PCN-490 Case Study: Kay
Kay, a 27-year-old Hispanic female, came to the local CMHC upon her medical doctor’s referral because she was increasingly despondent over the last few months. Her husband reported that she is a “basket case” because she wants to talk all the time about her problems to him; but all she has to do is to take care of things and everything will be all right. She has increased her drinking and marijuana use but she asserts that it is needed now and she has no problem with it because it’s under her control.
Family: Kay has two children: a son, age 5; and a daughter, age 2. Kay takes care of the children. She does not have to work because her husband has a good job. She feels isolated because she has no support here.
Kay’s parents moved to Puerto Rico about 6 years ago to retire, and they seem to have detached themselves from her since she got married. Kay’s mother- and father-in-law live in California and she does not stay in touch with them either. Her friends are the other mothers she meets when she drops her kids off at school. They talk for a while at McDonald’s but then they all go to their homes.
Medical: Kay suffers from stomachaches, and she described herself as always very anxious; then she says she just gives up and believes she will never be happy. She will always be trapped in a situation where she cannot do things for herself. Then her stomach problems kick in and she can’t sleep. Occasionally she takes sleeping pills, eats late at night, and smokes pot, which she gets from her husband, to relax. He also uses it to relax from his hectic job. She states she and her husband have no drug problem.
Psychiatric History and Current Situation: History is unremarkable. There are no previous hospitalizations or sessions with a therapist nor has she ever taken any psychiatric medications. Kay says she is not happy because she was unsuccessful at applying for a loan, which she needed to go to nursing school. Although she passed her entry exams, she would not have time or energy to do it even if she got the money. She desperately needs some adult socializing and learning so she can feel productive again. She used to be an executive secretary in New York City where she met her husband several years ago.
She also says her husband does not accept her, which makes her unhappy; but she could not describe this any further. This is the time when her self-esteem drops, she feels depressed, and does not know what to do. She retreats, makes sure her kids are okay and then she will drink, smoke pot, and plan for the future, but the plans never are realized by her.
When she makes a mistake (and it could be minor) with the children, paying bills, or other daily responsibilities, she believes she is worthless and inept. When she talks to her girlfriends at the kids’ school and they disagree with her, she interprets it as they don’t like her; and then she begins to ruminate over problems until she hates herself. When asked what she does when she “hates herself,” she repeats that she gets depressed and starts to drink – usually a bottle of wine, and, during those times, the pot use increases to more than one joint a day. Then she feels relaxed, gets her courage up, and goes into the bedroom to “give it to her husband.” But by then, he is asleep, and she is afraid that if she wakes him, then the kids will wake up too, and nothing will be resolved. Usually by then, she feels so tired that she sleeps on the couch and starts the day again in the morning.
Now, a new idea has come up that she wants to work on – Kay wants to start massage school. It is easier to get money for the classes and it will also be easier to get work when she graduates. She just recently got accepted. She applied without anyone knowing and had the interview and starts in one week. She also has the money for it by saving her allowance that her husband gives her. Now she has to talk to someone about babysitting a couple of nights a week. She started working on a friend to pick the kids up from their school and she would be at her friend’s house at 6 pm every Wednesday and Thursday night. This is a secret and her husband doesn’t know about it. He comes home at 7 pm anyway.
She can’t talk to her husband about it because he does not understand. She wholeheartedly believes she will make it through this school and eventually make 35 dollars an hour massaging people in a health spa. Who knows! Eventually, she said she might even get 50 dollars a session!
Studying anatomy and physiology will be easy since the books are easier than nursing school and she definitely can spend time studying and not get upset to the point where she uses the alcohol and pot. When she was asked if she had a plan yet to pull the whole thing together for next week, she said, “No, it will just happen.”
She wants help because she believes her value as a person depends upon what others think of her and what she can do. She wants to feel satisfied and happy as a regular person. She said she has no more self-confidence, energy, or motivation in the daytime and that worries her too. But, with this new idea, she will be a success.
You have been assigned this case because the previous counselor resigned from her job.
Here are some chart excerpts and summary notes from the counseling sessions.
Counseling Sessions 1 – 4
Kay: “About five years ago I started having trouble sleeping and started to take a tranquilizer (5 mg Valium). I normally take one or two pills two to four times a week to help me sleep through the entire night. I became afraid I’d become addicted, so I started drinking wine before bed and that did the trick.”
Counselor: Can you think of any cause and effect connections between what is going on for you to use alcohol and pot from what I read in the closing summary of the previous worker?
Kay: “I told the last counselor that I was having problems…with work, school, and especially with my husband. It must be all there in your notes. Right?”
Counselor: Yes, but I was specifically interested in your reasons about what brought you here seeking help.
