1.Using the Gray conceptualization helps to construct a competency based assessment, which is different than the diagnosis. You don’t need to write out these factors using a Venn Diagram (as shown in the text) or in paragraph form. A listing of factors under each heading is easiest to do and to use.
2.Determining DSM diagnoses is a skill; and skills need practice, practice and more practice. We will review many case studies in this course to get that practice. It is essential that you use the symptoms to support the diagnosis you select. You should be able to make your “clinical reasoning” clear as to why you have selected the diagnosis you have.
3.Always use both the number code and the diagnostic label from DSM 5.
Select one of these screening tools
•The Caregiver Strain Index
•The Michigan Alcoholism Screening Test (MAST) (PDF)
•Zung Self Rating Depression Scale (PDF)
Sally has been referred to you for an assessment by the school guidance counselor. Sally is about to turn 18 years old and is a junior in high school. Over the course of the last 8 months several of her teachers have complained of her negative demeanor and her quick reaction of being annoyed by any request. Her teachers want her to be successful, but Sally rejects any of their overtures for help or assistance in the classroom. There is growing concern that Sally may not be able to graduate. She has already failed a grade in high school (9th grade) and there is the possibility that she may fail this year as well if she doesn’t bring up her grades. When the guidance counselor approached her to discuss her status, Sally erupted in anger accusing the guidance counselor of always being negative and never having confidence that Sally can succeed.
Recently, Sally had a verbal altercation with her English teacher during class. The teacher had returned the midterm and Sally had failed the test. Sally became irate, accusing the teacher of intentionally making the test so difficult that students could not pass it. She tore up her test paper, and stormed out of the room. Sally had a similar argument with the teacher 3 months ago. Sally maintained that her English teacher is “stupid” and that she asks them to read “ridiculous” books. She stood up in class and told the English teacher her choice of books was “moronic” and refused to read an assigned book. Sally often slept during class when it was discussed. If Sally does not pass English she will likely not pass this year.
Sally arrives to the appointment with you dressed neatly in jeans and a t-shirt. You notice her full sleeve tattoo and multiple piercings in her ears. She says hello, but avoids your gaze. She is accompanied by her father, Eli. Eli relates that in addition to the school concerns, he has issues with Sally at home. “She thinks she knows best about everything! You can’t tell her anything!” Eli states that he and his wife, Sally’s step-mother, have repeatedly tried to reason with her. But she continues to question their parenting and refuses to comply with the family rules. Sally rarely meets curfew and at times doesn’t even explain where she has been. Often, she is out until 2 or 3am even though she is expected home at 10pm on school nights. He is aware that Sally has been meeting older men online. And he fears for her safety. He explains that no matter what he asks Sally to do, she blows up, stomps out of the room, and there is no further discussion. Eli also notes that on three occasions now, money has come up missing from his wife’s purse. They have asked Sally directly if she took the money. Sally chimes in, “It’s a total of $30 bucks – she probably spent it and doesn’t even know it”.
Recently, Eli gave Sally a ride to a friend’s party. When she got out of the car, she slammed the car door hard and yelled back over her shoulder “tonight I’m going to try pot!” He believes that she did this to intentionally upset him as he fears that she is using drugs. Sally giggles in session and assures you that she is not using any drugs. “I just know that it freaks him out.”
Sally has 3 younger half siblings from the marriage of Eli and his wife. “She’s a role model for her younger siblings, this has got to stop!” Sally’s father tells you that Sally historically was a “really good kid, kind and helpful around the house.” She got good grades until she started high school. She was a cheer leader in elementary school and her coach thought she had great potential. Her behavior has
changed in the last year and he doesn’t understand why. He notes that the problem behaviors seem to be escalating. Every week he is getting a call from the school or his wife about something Sally has done. Her step mother has stopped interacting with Sally, hoping that if her father initiates the interaction, Sally will be more receptive. But this has not worked. As her father relates this to you, Sally laughs. “Yeah right, I’m going to listen to you more if she stops talking to me!”
You ask Sally to share her story with you. Sally becomes agitated; she glares at her father and demands that he leave the room. “You don’t have to tell me, I’ll go!” And he abruptly leaves the session. Sally smiles, “it’s so easy to piss him off”. She shares with you that there is no point in her being here. No matter what she does, the English teacher is not going to pass her. “She will never give me a break.” And she has no intention of getting along with her father. “He and his wife don’t care about me ~ they just want someone to agree with their rules.” She laments that the only person who cares about her is her grandmother. She says what she really needs is your help with something else. Since her parent’s divorce when Sally was 5, she has had minimal contact with her biological mother. But Sally ran in to her mother 18 months ago at the opening of the new casino downtown. Sally had gone to the casino to meet a man she had met online. Sally was thrilled to see her mother and they have been in contact ever since. Sally has been frequenting the casino in order to see her mother over the course of the last year. She has a fake ID, and accesses the casino regularly now. Sally enjoys that she looks older than her stated age and that she is fooling the security personnel. She also enjoys the attention she gets from the older men at the casino.
