When providing a clinical assessment for clients, several colleagues may work with the same client and come up with varying perceptions of how the client is functioning. It is essential to work collaboratively with colleagues to provide the best client care. You need to be able to provide a respectful rationale to defend your assessment as well as be open to varying perspectives to come to a consensus on the best way to move forward with the client based on this assessment process.
For this Discussion, you will examine a case study of in the Learning Resources and begin to assess the client care needs for this client.
To Prepare:
Review the week’s Learning Resources.
Review the case study of Amy.
By Day 3
Post:
The primary concern of Amy.
Using the Triage Assessment Form (TAF) as a guide, identify Amy’s overall symptom severity on a scale from 1-30.
Identify what would be your next step to help Amy.
Course 6336: Crisis, Trauma, and Response
Case of Amy
Amy is a 25-year-old Native American and Caucasian mixed single woman who is seeking
counseling due to self-reported anxiety symptoms. She presents as well kept, and was dressed
casually wearing a blouse and jeans and fringed leather boots. She has olive skin and light
brown medium length hair and smiles as she steps into the office.
She sat in a corner on the largest sofa and quickly picked up a decorative pillow which she held
in her lap. She stated she lives in an apartment with her pug mix dog named Bandit and has
several close family members and friends nearby.
Her family upbringing was stable despite living in poverty while on the reservation. Her parents
divorced when she was a teen and she relocated with her mother and siblings when she was 15
to a smaller town in North Dakota. She stated her father was a heavy drinker when she was
growing up and her mother smoked some cannabis to “mellow” out since “she too struggles with
anxiety.”
She states that she has a strong spiritual background which is rooted in her Native American
beliefs but has felt disconnected as she does not currently participate in religious ceremonies of
her culture.
In addition, she has a brother and sister who live nearby, and they see each other and her
nieces and nephews most weekends as the family (including extended local relatives) often
gather together.
She currently works at a local medical clinic doing billing about 32 hours a week and stated she
recently went back to school to pursue an associates nursing degree. She stated “I have been
struggling with bad thoughts and panic / worry when I am on campus walking to class.” Upon
further evaluation Amy admits that she has flashbacks when walking around on campus to a
time when she was on vacation for spring break with her senior class in high school and was
sexually assaulted by a former male “friend,” a classmate that she had known for years.
She stated that sometimes while walking to class or to the student union building on campus
where there are a lot of students milling about she has flashbacks and recalls being physically
and emotionally paralyzed, unable to scream or ask for help despite hearing all kinds of people
being nearby at a party. While on campus, she often hyperventilates and feels flush and unable
to swallow for several minutes until she can get to her car for “safety.” She stated it “feels like I
am going to literally die.” She reports that this occurs more often when she has evening courses
and walks alone to her car in a nearby parking garage on campus.
She reports that she hasn’t dated or had a relationship since that time but had not “really
struggled” with any symptoms except mild anxiety until now as she started talking to a male
© 2018 Laureate Education, Inc.
colleague who recently asked her to go out on a date. She also stated she moved away shortly
after the incident (barely graduating high school due to missing so much and not wanting to
attend) and has only told her sister because the young man who violated her was the city
judge’s son and she was afraid of repercussions.
She admits her main reason for coming in is because of the horrible flashbacks and anxiety and
she doesn’t want to fail school but also she feels her time is “running out” to try to have a
“normal” relationship with a man.
She struggles with thoughts like, “Why did I let it happen? Why was I so stupid? I am damaged
goods now. No one is ever going to love me.” Even though she is really close to her family, she
mentions that she has “found myself not going around as much because I know they will notice
something is different about me.” She feels disconnected from her spiritual beliefs and instead
has started to “drink a few drinks at night to help numb out.” When asked about her drinking,
she looked away and was quiet for a few minutes before replying that she would typically have
one or two glasses of red wine in the evening and that this would occur from one to three times
per week.
In looking at her wrists, you notice some red whelps and she quickly puts the pillow over her
wrists and drops eye contact as she says “it is not a big deal. I just cut sometimes to help
release my feelings.” She states she has extreme difficulty even talking to men in class. When
asked what generally occurs when men approach her she reports, “I start to sweat, mentally go
off to la la land and I stutter in attempt to get away.” As she speaks, her knees are shaking, and
she is clenching the pillow and talking rapidly. “I get mad at myself because I truly want to have
a relationship with a man!” Plus she adds, “ “How am I going to do my medical rounds if I can’t be near men?”
references
James, R. K., & Gilliland, B. E. (2017). Crisis intervention strategies (8th ed.). Boston, MA: Cengage Learning.
Chapter 2, “Culturally Effective Helping in Crisis”
Chapter 3, “The Intervention and Assessment Models”
Chapter 7, “Posttraumatic Stress Disorder”
Hatala, A. R. (2013). Towards a biopsychosocial–spiritual approach in health psychology: Exploring theoretical orientations and future directions. Journal of Spirituality in Mental Health, 15(4), 256–276. doi:10.1080/19349637.2013.776448
https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4816.pdf
https://www.apa.org/ptsd-guideline/
