Case histories are a means for social workers to describe a ?specified individual’s mental health disorder and provide the ?individual’s family history as context. This skill is an importa

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Case History

Assignment Overview

Case histories are a means for social workers to describe a specified individual's mental health disorder and provide the individual's family history as context. This skill is an important component of advanced generalist practice with individuals, families, groups, organizations, and communities.

In today's society, there is vast cultural diversity. Diversity is no longer defined by race, but it includes lifestyles, sexuality, gender, religion, socioeconomic status, health, geographic regions, ethnicity, and more. As a leader within the social work arena, we often need to identify strengths-based strategies and empowerment strategies to address cultural competency in these diverse groups.

By successfully completing this assignment, you will demonstrate your proficiency in the following EPAS and specialized practices:

· Competency 6: Engage with Individuals, Families, Groups, Organizations, and Communities.

· C6.SP.A: Apply critical thinking and decision making in verbal and written communication through the use of leadership and technology when engaging with colleagues, individuals, families, groups, organizations, and communities.

· Related Assignment Criteria:

· 3. Communicate in a manner that is scholarly, professional, and consistent with expectations for leaders of the social work profession through the use of technology.

· C6.SP.B: Apply and integrate theories of human behavior and the social environment in the specialization of advanced generalist practice when engaging with individuals, families, groups, organizations, and communities.

· Related Assignment Criteria:

· 1. Describe a specified individual’s mental health disorder.

· 2. Describe the individual’s family history.

· 3. Communicate in a manner that is scholarly, professional, and consistent with expectations for leader of the social work profession through the use of technology.

· Competency 7: Assess Individuals, Families, Groups, Organizations, and Communities.

· C7.SP.A: Apply critical thinking and decision making in verbal and written communication through the use of leadership and technology when assessing colleagues, individuals, families, groups, organizations, and communities.

· Related Assignment Criteria:

· 3. Communicate in a manner that is scholarly, professional, and consistent with expectations for leaders of the social work profession through the use of technology.

· C7.SP.B: Apply and integrate theories of human behavior and the social environment in the specialization of advanced generalist practice when assessing individuals, families, groups, organizations, and communities.

· Related Assignment Criteria:

· 1. Describe a specified individual’s mental health disorder.

· 2. Describe the individual’s family history.

· 3. Communicate in a manner that is scholarly, professional, and consistent with expectations for leader of the social work profession through the use of technology.

· C7.SP.D: (Assess) Apply assessment instruments, leadership, technology, critical thinking, and interpersonal skills to identify problems, and assess and analyze capacities, strengths, and needs of individuals, families, groups, organizations, and communities.

· Related Assignment Criteria:

· 1. Describe a specified individual’s mental health disorder.

· 2. Describe the individual’s family history.

· Competency 8: Intervene with Individuals, Families, Groups, Organizations, and Communities.

· C8.SP.A: Apply critical thinking and decision making in verbal and written communication through the use of leadership and technology when intervening with colleagues, individuals, families, groups, organizations, and communities.

· Related Assignment Criteria:

· 3. Communicate in a manner that is scholarly, professional, and consistent with expectations for leaders of the social work profession through the use of technology.

· C8.SP.B: Apply and integrate theories of human behavior and the social environment in the specialization of advanced generalist practice when intervening with individuals, families, groups, organizations, and communities.

· Related Assignment Criteria:

· 1. Describe a specified individual’s mental health disorder.

· 2. Describe the individual’s family history.

· 3. Communicate in a manner that is scholarly, professional, and consistent with expectations for leader of the social work profession through the use of technology.

· Competency 9: Evaluate Practice with Individuals, Families, Groups, Organizations, and Communities.

· C9.SP.A: Apply critical thinking and decision making in verbal and written communication through the use of leadership and technology evaluations with colleagues, individuals, families, groups, organizations, and communities.

· Related Assignment Criteria:

· 3. Communicate in a manner that is scholarly, professional, and consistent with expectations for leaders of the social work profession through the use of technology.

· C9.SP.B: Apply and integrate theories of human behavior and the social environment in the specialization of advanced generalist practice evaluation with individuals, families, groups, organizations, and communities.

· Related Assignment Criteria:

· 1. Describe a specified individual’s mental health disorder.

· 2. Describe the individual’s family history.

· 3. Communicate in a manner that is scholarly, professional, and consistent with expectations for leader of the social work profession through the use of technology.

Assignment Description

For the first assignment of your course project, you will write a detailed individual and family case history as part of an assessment. Please keep in mind that this first component will serve as the basis for the rest of your course project. The more developed your initial case history, the easier it will be to develop your Comprehensive Case Study for the final project.

You were provided with four possible case studies in the Unit 1 studies. If you have not done so already, choose one of the case studies to work with throughout your course project.