Sally started playing slots as a way to pass the time until her mother had a break from her shift. “It’s a great stress reliever – after that stupid English teacher flunked me, I went straight to the casino and dropped some coins!” She lowers her head and tells you that she didn’t win that day. “But I’m sure that I will make it up soon!” Sally has been asking her friends if she can borrow money in order to continue trying to win back money. She assures you that once she wins again, she will pay them back. “This is just a bad streak, it will change soon. I may be in the hole, but that will turn around any day now.”
Sally asks you to please not share this with her father. “He wouldn’t want me to be talking with my mother.” When Sally was 5 her mother took off with another man. Her parents eventually divorced, and Sally was raised by her father and his mother. Sally remains very close to her grandmother. She’s the only one who sees the good in me. “My mom’s different now – she wants to get to know me and be a part of my life.” Sally and her mother have talked about the past, and Sally has forgiven her mother for leaving. Sally tells you that her father and step mother “have everything” and that she wants the same for her mother. Sally hopes that if she can just win, she can move out and go to live with her mother. Sally explains to you that she doesn’t have time for English class, or to read stupid books, when she needs to be trying to move out. Her mother is working double shifts and is very tired. Her mother does not know that Sally is playing the slot machines, and Sally knows that she wouldn’t approve. “But she’ll be proud of me when I tell her I have enough money for my own place.”
“So I really need your help, can you loan me $500? I promise I will pay you back soon”.
John is a 39 year old man who came for an assessment at the recommendation of his sister and his landlady.
John’s sister Mary had called before the appointment and explained, “I just wanted to warn you. John can get defensive, but he’s really a nice guy. If I’m there, I think I can make things go more smoothly. Oh, he has health insurance, but he wants to just pay cash for the visit.”
When you met John, he greeted you with “hello” and shook your hand without smiling. He wore jeans, a button down shirt, and a camouflage ballcap. He had a trimmed beard and wore glasses. Mary greeted you more warmly and had a bright expression. You explained to John that if he wanted an opportunity to speak with you without Mary present that he just needed to let you know. “I want her to be here, she’s better at this stuff than me,” he said.
Before you actually began the interview, John had several questions about
confidentiality. He wanted to know under what circumstances you would release his information without his consent. After you explained, he asked who enforces the rules to keep you from just telling “anyone” what he has told you. You described both your agency’s policies and the rules regarding licensure and practice for social workers. “So if you revealed information you weren’t supposed to, I could complain to your boss and to the state?” You agreed that there were a number of actions that could be taken to address unethical practice on the part of social workers. “But how would I know that they wouldn’t just cover it up?” he asked. You took a moment to show John the website where the state board keeps a record of disciplinary actions taken. You also wrote down the web address of the board for him. You also explained that he was not obligated to answer any questions he was uncomfortable with. “I still have some questions, but that’s enough for now, I guess,” he said.
When asked why he came to see you, John explained that there had been a recent incident at his house. “Mary was afraid of her asshole ex-boyfriend, so I had her come stay with me. He showed up a week ago, drunk, at two in the morning. He was pounding on the door and threatening to beat me up and kill her in front of me. I’m not a big guy compared to him, but I
got my Glock and opened the door. Turns out he had a baseball bat and had smashed out my pickup’s windows and lights. Mary called 911 and I kept my gun on him until the police showed. My landlady Evie lives next door and came over and stayed with Mary while we waited.”
Mary then explained that the police came, weapons drawn, and made both men lie on the ground and handcuffed them. After speaking to Mary and Evie, they released John, but he remains angry about it. Interrupting Mary, John said, “those pigs left me there for fifteen minutes! I’m protecting my sister and I’m treated like I’m the criminal!”
Mary turned to him and said, “John, they had to make sure. You were yelling at them and they needed to know who the bad guy was. They apologized, right?”
Calming down, John said, “Yeah, they did. I don’t think they meant it, but they said the words. If you and Evie weren’t there, they probably would have beat the hell out of me.”
Mary continued to explain. Mary’s ex-boyfriend was arrested, and has since been held in jail on unrelated issues. “We’ll probably all end up having to testify, but I feel safer now. The problem that brings us here is that Evie saw John’s guns.” When Evie entered the home to be
with Mary, she saw seven different firearms on John’s kitchen table. She did not realize that John had more than one gun and asked Mary how many John owned. “I probably should have kept my mouth shut, but I was stressed out and I told her he had over fifty.”
“Now she’s all worried about me,” John said. “She thinks I’m going to go on a shooting rampage someplace and she’s thinking about kicking me out. Mary talked with her and Evie said if I saw someone who could tell her I wasn’t a killer that I could stay. I’d just move, but Mary really wanted me to come in.”
