RUNNING HEAD: CASE ANALYSIS

Case Analysis

Shcaleah Kelton

North Carolina A&T State University & University of North Carolina Greensboro (JMSW)

Professor Cobb

652 Advanced Clinical Social Work Practice I

I have abided by the NCAT/UNCG academic integrity policy on this assignment.

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Section 1:

Theoretical frameworks:

Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), and

Motivational Interviewing (M.I). I would use either CBT or ACT along with M.I., after gathering

additional information from Helga.

Significance of CBT:

CBT is an evidence-based intervention that supports mental and psychological disorders

by the maintenance of cognitive factors. CBT focuses on symptom reduction, enhancement in

functioning, and decrease of the disorder. To achieve this goal, the patient becomes an active

participant in the collaborative process. Clients should test and challenge maladaptive cognitions

and to modify their negative behavioral patterns. CBT uses interventions that combine a variety

of cognitive, behavioral, and emotion-focused techniques ((Hofmann, Asnaani, Vonk, Sawyer, &

Fang, 2012, pp. 427-428). CBT will help Helga work on coping strategies to battle her constant

negative thoughts she feels about herself daily.

Significance of ACT:

ACT goals are to increase psychological flexibility and to improve the quality of life.

ACT is often used to treat anxiety disorders and depression problems' (Hertenstein

& Nissen, 2015, p. 250). Positive Psychology mentions ACT promoting acceptance of one's

thoughts and feelings versus neglecting the sense of guilt. This therapy acknowledges that going

through trying times is common for all people. ACT provides a guide that can navigate through

essential stages of treatment to increase self- efficacy. Those six stages are identified as

acceptance, cognitive defusion, being present, self as context, values, and committed action
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(Ackerman, 2017). ACT will allow Helga to accept her current situation to create self-identified

commitments and implement change.

Significance of M.I.:

M.I. is related to helping those who like to change their behaviors. The approach includes

a collaborative conversation that strengthening one's perspective to the commitment of change.

M.I.'s goal is to seek and resolve the uncertainty that people might have about themselves in

favor of a change. M.I. encourages people to envision what change looks like for them and

develop skills to facilitate that process. There are four stages involved in M.I., which include

engaging in a working relationship; focusing on a problem to change; evoking the person's desire

to change; and planning the change (Frost et al., 2018, pp. 1-2). With the use of M.I., Helga will

be the driving force in the change process.

Commonalities and Differences:

A significant difference between CBT and ACT, ACT does not focus on disputing the

content of dysfunctional thoughts but encourages the patients to disidentify with them and to

reduce their impact on behavior (Hertenstein & Nissen, 2015, p. 250). Whereas,

CBT is used to decrease symptoms and enhance coping skills to manage negative thoughts,

feelings, and behaviors. Although CBT and ACT elicit some form of change, M.I. walks through

the change process based on the client's perspective. M.I. is based on empowerment, the therapist

is a guide, and the client is the expert.

Section 2:

Biopsychosocial and Spiritual Dimensions:

The dimensions of the biopsychosocial and spiritual assessment include the biological

aspects of Helga discovering a lump in her throat, which was later removed and found to be
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benign. Since the onset of the medical condition was unknown, the lack of certainty caused

Helga to have intense fear and stress. From a psychological standpoint, Helga presents a history

of mental health issues that impacts her daily levels of functioning. She has multiple past

hospitalizations with thoughts of rejection, worthlessness, and hopelessness. Helga's behaviors

have led to self-injurious (cutting), intense fear, depression, acute anxiety, and several attempts

to end her own life. Socially Helga reported having few supports and only one friend. Helga says

she has issues connecting with others and never felt "at home" since she left Germany. Helga did

report being spiritual but not religious.

Importance of Culture:

By Helga identifying as a black female raised in Germany, her needs would require a

skilled therapist who understands her German culture. Helga is not from the U.S., which adds

another level of complexity when trying to connect her to resources that offer services to those

who resemble Helga ethnic background. Helga reports there is nothing in Germany for her to

return to, which may have caused Helga to dissociation from her home country. The feeling of

not being able to go back to her home country, along with feeling excluded in the U.S. can be a

result of some of Helga's psychological issues.

Presented Needs:

Helga's needs may include support groups, intensive individual therapy, and wellness

management resources. Helga would benefit from a support group(s) that not only addresses her

psychological needs but also incorporate her German culture. Helga's participation in intensive

individual therapy will allow her to report symptoms of depression, anxiety, suicidal ideation,

and developing coping skills to reduce inappropriate behavior. Attending therapy will allow

Helga to communicate her worries and satisfaction as it relates to her self-actualization. Wellness
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management resources will assist Helga with obtaining information and developing a crisis plan

to address her suicidal ideations and mental health issues. Linkage to a Primary Care Physician

(PCP) and a Psychiatrist to assess if there is a need for a medication regimen. Based on Helga's

history, Helga may benefit from an antidepressant. If Helga accepts medication management, she

will benefit from having an Assertive Care Treatment Team (ACTT). ACCT can assist with

medication reminders, education on the importance of taking medication as prescribed, and assist

with communication as needed regarding symptoms, needs for evaluations, or concerns.