Assignment Instructions

Use the Case Study Template media piece in the Course Resources to complete an individual assessment, including:

· Description of the individual's mental health history. (C6.SP.B, C7.SP.B, C7.SP.D, C8.SP.B, C9.SP.B) 

· Identifying Information.

· Referral Source.

· Presenting Problem.

· History of Problem.

· Previous Counseling Experience.

· Description of the individual's family history. (C6.SP.B, C7.SP.B, C7.SP.D, C8.SP.B, C9.SP.B)

· Description of the individual's personal history. (C6.SP.B, C7.SP.B, C8.SP.B, C9.SP.B)

· Medical History.

· Educational History.

· Social Class.

· Cultural History.

· Spirituality.

· Mental Status or Current Functional Exam. (C7.SP.D)

· References.

As you complete the Case Study Template media piece based on one of the provided case studies, use your text and the DSM-5-TR as guides as well as one of the assessment tools from this unit's studies:

· The guidelines for the mental status exam on pages 50–51 of Clinical Social Work Practice. Use questions 1–14 for the interview.

· One of the tools provided in the American Psychiatric Association's Online Assessment Measures (link in the Resources) for diagnostic assessment tools and resources.

When you have completed the template, follow the instructions to generate a document. Be sure to check it for accuracy before turning it in for your instructor to review.

Additional Requirements

The assignment you submit is expected to meet the following requirements:

· Written communication: Written communication is free of errors that detract from the overall message.

· APA formatting: Resources and citations are formatted according to the current APA style and formatting standards. 

· Use the Case Study Template provided in the Resources.

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Pepper Family

Olivia Pepper is a 30 year old Masters Student who was referred to the University Counseling Center from her professor for erratic behaviors. The referral report from the professor states that Olivia is a bright student with a 3.8 overall GPA in her last semester of school but that she is currently failing two of her courses that her attendance has been sporadic, and she is often late. One of Olivia's peers reported that they "smelled alcohol on her more than once after lunch and that they don't want to work with her because she wants to meet at the local bar and she is never engaged in learning and more worried about what is next to drink."

Olivia's intake paper work shows that she is African American, married with three children (ages 2, 6, and 8). Her religious affiliation is listed as Baptist. Her records indicate that she is receiving several financial need scholarships and that she is currently not working. Olivia reports that she is currently not on any medication but has previously taken Zoloft and Wellbutrin. Her intake paperwork also lists two residential treatments once as an adolescent for alcohol use and the second when she was 24 for depression and alcohol use. She has had two DUI's her first when she was 16, and the second when she was 22 years of age. Olivia indicates that she went to family counseling as a teenager.

Upon her first visit Olivia is 15 minutes late for her appointment, she is in baggy clothes that look dirty and her is unkempt, she appears agitated and nervous. When asked why she was there she stated "because my teacher is worried I have fallen off the wagon." When asked to explain what that meant Olivia shared that she is a great student and she is just having a hard semester so she is not doing as well but that it has nothing to do with her drinking. Olivia continues that her husband was fired from his job so it has created great stress in her house and that he wants her to stop school and work until he can find work again. Olivia starts to cry and states, "I am almost done, how am I supposed to quit, but my family needs me." "Most days I just don't want to get out of bed and face my day, I am overwhelmed, everyone needs something, and I just want to sleep." When asked how many days of the week this happens, Olivia shard that this occurs every day. She reported sleeping 10-12 hours a day, isolating herself from her family, and not going to school because she just doesn't care. When asked how long this had been occurring she stated it has become worse over the past six months but that she has been in a "funk on and off my whole life." She continued with, "You know what is crazy that it doesn't matter how much sleep I get, I am just exhausted all the time, and I just feel worthless"

Olivia reports that she has no reason to be so sad all of the time. She grew up with loving parents who worked hard. Her mother left them when she was 14 and that is when she started to drink. She reported she had a boyfriend and drinking with him would make her feel better. When she received a DUI at the age of 16 her Dad didn't know what to do so he put her into treatment, which was a waste of time as drinking was not her problem. Olivia shared her second trip to treatment was after the birth of her first child, she just felt guilt all the time for working and not being with her baby so she started to drink again. She stated that he was a cranky baby and it was the only way she could cope. Olivia shared that when she received her second DUI at the age of 22 it was too much to handle as she lost her job because she was not allowed to drive after that. She stated it was a long couple of years and after the birth of her second child it was too much to take and she tried to make it all stop. Olivia stated she was admitted into a hospital for attempted suicide for a drug overdose on her Wellbutrin with alcohol. Olivia stated that scared her and she started to go to AA and started to feel better.