John grew up in the town where he lives, and did well in school, though he kept to himself. Mary, two years older than John, is his only sibling. John reported that his childhood was free of trauma and he loves his family. When his father died five years ago, he felt the loss deeply. John has no close friends, but he does spend time with his sister and mother.
He finished high school and has worked as an auto mechanic since. He had worked at several different shops over time, but left each of them for various reasons. At one he believed the owner was too interested in his personal life. Another job lasted only a couple of months because his boss called him “Johnny.” “He just kept putting me down by calling me a kid’s name. I see him around sometimes. He’ll say hello, but I don’t acknowledge that bastard. There are people who are good at that, you know. They look and act like they’re being friendly, but I see through them. There’s a few of ‘em I used to know and I just act like they don’t exist if I run into them.”
He eventually bought his own auto shop and remains self-employed. He used to hire other mechanics to help out, but always worried that they might steal from him so he works alone now. No money was ever missing but, “…they would watch where I kept things. Being able to take the extra business was good, but I couldn’t take the risk. I also wasn’t sure I could
rely on their work. I don’t have a huge business, but I have a lot of return customers because they know I do good work and I’m dependable.” John mentioned that he likes having his own
business because “I get to manage my own books.” When you asked why that is important, he said, “I know how much money I have coming and going and I tell the taxman all he needs to know about my business.”
John keeps some of his earnings in several bank accounts, but also keeps quite a bit of
cash “squirreled around.” He reported that he worries that the government knows too much about everyone. “Most people don’t care, they’re sheep. But I do care, and I know that I could be a target.” When you asked if he believed the government was watching him in particular, John replied, “Snowden showed us that the feds keep track of everything. They can read our email, follow all our transactions. They don’t read it all, of course, there’s too much. But they can check out anyone they want. I’m really careful in my internet and email now. I’ll read political boards, but I don’t post much.”
John has never been arrested, though he has had speeding tickets over the years. He reported that the police enjoy having power over people in situations like that. “Keeping you on edge, taking your license and going back to their car, making you wait there. You read those stories about cops shooting family pets when they’ve entered the wrong house on a warrant. It’s all about power, you know. They don’t know they’re terrorizing the wrong house, but I don’t think it really matters to them.”
John is alone most of the time. “When I was a kid, I figured out that outside of blood relations, people are just takers. I don’t mean people are evil generally; it’s just the way they’re made. Unless they are deeply connected to you, they’ll take advantage of you. You have to keep people at a distance to protect yourself. You can’t trust them. I think most people just try to pretend that isn’t true. In a way, it’s like a curse to be able to see it.”
John often feels lonely, and wishes he had someone to spend his time with. He occupies
himself outside of work by watching television and movies at home, taking his dog for hikes and
camping and occasionally going to gun shows. He belongs to a gun club and interacts with the other members, though he keeps them at a distance. “I’ll have lunch with them, but we don’t really hang around. You’ve got to be careful, you know.” John enjoys political conversations and reads a few online discussion forums.
John has had girlfriends in the past, but none of the relationships lasted over six months. He explained that none of the women he has dated turned out to be trustworthy. “They would just keep prying into my business without any reason. We weren’t married! Why would they
even need to know everything about me? They’d push too hard and I could tell they weren’t with me for me, it was for my money or for something else. If there’s one thing I’ve learned from all the crap Mary’s gone through, it’s that stalking is a horrible thing. What my so-called girlfriends were doing was just one step short of stalking me.”
John has not dated for the last ten years. He sometimes meets a woman who he finds attractive, but he believes that he will be taken advantage of. “The risk isn’t worth it. I’d like to be with someone, but look what happened to Mary. Too many people want to own you, take advantage of you, or ruin you.”
When you asked about the guns, John replied that guns are a hobby for him. He and his father hunted together when he was a boy. He rarely hunts now, but his interest in guns remains. “Look, I know that guns can make people nervous. I collect guns because I’m interested in them. I also have them for self-defense. That’s what got me here. I would never go out like some crazy person and kill people. I could have shot Mary’s ex and claimed self-defense even though he stopped when he saw my Glock. I have all kinds of reason to hate him for what he’s done to Mary, but I didn’t shoot him. That just isn’t who I am.”
John reported that he is healthy. He does drink beer but no more than one or two after work, and not every day. He denied any other use of substances. He has health insurance but has not seen a physician for several years. When you asked why he preferred to pay cash for the
visit, he said, “The insurance company doesn’t need to know any of this.”
When they left your office at the end of the interview, John asked if you could direct him to a grocery store other than the one on the next corner. “Yeah, I went in there and they wanted me to fill out some frequent shopper application. That’s none of their goddamn business!”