Sara

Presenting Problem

Sara is a 29-year-old married Hispanic Female, currently unemployed. She is seeking help at the XYZ Mental Health Center due to problems with her husband, David, age 32, who threatened to leave her because he can no longer tolerate her jealous behavior. Sara states that she doesn't want David to leave and she's willing to "try therapy if that will help". Several times within the past six months, she has waited in the parking lot of the lumber yard where David is employed watching to see if he is meeting or talking to someone. She admits that she has seen nothing suspicious, but still fears that "David is going to leave me for another woman." When David was late coming home from work last Friday, Sara made a superficial cut on her arm with a razor blade.

Sara feels that David spends too much time with Crystal, his 7-year-old daughter from his first marriage. Sara complains that Crystal "hates me" and "wants me out of the picture so she can get her parents back together." Sara frequently gets angry with David for spending time with Crystal, which often results in Sara throwing things and yelling. Sara says, "I just get so angry, I can't even think. I have to do something to make myself feel better."

David's Perspective

David, a second generation Mexican-American, accompanied Sara to her initial appointment at the Mental Health Center. He was initially attracted to Sara because of her energy and high spirits. For the first year and a half of their marriage, they spent a lot of time together and there were few problems. After Sara got laid off due to the company's restructuring, they spent less time together and David started spending more time with his daughter.

David denies having an affair and is embarrassed by Sara's showing up at work to check on him. He is thinking about leaving her, primarily because of her behavior toward his daughter, Crystal. David explains that he wasn't a very involved father when Crystal was younger and making an effort now is important to him. He doesn't want to have to choose between Crystal and Sara, but feels that Sara is forcing the issue. David said that he has never been abusive toward Sara, even when Sara's attacks physically injured him, and typically he responds to her outbursts by trying to comfort Sara and spend more time with her.

History

Sara's parents and older brother, Ceasar, immigrated to the United States before her birth. Her father supported the family by working long hours at jobs requiring manual labor; Sara's mother was not employed outside the home. Caesar, eight years older than Sara, began sexually abusing Sara when she was six years old. The abuse progressed from genital fondling to oral-genital contact and occurred on a weekly basis for four years. When she was 10 years old, Sara told her mother about the abuse. Her mother refused to believe her and reacted by withdrawing all affection from her daughter. Caesar, however, was frightened enough by Sara's exposure to stop the abuse.

Sara was an average student who had no strong interest in any subject in school. She was very attractive and lively, which made her popular with classmates. She dated extensively in high school, "falling in love" quickly and intensely with one boy, breaking up, then immediately beginning another intense relationship.

Following high school graduation, Sara left home, and got a job as a waitress. She began dating Horace, a man 15 years older than she, who encouraged her to further her education. With his support, she began a two-year computer course at night and graduated in the top third of her class. When Horace ended the relationship due to Sara's frantic demands that he spend more time with her, Sara reacted by slashing her wrists resulting in a psychiatric hospitalization.

For the next few years, Sara was involved in several short-lived but intense relationships with men. She was self-supporting during this time, working at computer jobs. She met David when both worked at the lumberyard and was attracted by his composure and steadiness. Case application (Questions 1-6 below): You will use the same case application (Sarah) as the mid-term exam which is a word attached to this assignment. Short/Medium Answer: (12 points each for # 1-6 )

1. DBT: Describe the stages of treatment with DBT. What would be the main focus in each stage applied to the case of Sarah?
2. DBT: Apply the biosocial theory to Sarah's case. How do we understand her mental health problems according to this theory. Please include at least one dialectical dilemma in your understanding of Sarah
3. DBT: Describe in detail the process of conducting a behavioral analysis, chain analysis and solution analysis with Sarah. Please include the goal of each (i.e. behavioral analysis, chain analysis and solution analysis) and apply specifically to Sarah's maladaptive behavior. Give at least two suggestions you would make for the solution analysis
4. From the DBT perspective, discuss how you would prioritize what to work on first with Sarah. What would you prioritize next once the initial target behavior is reduced?
5. Discuss how the goal(s) for treatment would be different working with Sarah if you were utilizing DBT, psychodynamic, and cognitive behavioral therapy. Provide an example of a treatment goal for each modality
6. From your perspective, what would be the least effective type of therapy out of the modalities we discussed/reviewed in class to utilize with Sarah (you can choose from DBT, CBT or psychodynamic)? Please discuss the limitations.
7. Indicate an alternative therapy that may be suggested for Sarah. In your answer discuss what the specific goal would be using the alternative therapy. Also discuss potential benefits of the alternative therapy in addition to some of the limitations.

Motivational Interviewing Case

Lisa is a 35-year-old female who has decided to come for outpatient counseling because she is depressed about being unemployed and anxious about looking for work. She was fired from her job at BGE a couple months ago. Lisa explains that since she was fired, she has been smoking marijuana daily. She says that she doesn't want to stop because she enjoys smoking and it relaxes her; she also shares that she thinks smoking may be reducing her energy and motivation to find a job. Lisa is divorced and has a 15-year-old son. She lives with her boyfriend Larry; they have been together for two years. Lisa says that she is happy with her relationship with Larry. She feels that he is nice to her, unlike her past husband.She also mentions that Larry would like her to stop using marijuana and that they fight about this occasionally. Lisa is very concerned about their finances and really needs to return to work. Lisa is relaxed and cooperative in the session but when you try to help her with an action plan to stop smoking marijuana, she becomes very defensive.

8. Based on the case information, name potential 'change talk' that can be elicited from the client. Briefly indicate 2-3 questions you may ask Lisa that demonstrates the spirit of MI. Finally, briefly discuss how you would specifically roll with resistance.

9. Cultural Humility: (8 points): Think of a client that you are currently working with, have worked with in the past or describe a client that you may work with in your field placement. Apply at least one suggestion from either Hardy (2013) or Boyd-Franklin (2003) to a client situation and discuss how this may have improved your work together

10. Ethics Question: (20 points): Summarize an ethical issue you experienced in your field placement. Apply an ethical decision making model/process to the dilemma to reach an ethical solution. Include as relevant an explanation of competing values, and consideration of the NASW Code of Ethics, relevant state/federal laws, and alternative solutions.