical
\nstructure to follow dialectical behavior therapy modules. Denise begrudgingly
\nestablished the clinical goals of eliminating self-injurious behaviors, increasing insight
\ninto her unhealthy emotional reactivity within interpersonal relationships, and improving
\nher overall sense of self-worth. In addition, Denise agreed to partake in a full substance
\ndisorder Assessment and treatment at an adjoining substance abuse outpatient clinic.
\nThe Assessment revealed an alcohol use disorder-mild and an opiate use disordermoderate level, which Denise initially refuted, stating that her alcohol use was \u201cjust
\nnormal partying with friends\u201d and that she was taking her medication \u201cas prescribed by
\nher physician.\u201d She declined to engage in substance use education or follow-up care. A
\nmultidisciplinary team meeting with her primary care provider was held to review the
\ncurrent case management, and it was determined that Denise would not continue to
\n\u00a9 2016 Laureate Education, Inc. 7
\nreceive opiate medications. She was then referred to a pain management clinic. She
\nwas placed on a sole-provider program to ensure she would not be able to obtain opiate
\nmedications from any prescriber other than the pain management clinic.
\nA thorough treatment plan was developed, and the clinical interventions included
\ndialectical behavior therapy to address the negative behaviors and maladaptive
\ncognitions typical of borderline personality disorder; seeking safety skills to address the
\nemotional reactivity and distress she experienced during times of crisis; cognitive
\nprocessing therapy to address the history of sexual trauma she experienced during her
\nteen years; and schema therapy (a form of cognitive-behavioral therapy) to address the
\nnegative underlying core beliefs about herself, others, and the world. In addition, a
\nbattery of psychological testing that included the MMPI-RF, MCMI-II, PAI, and Beck
\nDepression Inventory was utilized to provide an objective assessment of her personality
\nstructure. The results of the psychological testing supported the clinical Assessment and
\ncollateral information that Denise did meet the diagnostic criteria for borderline
\npersonality disorder with histrionic traits. Furthermore, at each session the provider
\nutilized ongoing clinical assessments, which included the Basis 24, PHQ-9, and the
\nCAMS risk assessment for suicide. Denise soon became frustrated with the ongoing
\nuse of these measurements and began to intentionally mark the highest levels possible
\nas a way of disrupting the clinical process and to manipulate the content of the session
\nto avoid the more difficult clinical trauma work.
\nThe primary case conceptualization is that Denise manifested a long history of
\nself-destructive behaviors due to family dynamics of being emotionally distant and
\nhypercritical, combined with recurrent sexual abuse that resulted in a very poor sense of
\n\u00a9 2016 Laureate Education, Inc. 8
\nself-worth. In addition, Denise modeled her mother\u2019s emotionally reactivity and limited
\ninsight. The resulting emotional volatility and self-injurious behaviors were positively
\nreinforced, as others would quickly respond with cursory support or nurturance. Denise
\ndeveloped about herself and others core beliefs (schemas) of emotional deprivation,
\nmistrust\/abuse, defectiveness\/shame, and entitlement.
\nDenise\u2019s family of origin was detached, rejecting, withholding of emotional
\nnurturance, unpredictable, and abusive. Therefore, the core belief of emotional
\ndeprivation that Denise maintains is that a normal degree of emotional support and
\nbelonging will not be adequately met by others. She was deprived of vital nurturance
\nand empathy at an early age; she therefore subconsciously expects all people will not
\nmeet her emotional needs, and subsequently she engages in a self-fulfilling prophecy
\nthat evokes this situation to sabotage close relationships. Denise also continues to hold
\nthe schema of mistrust\/abuse, which creates the expectation that those closest to you
\nwill eventually hurt, abuse, manipulate, or take advantage of you. This perceived
\nintentional and malevolent harm by others negates any establishment of genuine trust.
\nThis often manifests as quick and destructive emotional reactions of anger and
\nrejection. A primary schema related to her sense of self is defectiveness and shame, as
\nit related to Denise\u2019s low self-esteem and sense of inferiority to others. She often
\nrevealed her belief that if people became too close to her personally, they would
\neventually reject her and discover her fundamental flaws. Lastly, as a compensatory
\nschema of entitlement, Denise developed this counter-response that she should be
\nentitled to special rights and is justified in acts of demanding and controlling behaviors.
\nHer appearance of being cocky and selfish was this manifestation to overcompensate
\n\u00a9 2016 Laureate Education, Inc. 9
\nfor the internally perceived low self-image and flaws that can only be \u201cmade right by
\ngetting what she deserves.\u201d
\nDenise had been in treatment for approximately one year when she began to
\nexhibit a return to her maladaptive behaviors. She started an intimate relationship with
\nsomeone she had met during her inpatient psychiatric admission earlier that year, and
\nshe soon began to display emotional volatility and self-injurious behavior when the
\nboyfriend returned to his hometown over the holidays. Her overwhelming feelings of
\nabandonment and mistrust resurfaced when she was unable to contact him one
\nevening, and she took an overdose of Tylenol and alcohol that left her in a coma for
\nthree days. She was fortunate to have been discovered by a friend, who called
\nemergency services. She did not suffer any long-term medical complications, and she
\nwas released back to the outpatient clinic to resume her individual therapy and
\npsychiatric psychopharmacology.
\nFrom a clinical perspective, there are existing challenges that will likely persist
\ndue to the pervasive personality structure that has been engrained to the degree that
\nDenise still enjoys the interpersonal chaos and energy that she derives from the
\nunhealthy conflict with others close to her. A particularly difficult driving force to maintain
\npathology is the primary and secondary reinforcement for Denise, including the
\nimmediate gratification of obtaining sustained attention from peers and co-workers, the
\nmanipulation of intimate relationships to meet her emotional needs, and establishing
\nself-identification as a \u201cpatient\u201d so that she is not held to the same occupational or
\nprofessional standards due to her clinical diagnosis. It is unclear if she will resume her
\nmisuse of opiate medication to suppress her emotional turmoil. A sign of optimism is
\n\u00a9 2016 Laureate Education, Inc. 10
\nthat Denise continues to engage in outpatient mental health treatment, and she has
\ndeveloped a sound therapeutic relationship and is making gradual, albeit slow, progress
\nin the areas of cognitive insight and decreased emotional reactivity. The establishment
\nof a comprehensive safety plan if and when Denise becomes suicidal again has been
\nhelpful in creating a healthier support system. However, it remains uncertain if Denise
\nwill sustain the motivation to remain in therapy to genuinely work through the various
\nlevels of trauma and develop healthier schemas that will help guide her through future
\nstressors without resorting to impulsive suicidal behaviors.<\/p>\n","protected":false},"excerpt":{"rendered":"
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