MID-TERM PAPER: Case Analysis Instructions Use the Triage Assessment Form to assess Mary in the attached case.

MID-TERM PAPER: Case Analysis Instructions

Use the Triage Assessment Form to assess Mary in the attached case.

Conduct a lethality assessment (Risk factors). Bullet points may be used for risk factors.

Explain the dynamics that led to Mary’s crisis from a Person-In-Environment perspective. How did her thinking, emotions, behavior, and social environment interact to produce her crisis.

Evaluate the severity of her crisis using the data in the case and TAF.

Using the Six-step crisis intervention model, explain how you would intervene and include your rationale for each intervention. Bullet points can be used for steps 3 & 6. Write out answers for steps 1, 2, 4, and 5. Taken together, your interventions should constitute a comprehensive crisis response.

Make recommendations for interventions that -as a crisis worker- you would not provide and/or would be necessary in the future. This may be included in step five and done with bullet points.

You may add facts that are absent but necessary to your analyses. Do not skip questions because of a lack of data.

Your paper should read more like a report than an academic paper. Do not include citations.

It should be no longer than five (5) pages in length, plus the TAF.

AN OBSESSIVE-COMPULSIVE DISORDERED CLIENT IN CRISIS

Presenting Problem and its History:

Mary is a 68-year-old married homemaker in a middle-class suburb of Pittsburgh. She and her husband have been married for 46 years and have four children (three sons and a younger daughter) and 10 grandchildren; three children and eight grandchildren live in the same town. Mary and her husband are both the children of Polish immigrants and were raised in strict religious homes. They have continued this tradition in their own family, and Mary describes herself and her family as devout Catholics.

Throughout her life Mary has been neat and orderly. She has always valued cleanliness and has quite a disdain for dirt and clutter. She put great effort into keeping her house clean and tidy (which was quite a job with three sons), and she has always been very careful in her personal habits. In the course of a typical day Mary would brush her teeth three or four times and wash her hands perhaps six to eight times.

Mary has also been very careful in her religious practices. For example, she often worried about whether she had confessed completely or whether she had performed various rituals correctly. Over the past few years, however, her religious obsessions have become markedly more severe, leading her to perform compulsions that occupy several hours every day. Her increased anxiety seems to focus primarily on one issue-the taking of the wafer during Holy Communion.

The worship service of most Christian denominations includes some form of communion, a ritual where the congregation members partake of the body of Christ (usually symbolized by a small piece of bread or a wafer) and the blood of Christ (usually symbolized by wine or juice). According to traditional Catholic doctrine, the wafer and wine are not merely symbolic but are actually part of the Host and are themselves holy. As a result, only someone who is absolved of sin (the priest) can touch the sacramental elements without contaminating them, and he must place the wafer directly into the mouth of the parishioner. Then in 1969, Pope Paul VI declared that this procedure was no longer necessary. This pronouncement caused great anxiety for Mary, since she considered herself unclean and feared that she would contaminate the Host by touching the wafer. Much to her relief, her priest was very conservative in his practices and continued to place the wafers into the mouths of his parishioners.

But about 10 years ago, this priest retired and was replaced by a younger man who encouraged his parishioners to take their wafers directly. Mary, along with a few others, insisted that he continue to feed her the wafer, and he honored her request. However, Mary’s husband, children, and friends now took their wafers directly. Interestingly, Mary did not see her family members as contaminating the Host; rather, their contact with the Holy Spirit allowed the Host to be transferred to everything they touched. This idea began with their drive home from mass. The steering wheel, the door handles, and eventually the entire car was now holy and could not be contaminated. Any object at home that was touched, be it a chair, a table, the kitchen sink and even the toilet, was imbued with the Holy Spirit and had to be avoided. At first Mary tried to keep track of what was touched and what wasn’t, but she couldn’t keep up. She also realized that her family could touch many things without her knowing it. She eventually became agoraphobic. She spent most of her time shut up in her room and would not allow others to enter.

Mary began to equate her fate with that of King Midas: she was trapped in a house where she couldn’t touch anything or anyone. When the extreme anxiety generated by this situation became too much to bear, Mary settled on a compromise that entailed two types of responses. One response was to make herself as clean as possible before she touched the Holy Spirit, thus minimizing her contamination of the Host. Her hand washing became more frequent, until she was at the point of washing her hands for six to eight hours every day until they were cracked, raw, and bleeding. The other response was to try to rid an object of the Host before it could be contaminated with her touch. Mary’s washing compulsions gradually escalated to the point where she would spend hours busily scrubbing fixtures that were already gleaming and wiping furniture that had no visible signs of dust. Mary mentioned that the most baffling problem was the faucet, which left her with a catch-22: she couldn’t touch the faucet handles without first washing her hands, but she couldn’t wash her hands without touching the faucet handles.

