Case Scenario
Sally is a 19-year-old, heterosexual, Afro-Latina female who is able-bodied. She resides with her parents in a middle-class neighborhood and is attending community college locally. She was referred by the hospital for outpatient mental health services after alcohol intoxication, in addition to which she also reportedly consumed a significant amount of Advil (20 pills). Her parents are in the waiting room and you meet with Sally for the intake as a social worker at the outpatient mental health clinic where she has been referred.
Upon asking Sally what brings her to treatment she states, “I have a lot going on” and appears guarded. Sally reports she is in a long-term relationship with her boyfriend since high school, which she describes as “a roller coaster . . . some days I hate him, other days I know that I can’t live without him.” According to Sally, they have broken up at least three or four times over the course of their relationship, always getting back together.
When asked about her recent visit to the hospital, Sally stated that she wasn’t trying to kill herself, and that she used alcohol with the pills because “I didn’t want to feel anymore and just did it.” Sally reported difficulty coping, which at times leads her to be impulsive. When asked how many times she consumes alcohol weekly, she states, “A few times a week, but so does everyone my age. It’s normal and helps me feel better.” Sally’s affect shifted to being intense when discussing her alcohol use, and defensive. “I know what you are thinking,” she stated.
Upon further exploration, Sally reports she has engaged in cutting herself in the past, superficially on her wrists and leg, to numb her feelings. Sally stated, “I feel like I don’t know who I am sometimes and especially when I break up with my boyfriend. It is like, I am empty inside, and that is a horrible feeling.” Sally denied suicidal or homicidal thoughts, intentions, or planning. However, she did share that at times she engages in risky sexual behavior when she is on a break from her boyfriend, in an effort to not feel empty and alone.
Case Scenario Questions
Given the diagnoses in this module that you have learned about, what are some of the symptoms that you can identify Sally is experiencing/demonstrating/reporting during her intake?
As the intake clinician, what diagnoses would you consider for Sally? Justify the reason for each diagnosis, reporting the symptom criteria leading you to consider the diagnosis.
What differential diagnosis would you consider? For example, what are similar diagnoses that you would explore in order to rule out and narrow down the client’s specific diagnosis?
Related to the presenting symptoms and the client’s diagnoses, what would you recommend for the client’s plan of treatment? Please offer a rationale.
Would you consider asking the parents to come into the session? Why or why not? Please offer your justification.