Presented Strengths:

Helga's strength includes; having a graduate degree, maintaining stable employment, and

independent living skills. Helga, being employed as a part-time instructor at a local community

college, shows that she has qualities relating to communication, critical thinking, writing, and

resourceful skills. All Helga skills will be useful when working with a therapist. Helga has

demonstrated that she can maintain employment through adversity. Helga understands her

mental health condition and symptoms. Helga acknowledges that she does not want to go back to

the hospital, which is an indicator that she is ready for change. Helga has necessary living skills

such as cooking, cleaning, and techniques used to aid in the daily task at home. The therapist can

provide psychoeducational material about maintaining necessary living skills with a mental

health diagnosis. The therapist can practice and process with Helga about her progress with

independent living skills.

Section 3:

Presented Challenges:

Foreseen challenges for Helga may consist of; building rapport, safety, and security,

conflicting work and treatment schedules, and group work issues. Helga reports she has a hard
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time feeling connected to others. Helga may be reluctant to disclose her information if she does

not feel a connection with the therapist. Based on Helga's culture, she may feel the therapist

cannot relate to her ethnic background. Helga reports she has few supports, no intimate

relationships, and she feels a deep sense of rejection; Helga may not feel a sense of safety of

security without the support of others. With Helga being a part-time instructor at a local

community college, it may interfere with the hours of operations of therapy. Helga reports it has

been about a month since she has been to her group. The group may be challenging for Helga if

she does not feel accepted, supported, and understood by others in her treatment group.

When engaging with Helga, it would be essential to make her feel comfortable in the

space; she is seeking services. To prevent client retention and build rapport with Helga, the

therapist should be professional, have insight regarding Helga's culture, and display attunement.

When forming a plan of intervention for Helga, one should consider; developing a working

relationship, knowledgeable about history, incorporate M.I., provide flexible schedules,

encourage group work, increase contact during treatment, provide resources, and show a great

interest in her success.

The therapist should be mindful that Helga is educated and a working professional, and

professionalism is expected. Asking questions about Helga's culture versus making assumptions

may create trust. The therapist should display honesty when discussing cultural differences

because dishonesty can result in Helga withdrawing from therapy. The therapist should be

vigilant when talking about specific topics with Helga. The therapist should be aware of Helga's

body language, eye contact, and facial expressions to ensure that the session feels safe and

secured. At any time, Helga does not feel safe or secure, the therapist should incorporate

mindfulness activities to ease Helga's mind. The therapist should be aware of Helga's work
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schedule and create a plan that works best for Helga and the therapist. It may be difficult for

Helga to adjust her work schedule if a collaborative treatment schedule is not made. The

therapist should link Helga to groups that would be viewed as a benefit and not as busywork.

Helga is a college graduate, so group referrals should be well designed and organized to avoid

client retention.

Section 4:

The Change Process

Helga appears to be in the first stage of change. Helga recognizes that change needs to be

made. She realizes that she does not want to go back to the hospital. She is opened with her

therapist and provided a lot of information to formulate a baseline of her needs. The therapist

should further assess Helga's level of change by asking additional questions. Examples of

questions a therapist may ask:

 On scale 1 to 10, how ready are you to make a change in your life?

 What is your motivation for change?

 What's different now, then times before when you tried to make a change?

 Can you foresee any obstacles that would block you from change?

 Name one thing; you would like to change during our treatment sessions?

Coping Strategies

Helga reports that she likes to listen to music, eat German food, to cook, and to go to

church occasionally. Helga did not identify her coping strategies. The therapist would need to

explore Helga's current coping mechanisms. Helga must have some coping strategies because her

last hospitalization was one year ago. Proposed questions may contain;

 What are some ways you cope when experiencing negative thoughts?
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 How do you get out of bed in the mornings when it seems nearly impossible?

 How do you relax when you are feeling stress?

 How often do you talk to your good friend that lives nearby?

 What kind of music do you enjoy listening to?

The therapist should capitalize on the fact that Helga is currently maintaining her current

symptoms since being discharged from the hospital a year ago. The therapist should ask for

Helga's consent to contact her one good friend to include them in her crisis plan and add them to

her support system. Helga's strength of seeking services shows she is committed to her mental

health and getting better. The therapist should give Helga praise for starting the journey with

little support and acknowledge her for being brave.

The Diagnosis

Based on Helga's assessment and history the counselor should consider the following

diagnoses;

 Primary: Major Depressive Disorder with Anxious Distress, Mild.

 Secondary: Other Specified Anxiety Disorder.

 Tertiary: Obsessive-Compulsive Disorder with Poor Insight.

Major Depressive Disorder with Anxious Distress, Mild

Helga presented five or more symptoms during the same 2-week period and had a change

in mood and interest. Based on the assessment, Helga has been experiencing extreme stress for

the past 18 months and was last discharged from a hospital setting a year ago. She does not meet

the 2-year criteria for Persistent Depressive Disorder without engaging in further questioning.