Perhaps the most tragic aspect of Mary’s illness concerned her relationship with her family. She had to limit her contact with her loved ones, since they themselves were holy and would carry the Holy Spirit to other objects. When Mary insisted that they constantly wash their hands and take frequent showers (which was her attempt to rid the Host from their bodies), they responded with annoyance and resentment. It has been three years since she last kissed or hugged her husband or any of her children and grandchildren, and she has had no contact at all with her grandchildren for the past several months.

Mary was well aware of the illogical nature of her obsessions and the compulsive behavior needed to reduce her level of anxiety, but out of embarrassment she kept her religious anxieties to herself. Along with her anxieties, Mary suffered from intermittent periods of depression as a result of the uncontrollable nature of her compulsions and the increasingly limited contact with her family. Mary had always been in fairly good health, and she was always wary of doctors. Consequently, she had no primary-care physician, and her raw hands and depressed affect went undiagnosed and untreated. Eventually her anxieties and depression became overwhelming, and Mary began to have persistent suicidal thoughts. She finally confided in her husband. After hearing her concerns over contaminating the Holy Spirit, he urged her to discuss this problem with their priest. She met with a priest and disclosed to him that she intended to execute her plan to join her Savior, by overdosing, the very next day. After much cajoling, she agreed to go to the emergency room to be evaluated.

Personal History

Mary’s childhood appears to be unremarkable. She is the second of five children, with an older brother, two younger brothers and a younger sister. Her older brother served in World War II and one younger brother served in Korea, but neither was injured or seems to have been noticeably affected by their wartime experiences. This same younger brother died of a heart attack eight years before her admission to the clinic. Her other siblings are alive and keep in regular communication.

Although Mary described her upbringing as strict, she denies any cruelty or abuse, or even that it was oppressive. In Mary’s words, “When I said a ‘strict’ upbringing, I meant disciplined, not mean or vindictive or anything like that.” Mary could not think of any particularly upsetting event in her childhood or adolescence; instead, she said she had “the usual ups and downs of childhood.”

As noted in her presenting complaint, Mary has a history of mild obsessions and rituals. For example, she frequently had notions that some numbers were good, and others were bad which would lead her to perform minor compulsions such a turning light switches off or on a certain number of times or buying a certain number of items at a store or inviting a certain number of guests to a party. Mary is an avid gardener and enjoys growing many types of flowers. But after seeing petunias at a friend’s funeral, she stopped growing them because “they would bring bad luck.” (It is interesting that Mary had no fear of dirt or germs, particularly since her obsessions involve themes of contamination.) Mary also admits to having several minor phobias, including spiders, snakes, and electricity. Mary’s problems with her anxieties have waxed and waned over the course of her lifetime but have generally not interfered with her duties as wife and mother. The one exception occurred when she was 22, when her first child was 15 months old, and she was pregnant with her second. At that time, she began having obsessional ideas about harming her son and did not want to be left in charge of him. Mary’s mother moved in and took care of her son for about three months. Mary’s obsessions gradually diminished as her pregnancy progressed, and she had no further obsessions after the birth of her second son.

Mary’s family history shows no evidence of any mental illness. Mary’s daughter, however, has been in therapy for depression and continues to take antidepressant medication. In addition, Mary’s oldest son has intermittently suffered from periods of anxiety. From Mary’s description, he seems to suffer from panic disorder, but because he has never sought treatment, this cannot be confirmed.

Triage Assessment Form(TAF): Crisis Intervention Adapted from R.A. Myer, et al. 1991, NIU

CRISIS EVENT
Identify and describe briefly the crisis situation:

AFFECTIVE DOMAIN
Identify and describe briefly the affect that is present (If more than one affect is experienced, rate with #1 being primary, #2 secondary, #3 tertiary):
ANGER/HOSTILITY:

ANXIETY/FEAR:

SADNESS/MELANCHOLY:

