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Case Documentation Exercise (Clinician)
Crystal is a 16-year old female whose father, Mike, committed suicide one year ago. She has been depressed since then, and sometimes talks about “wanting to join him.” Crystal lives with her mother, Sara, who also has been struggling with her own depression since her husband’s death. Sara reported that Mike’s suicide was the result of a recent job loss and his fear that his house might be foreclosed. Still, Sara felt Mike’s death was “out of the blue,” with no family history of mental illness or substance abuse. Sara and Crystal are both engaged in outpatient therapy and a suicide survivor group, which they feel are helpful.
Crystal has Type I Juvenile Diabetes, which was first diagnosed seven years ago. She has been able to manage her illness independently for the past three years. Until her father’s death she was described as “medically stable.” Crystal has an involved and dedicated team at her local hospital that has worked with her and Sara to make sure her diet, activity level and care are in sync. Recently she has struggled to keep her sugar level in balance. She has not changed her eating habits or activity level yet still has had several episodes in which she felt faint and lightheaded. At school she was observed to fall asleep in class and needed prompting to check her sugar levels. Crystal is distressed by these changes and shares that, “I used to be on top of all of this, but now I’m really struggling to keep up.” Crystal has always been popular with peers and a good student, though this year her grades have declined. When her mother tries to talk with Crystal and express her concern about her poor attendance at school she storms to her bedroom, slamming the door. Crystal and her mother are struggling to communicate with one another since the death of her father.
Crystal and Sara have a number of involved adults working with them: her nurse and guidance counselor at school; her individual, family and group therapists; her pediatrician and health care team that works with her diabetes care. Crystal especially feels connected with her individual therapist and reports, “She really understands me and what’s going on. But sometimes the other adults don’t seem to get it. It feels like there are so many people working with me and they’re not all on the same page.”
1.) What mental health diagnosis would you give Crystal? Please explain.
2.) Would you give Crystal a personality disorder diagnosis? Please explain.
3.) What are Crystal’s medical issues? Please explain.
4.) What are the psychosocial stressors Crystal is dealing with? Please explain.
5.) Where would Crystal fall under the global assessment functioning scale? Please explain.
6.) What are Crystal’s personal strengths? What are areas of needs? What are the family’s strengths and needs?
7.) Please state the problems in this case vignette.
8.) Please write a clinical formulation on Crystal.
9.) Please identify the goals and objectives for the problems.
10.) Crystal stated that there were a lot of people working with her but they were not on the same page as her clinician; how would you address this?
11.) What would you do if you were invited to a family gathering to honor the deceased family member?
12.) Based on the case vignette do you think Crystal needs a risk assessment/safety plan? Why or why not?
13.) You have learned that Crystal and her mother are trying to process their grief with the TT&S and TM. What do you do?