A couple of years ago she decided that she wanted to finish school so that she could help kids like her and maybe help them avoid "this mess I am in." Olivia stated everything was going ok and that she has not been on medication. She reports that church and AA have been very important to her and they help her get up in the morning. Olivia reports she has no family, that she has not seen her mother since she left her as a child and that her dad passed away two years ago from 'drinking himself to death.' Olivia has a sister that moved out of state years ago and they talk on the phone occasionally but that they are not close.

Olivia admitted that she has started to drink and typically when she goes to school during lunch she will have a drink to help her get through the rest of the day. She also reports sneaking drinks into her lemonade at home so that her husband and children do not know she is drinking.

Olivia stated her husband is very angry with her and wants her to quit school and just "yells at me to get out of bed." She states that her eight year old daughter helps with the two year old, that she watches her so I can do my homework, and gets her ready in the morning. She stated her two year used to go to day care but now stays at home seeing her husband is always home. Olivia states this is part of the problem "so I go to school and don't want to go home so I go to the bar instead. This is the real problem, if I am not home I don't do my school work, this is why I am so far behind." Olivia states her six year old is very quiet and keeps to herself and that she is worried about her the most. That her teachers say that she is not doing well in first grade and has no interest in making friends or doing well in class. Olivia stated "she is just like her mom."

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The Mental Status Exam

The mental status exam is a way of organizing and recording information about the mental state of the client, according to guidelines established by medical schools in the United States (Jordan & Franklin, 1995; Othmer & Othmer, 2002; Paniagua, 2001; Robinson, 2001; Sommers-Flanagan & Sommers-Flanagan, 2009; Taylor, 1981). A mental status exam helps the social worker assess the quality and range of perception, thought, feelings, and psychomotor activity of a client so as to better understand how the client’s behavior may be symptomatic of a mental disorder. It leads to establishing a diagnosis according to the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013), a classification system that divides mental disorders into categories with defining features. The following are the broad categories that are considered in the mental status exam:

1. Appearance. Is the client well groomed or disheveled? Is his manner of dress appropriate for the occasion of the interview? Is he flamboyant or bizarre?

2. Attitude. Is the client cooperative? Guarded? Suspicious? Aggressive or belligerent?

3. Motor Activity. Is the client calm or agitated? Does he have tremors, tics, or muscle spasms? Is he hyperactive?

4. Affect. Is the client’s tone appropriate to the conversation? Is he, for example, talking about a sad event and smiling? Is his affect flat or blunted, apathetic, or labile—rapidly switching up and down. Is he expansive or constricted? A flat affect is a term used to describe clients who seem unable to relate emotionally to other people. Blunted affect describes a client who has a restricted, minimal emotional response (Sommers-Flanagan & Sommers-Flanagan, 2009, p. 221).

5. Mood. What does the client report? How does the client seem? Is the client depressed or anxious? Is there variability in his mood? Mood tends to be longer than affect and changes less spontaneously than affect.

6. Speech. Is the client’s tone of voice loud or soft, whiny or high pitched? Are there any unusual characteristics or affectations (such as an accent or a halting manner)? Is the speech rapid or pressured? Does he stutter?

7. Thought Processes. Do the client’s thoughts flow logically? Are the thoughts organized or disorganized? Is the client coherent? Are there perseverations (repetitions of thoughts as if the client were stuck)? Does the client experience thought blocking (thought stopping or interfering thoughts) or loose associations (not following logically from one thought to another)?

8. Thought Content. Are hallucinations or delusions present? Does the client speak of being controlled by external sources? Is the content of his thoughts grandiose or bizarre? Is suicidal ideation present? Is the content circumstantial (the client demonstrates the loss of capacity for goal-directed thinking) or tangential (the client loses the main idea of the conversation and is unable to return to it)?

9. Perception. Is the client’s view of reality correct, or are there distortions in his thinking? Is there evidence of depersonalization or derealization?

10. Orientation. Is the client oriented to time, place, and person? How is his memory for present as well as past events? (Does he forget what he ate for breakfast but recall childhood events?) How are his concentration level and attention span? Is anxiety, a mood disturbance, or a learning disability responsible for the difficulty in focusing?

11. Cognitive Function. What is the client’s general fund of knowledge? Is it intact? (This function can be tested by asking the client to count backward serially by sevens.) It is important to consider the client’s intellectual level when assessing cognitive function, as his IQ may impact his ability to perform this as well as other cognitive functions, including the ability to be abstract or problem solve.

12. Abstraction. Is the client an abstract or concrete thinker? (To help you assess this function, ask him to interpret a proverb.)

13. Judgment. Are there any disturbances in judgment? Does the client understand the consequences of his behaviors, and to what degree?

14. Insight. Does the client have insight into his difficulties, or are there impairments (minimal, moderate, or severe) that lead him to deny them? Is the insight intellectual or does he have an awareness of motives and feelings on an emotional level?

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