Essay Grade

PRACTICE
Mental Health Diagnosis in
Social Work: The Case
of Miranda
Miranda is a 35-year-old, Scottish female who sought c­ ounseling
for increased feelings of depression and anxiety. Her symptoms
include constant worry, difficulty sleeping, irritability, increased
appetite, unexplained episodes of panic, feelings of guilt and
worthlessness, and feelings of low self-esteem. She denied any
­
suicidal/homicidal ideation but verbalized feelings of wanting to be
dead. She maintained these thoughts were fleeting and inconsistent. She reported an increase in alcohol consumption, although
clarified it was only when she felt anxious. She denied any blackouts or reckless/illegal behavior while drinking. She denied any
other drug use.
Miranda works in the fashion industry and reported that she is
very well liked by her peers and clientele. She is regularly chosen
to train other staff members and comanage the store. However,
she is often given a heavier workload to compensate for coworkers
who are unable to perform at the expected level of her employer.
Miranda stated that she has trouble saying no and feels increasingly irritable and frustrated with her increased workload.
Miranda has been married to her husband for 3 years, and they
have no children. She reported that both her mother and father
have a history of mental illness. Miranda’s parents are divorced,
and when they separated, Miranda chose to live with her mother.
Miranda’s mother remarried a man she described as “vicious and
verbally abusive.” Miranda stated that her stepfather called her
names and told her that she was worthless. She said he made
her believe that she was sick with chronic health issues and many
times forced her to take medicine that was either unnecessary
or not prescribed by a doctor. Eventually he asked Miranda to
leave her mother’s home. Miranda stated that her mother was
well aware of her stepfather’s behavior but chose not to intervene,
stating, “He is a sick man. Just do what he says.” She denied any
physical or sexual abuse in the home.
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SOCIAL WORK CASE STUDIES: CONCENTRATION YEAR
In order to treat Miranda’s symptoms, we first addressed the
need for medication, and I provided a referral to a psychiatrist. The
psychiatrist diagnosed her with panic disorder and major depressive disorder and prescribed appropriate medications to assist her
with her symptoms. Miranda and I began weekly sessions to focus
on managing her boundaries both at work and with her family.
We discussed her behavior around boundary setting as well as
the possibility of enlisting her husband as a support person to
encourage and promote healthy boundaries. We also discussed
unresolved issues from her childhood. This approach enabled
Miranda to gain insight into the self and how her maltreatment as
a child affected her functioning in the present time. This insight
enabled Miranda to validate her feelings of anger, frustration, and
sadness about her upbringing and further give herself permission to set appropriate boundaries in her relationships. We also
discussed the need for relaxation and stress management. Miranda
was able to identify that she used to enjoy cycling and running but
had not been engaging in them because of the demands at work.
After discussing the importance of self-care, Miranda began to
exercise again and set a goal to enter local running and cycling
events to encourage herself to continue.
After 1 year of therapy, Miranda decided to taper down her
medication, which was monitored by her psychiatrist. She has
chosen to remain in therapy weekly to monitor her mood as she
decreases her medication. Miranda’s overall presentation has
improved greatly. With the use of medication, behavioral therapy,
relaxation techniques, and psychodynamic therapy, Miranda’s
affect presents as stable and her symptoms of depression are
gone. Miranda is a client that is able to verbalize the benefits of
treatment in helping her gain insight and empower herself to validate her own emotional needs. She has been a highly motivated
patient who enjoys the safety of being able to express her thoughts
and feelings without judgment.
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APPENDIX
Reflection Questions
The social worker in each of the cases answered select additional questions as follows.
Practice
Mental Health Diagnosis in Social Work:
The Case of Miranda
1. What specific intervention strategies (skills, knowledge, etc.)
did you use to address this client situation?
I referred the client to a psychiatrist. I used behavioral therapy,
relaxation and stress management techniques, and psychodynamic and structural family theories to address underlying
issues from childhood.
2. Which theory or theories did you use to guide your practice?
I used psychodynamic and structural family theories to address
adult survivors of child abuse in order to help Miranda connect
to the effects of her stepfather’s maltreatment, regain her sense
of self, and recognize the unhealthy functioning in her present
relationships and daily living.
3. What were the identified strengths of the client(s)?
Miranda was motivated, identified goals well, and had a supportive
husband.
4. What were the identified challenges faced by the client(s)?
Miranda reported a mental health history.
5. What were the agreed-upon goals to be met to address the
concern?
The initial goal was to decrease symptoms of anxiety and
depression. As therapy progressed, the greater goal became
gaining insight into Miranda’s childhood to allow for more selfcare and stress management.
6. How can evidence-based practice be integrated into this
situation?
Miranda’s case is a great example of the benefit of a combination of medication and talk therapy for overall improvement of
emotional and mental health.
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SOCIAL WORK CASE STUDIES: CONCENTRATION YEAR
7. Is there any additional information that is important to the
case?
It is important to note that prior to seeing me for treatment,
Miranda had been to several psychiatrists who misdiagnosed her with borderline personality disorder and bipolar
disorder specifically based on the fact that she was female
and had a history of abuse. She had been given a series of
medications that were ineffective due to misdiagnosis. When
Miranda came in for the first session she was very distrusting
of psychotherapy as well as medication. My ability to create
a safe and trusting environment was of the upmost importance in order for Miranda to get well and work with her
underlying issues.
8. Describe any additional personal reflections about this case.
Miranda’s case is a great example of the need for a thorough
mental health history, mental status exam, as well as family
history of mental health issues and relationships. With individuals, it is important to ask critical questions that reflect mood
and affect presentation as well as history of drug and alcohol use,
family dynamics, and any past history of abuse. There is almost
always a reason for a patient’s mood deregulation. A proper evaluation session allows for accurate diagnosis and treatment planning as well as letting you, the social worker, know if this is a case
that will fit within your practice.
Social Work Supervision: Trauma Within Agencies
1. What specific intervention strategies (skills, knowledge,
etc.) did you use to address this client situation?
This was a difficult tragedy to deal with, and it was difficult
to know how to proceed. I had contacted the county (who
funded the agency) for help. The people I contacted at
the county did not know what to do and were of little help
because, as they stated, they had never dealt with death of a
staff member. I turned to my senior staff, and we as a group
came up with a plan to notify each client in the most sensitive
way possible. In addition, the use of another agency and our
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