However, the counselor can assume she has been experiencing her symptoms during a two 2-

week period based on the information provided. Helga meets the below criteria:
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 Depressed mood most of the day, nearly every day, as indicated by reporting how lonely

and isolated she feels.

 Diminished interest or pleasure by regularly attended outpatient individual and group

therapy, but now it's been about a month since she has been to her group, and he does tell

you that she goes to church on occasion.

 Fatigue or loss of energy nearly every day because Helga reports that she dreads getting

up every morning. Everything seems like such a chore.

 Feelings of worthlessness or excessive or inappropriate guilt. Helga reports she feels so

worthless, rotten, and full of guilt and hatred for herself

 Recurrent thoughts of death and suicidal ideation without a specific plan. Helga says that

she has constant thoughts of ending her life, but she is not sure how she would do that or

if she even wants to do it.

The specifier of anxious distress was used because Helga met the criteria of at least two of the

symptoms, which included; difficulty concentrating because of worry and fear that something

awful may happen. Helga may present additional symptoms with additional questioning. Mild

severity was used in conjunction with the two symptoms indicated.

Other Specified Anxiety Disorder

The counselor may consider diagnosing Helga with Other Specified Anxiety Disorder

based on the information provided she did not meet the full criteria for an anxiety disorder. The

therapist would need to ask more questions about timeframes, events/activities when she feels

more anxious, and explore symptom-related questioning. Information received will allow the

therapist to have a clearer understanding of what Helga is experiencing.

Obsessive-Compulsive Disorder with Poor Insight

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Helga presented diagnostic criteria for Obsessive-Compulsive Disorder. Helga meets the

repetitive behaviors or mental acts that a person feels driven to perform. Helga reports that she

repeatedly checks doors, locks, and windows before she leaves the house or goes to bed to make

sure that they are secured. Helga also reports that she has an intense fear of making mistakes and

being responsible for "something bad happening." The compulsiveness behind Helga's behaviors

is geared to reducing anxiety or distress or preventing something terrible happening.

Section 5:

The Plan

The therapist should formulate a plan that includes completing Helga's intake process,

creating a person-centered plan, and reviewing past evaluations and assessments. The counselor

should make sure that referrals are completed to assist Helga with additional services. The

therapist should keep in mind, Helga's gender, race, socio-economic class when seeking outside

services. Handling her case with diligence will decrease discriminatory experiences. Helga has a

unique ethnic background, and other providers involved with her care should be aware of her

needs before any referrals are made. Also, the therapist should monitor and document services,

assist with securing funding for her services, if needed. The therapist should assess Helga for the

appropriate level of service based on her acuity. The counselor should remain mindful of Helga's

window of tolerance and evaluate for any past traumas.

Sample Goals and Strategies

Sample goals may include;

 Helga will learn and incorporate five adaptive coping mechanisms over the next six

months while educating herself on her new diagnosed mental health conditions.

 Helga will go to a group of her choice at least once a month for the next six months.
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 Helga will engage in peer and social interactions at least once a week for the next six

months (e.g., out to eat, movies, the mall, etc.)

 Helga will participate in therapy services to address symptoms of mental health issues

and learn coping skills to reduce depression and suicidal ideations.

 Helga will identify a PCP and make an appointment for a wellness check in the next six

months.

The therapist may include strategies for Helga to use outside of therapy, such as;

 Mindfulness breathing exercises or meditation.

 She should consider writing positive thoughts in a journal.

 She should consider finding fun activities outside the house.

 She should consider reading books before going to bed.

 Physical activity.

Section 6:

The Evaluation

The therapist should measure their intervention plan by client engagement, decrease in

symptoms, increase in social supports, and completion of goals. The counselor should consider

measuring Helga's severity by using Generalized Anxiety Disorder- 7 (GAD-7) and Patient

Health Questionnaire- 9 Depression Scale (PHQ-9). These scales will be used by the clinician to

monitor Helga's acute anxiety and depression. Helga will be a vital component of the evaluation

plan as it will be essential for her to self-disclose to get the appropriate treatment.
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References

Ackerman, C. (2017, January 3). How Does Acceptance And Commitment Therapy (ACT)

Work? Retrieved November 4, 2019, from Positive Psychology website:

https://positivepsychology.com/act-acceptance-and-commitment-therapy/

Frost, H., Campbell, P., Maxwell, M., O'Carroll, R. E., Dombrowski, S. U., Williams, B., . . .

Pollock, A. (2018). Effectiveness of Motivational Interviewing on adult behaviour

change in health and social care settings: A systematic review of reviews. PLoS One,

13(10). https://doi.org/10.1371/journal.pone.0204890

Hertenstein, E., & Nissen, C. (2015). Comment on 'A Meta-Analysis of the Efficacy of

Acceptance and Commitment Therapy for Clinically Relevant Mental and Physical

Health Problems'. Psychotherapy and psychosomatics, 84(4), 250-251.

https://doi.org/10.1159/000374124

Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., & Fang, A. (2012). The Efficacy of

Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive Therapy and

Research, 36(5), 427-440. https://doi.org/10.1007/s10608-012-9476-1