Kay: “I can’t figure it out anymore. I should be able to. I am not satisfied and when I try out something I am afraid I will fail. I can’t relax or sleep or even become satisfied with taking care of my kids. I just do things: With the two kids I am obligated; with the rest, I can’t relax and I want to be like everyone else – comfortable and secure.”
Counselor: I know what you mean. Things that you can stand up for yourself when you are feeling good about yourself just get to be too much when you’re under some kind of stress or feeling hopeless.
Kay: “That’s it! I have been under stress and uncomfortable. I am so glad to be home but then I want to try out new things and I get scared and give up; even though I don’t want to.”
(Discussion Question #1: In-Session Analysis)
What would your next statement be if you were the counselor? Explain your reason for it.
In the morning she drinks at least three to four cups of coffee daily, even on the weekends. She noticed that her sleeping problems developed around the same time her parents moved. They were in their early 50’s and they were very close. The move hit her hard and she says she wanted to give in to a big depression because maybe they didn’t like her husband being an American. However, she fought it and lost herself in her kids and trying to move forward to “be something” like her parents wanted her to be. She can barely make it to pick up her kids and do after-dinner chores.
Lately however, she has noticed that she has been steadily increasing her use of wine. Before, she would only have a few glasses with dinner but now…
Kay: “More often than not, I finish off the bottle before going to bed. I just can’t seem to stop. A lot of times I will come home and tell myself that I’ll only have one glass and no more, but by the time I go to bed, the bottle is empty and I’m deciding whether I should open another or not. I never used to drink to excess or take anti-anxiety medication before. Now I can’t seem to stop drinking or taking these ‘downers’ at social events. I can’t seem to control when I take them and things are happening that I’m not too
happy about.
Kay explains to the counselor that last week she had a fight with her husband because he stopped her pot (he had none for himself) and she can’t even talk about what happens during the day to him, because he refuses to listen. He is a good provider but Kay reported: She could not get out of bed that morning because, “he tells me to shut up and handle things.” He pays the bills and she is supposed to take care of the kids and then do what she feels like doing because that’s her business! It took all her willpower to get up and get dressed. As it was, she was still 20 minutes late driving the kids to school, “which is inexcusable.” She was so nervous and sick she had to get a friend to pick the kids up in the afternoon.
Counselor: It seems like while you were upset with your husband, you were hesitant to talk and state what you needed from him.
Kay: “The next day I met with my friends and they recommended (ordered) I make an appointment with your agency again. I’m really scared and worried. I don’t have anything to live for. Well, not really. But I want to live more. I accept my life, and then I feel frustrated, angry. I try to calm down with the help of some wine and weed; I can’t seem to get out of the hole!”
Counselor: Even though you lose hope sometimes, it sounds like you are committed to work some things out and try to stay clean. Do I have that right?
Kay: “Yes. I am going to have to decide what to do. I thought I was strong enough for anything, but this scares me.”
(Discussion Question #2: In-Session Analysis)
What would your next statement be if you were the counselor? Explain your reason for it.
(Discussion Questions #3: Out-Session Analysis)
- What would your initial assessment of Kay be? (Give your diagnostic impression)
- What would you say Kay’s main drug of choice is and do you think she will need to address it in spite of all her other problems?
- Based on Kay’s emotional situation and the medications she is taking, what if any dangers do you need to be aware of?
- Based on the information Kay has given you, whom would you need to contact to advise anyone about her situation and what would you need from Kay to make these contacts?
- If Kay’s husband calls your office to find out about her, how would you respond to his inquiry? What are his rights to know if Kay has appointments with you?
- What possible dual diagnosis issue(s) might Kay have and how would you confirm this possibility.
- Are there any other issues that you feel may need to be addressed in this case?
Counseling Sessions 5 – 8
Counselor: Kay, from what we’ve studied about your case in our agency, we believe further treatment may be necessary to help you with your depression and drug problem.
Specifically, your expression of frustration with getting the support you need from your husband and trying to manage your own personal goals with some maladaptive substance abuse behaviors.
Kay: “The drugs are worrying me. I don’t deny that. About 10 years ago I started that for a short time because I was rejected by a boyfriend when I gave him everything. Thank God my mother was there to help me then.”
Counselor: Perhaps we can prioritize some problems; find out what is the most important ones to work on…to make you feel better?
Kay: “Okay. I want to be able to get the support I need from my husband to figure out my work desires without being afraid to talk to him.”
Counselor: It sounds like he may be a trigger that gets you feeling confused?
Kay: “Yes, but I remember I have always had a problem like this and tried to fix it by saying what I wanted.”
Counselor: Can you give an example?
Kay: “When I didn’t like something I’d yell and cursed, then I’d say I was sorry. But I felt the person didn’t believe me. It’s happened with my mom, my husband, friends……ever since I was 17.