AFFECTIVE SEVERITY SCALE
Circle the number that most closely corresponds with client’s reaction to crisis.
1 2 3 4 5 6 7 8 9 10
No Impairment Minimal
Impairment Low
Impairment Moderate
Impairment Marked
Impairment Severe
Impairment
Stable mood with normal variation of affect appropriate to daily functioning. Affect appropriate to situation. Brief periods during which negative mood is experienced slightly more intensely than situation warrants. Emotions are substantially under client control. Affect appropriate to situation but increasingly longer periods during which negative mood is experienced slightly more intensely than the situation warrants. Client perceives emotions as being substantially under control. Affect may be incongruent with situation. Extended periods of intense negative moods. Mood is experienced noticeably more intensely than situation warrants. Lability of affect may be present. Effort required to control emotions. Negative affect experienced at a markedly higher level than situation warrants. Affects may be obviously incongruent with the situation. Mood swings, if occurring, are pronounced. Onset of negative moods are perceived by client as not being under volitional control. Decompensation or depersonalization evident.

BEHAVIORAL DOMAIN
Identify and briefly describe which behavior is currently being used. (If more than one behavior is being utilized, rate with #1 being primary, #2 secondary, #3 tertiary.)
APPROACH:

AVOIDANCE:

IMMOBILITY:

BEHAVIORAL SEVERITY SCALE
Circle the number that most closely corresponds with client’s reaction to crisis.
1 2 3 4 5 6 7 8 9 10
No Impairment Minimal
Impairment Low
Impairment Moderate
Impairment Marked
Impairment Severe
Impairment
Coping behavior appropriate to crisis event. Client perform those tasks necessary for daily functioning. Occasional utilization of ineffective coping behaviors. Client performs those tasks as necessary for daily functioning, but does so with noticeable effort. Occasional utilization of ineffective coping behaviors. Client neglects some tasks necessary for daily functioning. Client displays coping behaviors that may be ineffective and maladaptive. Ability to perform tasks necessary for daily functioning is noticeably compromised. Client displays coping behaviors that are likely to exacerbate crisis situation. Ability to perform tasks necessary for daily functioning is markedly absent. Behavior is erratic, unpredictable. Client’s behaviors are harmful to self and/or others.

COGNITIVE DOMAIN
Describe the cognition related to these areas. If more than one area is affected, rate with #1 being primary, #2 secondary, #3 tertiary.)
PHYSICAL (FOOD, WATER, SAFETY, SHELTER, ETC.) Describe:

PSYCHOLOGICAL (SELF-CONCEPT, EMOTIONAL WELL- BEING, IDENTITY, ETC.) Describe:

SOCIAL RELATIONSHIPS (FAMILY, FRIENDS, CO-WORKERS, ETC.) Describe:

MORAL/SPIRITUAL (PERSONAL INTEGRITY, VALUES, BELIEF SYSTEM, ETC.) Describe:

COGNITIVE SEVERITY SCALE
Circle the number that most closely corresponds with client’s reaction to crisis.
1 2 3 4 5 6 7 8 9 10
No Impairment Minimal
Impairment Low
Impairment Moderate
Impairment Marked
Impairment Severe
Impairment
Concentration intact. Client displays normal problem-solving and decision-making abilities. Client’s perceptions and interpretation of crisis event match with reality of the situation Client’s thoughts may drift to crisis event but focus of thoughts is under volitional control. Problem-solving and decision-making abilities minimally affected. Client’s perception and interpretation of crisis event substantially match with reality of situation. Occasional disturbance of concentration. Client perceives diminished control over thoughts of crisis event. Client experiences recurrent difficulties with problem-solving and decision-making abilities. Client’s perceptions and interpretation of crisis event may differ in some respects with reality of situation. Frequent disturbance of concentration. Intrusive thoughts of crisis event with limited control. Problem-solving and decision-making abilities adversely affected by obsessiveness, self doubt, confusion. Client’s perception and interpretation of crisis event may differ noticeably with reality of situation. Client plagued by intrusiveness of thoughts regarding crisis event. The appropriateness of client’s problem-solving and decision-making abilities likely adversely affected by obsessiveness, self-doubt, confusion. Client’s perception and interpretation of crisis event may differ substantially with reality of situation. Gross inability to concentrate on anything except crisis event. Client so afflicted by obsessiveness, self-doubt and confusion that problem-solving and decision-making abilities have “shut down.” Client’s perception and interpretation of crisis even may differ so substantially from reality of situation as to constitute threat to client’s welfare.
DOMAIN SEVERITY
AFFECTIVE: _______
BEHAVIORAL: _____
COGNITIVE: _______ TOTAL: ________