(Discussion Question #4: In Session Analysis)
What would your next response be if you were the counselor? What technique would you use to change this and her related problems with this assumed social skill and coping skill deficit? Outline a treatment plan for Kay.
Kay: “The idea of a trigger makes sense to me. If I learned how to get my point across to my husband and not use so much when frustrated, perhaps I can be free to go to massage school.”
Counselor: Perhaps; so, if I can summarize things to find out if we understand each other:
Your unassertiveness is influencing your drug use and not getting you what you want. Additionally, you need support from your husband primarily to help you with the family, more than just being a good provider, to make the changes you need for yourself. Is that accurate?
Counselor: Well Kay, We have been working on some changes and practicing them during sessions. Do they seem to be working out Okay?
Kay: “Okay, but your attitude sometimes reminds me of my husband, always taking charge. I feel like you will criticize me if things don’t go well.”
(Discussion Question #5: In Session Analysis)
Describe what your next response would be if you were the counselor and explain what is happening in the session. State a possible solution to be able to move on with the client.
(Discussion Questions #6: Out Session Analysis)
- What is happening in this middle phase of the counseling process?
- What plan would you hypothesize for the final phase of the counseling process?
- What kind of counter-transference (affect) would you have with Kay if you were the counselor? Outline a plan to manage it in your next supervisory session.
Counseling Sessions 9 – 12
Counselor: Kay, regarding the homework between sessions, have you noticed any changes….better or worse?
Kay: “I am sleeping better. I told my husband to stop smoking the pot so I won’t be tempted. He gives it to me, you know! The wine is still a problem on the weekends, but I drink less during the week.”
Counselor: Sounds like there are some changes in the positive direction.
Kay: “Yep, I may have a drinking problem, but I am not an alcoholic.”
Counselor: Remember we discussed your practicing “cognitive restructuring.” Let’s see if we can do some now, Okay?
Kay: “Okay! So, when I said that I may have a drinking problem, but I am not an alcoholic, I should check out this by asking myself…(Is my thinking likely to help me or hinder me in achieving my short- and long-term goals?) Well, I feel that if I don’t make progress, I will be depressed, but I can see how getting stuck on that thought brings up some negative self-statements and my self-esteem issues that will interfere with my goals as I try to reach some of them.”
Counselor: So, how can you handle this one now?
Kay: “Like I practiced before……I have to be aware that if I hang in there, there will be times when I get ahead of myself and I have to tell myself that progress comes slow, and there may be some backsliding in my thinking and my behavior. But that is part of the process and I can always ask for help from you or some strong supports that I am trying to develop.”
Counselor: Can you measure how you felt before with your premature conclusion about drinking and how you are measuring your feeling now?
Kay: “When I said it I was anxious about 60 percent; now, after working it through, I feel about 30 percent anxious.”
Counselor: That’s good. It seems like you are becoming more aware and even continuing to make changes in the sessions and outside of them too!
Kay: “Yep, I think it started when I told my husband that I am going to massage school. I didn’t want to keep it a secret anymore. I got no response from him. But he later asked about it, when it started, and if I could practice on him because he needs it.”
Counselor: Do you think he should be invited into the sessions?
Kay: “Not at all! He will never understand this stuff we are discussing. I can work on him myself. Are you going to tell him I am coming here?”
(Discussion Question #7: In Session Analysis)
What would your next statement be if you were the counselor? Give your reason for it.
(Discussion Question #8: Out Session Analysis)
Describe and define the treatment techniques used by the counselor in the middle phase of treatment with Kay. Explain the rationale for slightly similar techniques with this client.
Counselor: Since we prioritized problems weeks ago; do you think it is time to include other issues now?
Kay: “Well, not really, but I think I will need some help with the stress of massage school when I am there. I don’t think I will take up the pot, but the weekend drinking may be tough. I agree it is poor coping. I want to find out how I can decompress better. Massage school is rough, you know. I don’t want to relapse, and I know my insurance is almost up to pay for this counseling.”
(Discussion Question #9: In Session Analysis)
What would your next statement be if you were the counselor? Give your reason for it.
(Discussion Question # 10: Out Session Analysis)
If Kay relapsed during termination, explain how you would manage it. In your answer include: One model you would use, one technique to intervene, and one mutually agreed goal and objective you would work on.
(Discussion Questions #11: Out Session Analysis)
- Describe your plan with Kay for termination and booster sessions taking into consideration the limits of her medical insurance.
- Explain what else Kay may need from counseling if she had a better insurance to continue counseling.
- Write your own (one page) treatment summary for this client (from what you have so far) because her case has to be closed due to lack of insurance with no extensions granted for the next 10 months.
