Question: Anna is a 68-year-old widowed Asian American. She lives alone in a condominium she and her husband purchased prior to his death 4 years ago.

ANNA CASE STUDY

Anna is a 68-year-old widowed Asian American. She lives alone in a condominium she and her husband purchased prior to his death 4 years ago.  Anna has three adult children who live outside her home.  Her oldest daughter lives in the same suburban community while her middle son and youngest daughter both live in adjoining states.  Anna is the primary caretaker of her 90-year-old mother who lives in the home with her.  Anna stated that she took on the care of her mother to keep her from entering a nursing home, which would be shameful for her to allow.  Anna’s parents immigrated to the United States two years prior to Anna’s birth and Anna holds to many of her parents’ Asian traditions, including the need to prevent her mother from entering a nursing home.   Anna reported that the primary reason she is seeking counseling is due to her increasing anxiety.  Her oldest daughter, who also provides care for Anna’s mother, has threatened to stop coming to the home if Anna does not do something to get her anxiety under control.  Anna saw her family doctor and requested medication to help with the anxiety.  She was prescribed Paxil and has been taking the medication for four weeks. Her doctor referred Anna to you for an assessment and treatment.

Anna reported that she has always been “high strung,” according to family and friends.  Anna’s oldest daughter confirmed that “Mom has always been somewhat anxious. When I was growing up, she would have been classified as somewhat of a helicopter parent. Not really pushing us to succeed, but always being present, worried and attempting to protect us from some sort of unseen harm that she always believed was on the horizon. Ever since her retirement she has gone from being high strung to absolutely uncontrollably anxious about everything.”  Anna stated that her mother was very anxious until she went into menopause and has relaxed a lot in the last 30 years. Anna reported that three years ago she began having some trouble sleeping but attributed it to her life changing so much in such a short time.  She reported that she started noticing that her mind would race with various worries for part of the day 2-3 days a week about 2 years ago.  In the past 18 months the worry has increased to daily for a majority of the day.  Anna stated that she worries about “Are the kids safe?  Do I have enough money for the rest of my life?  Is the condominium building I am living in going to fall into a sink hole?  Do people like me?  Did I say something stupid when I was talking to someone? Do my grandchildren like me?  Will my children take care of me when I am 90?  Am I allergic to milk?  I love milk and would be so sad if I developed an allergy.  Is the chicken I just bought safe or does it have salmonella?  Do I look OK or do people see me in public and think I am crazy?  Do I have body odor?  How are the kids in my classes doing?  Are they successful or did I do something to lead them down the path to being criminals?  Is my neighbor’s dog going to bite me and if he does, will my neighbor yell at me?  Will I get rabies? Am I taking good care of my mother?  Would my father and husband approve of the care I am giving her?” Anna continued for at least 5 minutes with a wide variety of worries.  She stated several times that she has never experienced any of the events she is worried about.  She has never had food poisoning, any traumatic injury, any family member harmed or any friend/ neighbor express dislike for her.  She stated she rationally knows that her worries are unfounded, but she is unable to stop them from popping into her head.  “Once they are in my head, I cannot seem to let them go.  They roll around and around until another worry pops in and takes over. I try to tell myself to stop worrying… to just stop.  It never works.”

Anna reported, and her daughter confirmed, that she has been very difficult to get along with since the worry increased 18 months ago.  She is irritable and will “snap” at her daughter and mother if they confront her about her worry.  She will also get angry when her other two children tell her to stop calling to check on everyone. “About a year ago I started calling my son and younger daughter daily to make sure that everyone in the family was safe and that none of my worries had come true. My daughter will always answer the phone but in the last several months she has started telling me that she's going to start letting my calls go to voicemail because I spend 30 minutes listing off all the terrible things that could happen to her family. My son's wife tends to answer the phone when I call and have started letting my calls go to voicemail. She and my son will call me about every other week to make sure I'm OK. But outside of that, they have no contact with me right now. This makes things very difficult as I used to have a very good relationship with my son and daughter in law and their children. I miss interacting with them about things besides my worry, but I just can't help the worries spilling out when I talk to them.” And her older daughter reported that she and Anna have gotten into multiple fights over the last 12 months because of Anna's irritability and constant reports of worries. Anna reported this strained relationship also makes her very sad as she had a very positive relationship with her older daughter until about two years ago. Anna stated that even though she is sad over the strain in her relationships, the emotion she feels most of the time is worry and anxiety.

Anna reported that over the past 24 months she has felt increasing tension in her body.  “I used to get a headache 1-2 times a year.  I now have a headache 3-4 times a week.  The doctor and my daughter call them my worry headaches. My shoulders and neck hurt all the time and I feel like a rubber band that has been overwound.”  Anna stated that for the last 12 months she has difficulty sitting still when she starts to worry and will often get up and walk around due to feeling like she might “jump out of my skin at times”.  She went on to report “You would think because I feel wound up all the time that I would have a lot of energy and I would get a lot of things done. But I don't! I feel tired all the time and I have a really hard time motivating myself to do anything around the house that doesn't absolutely have to be done.” She reported her fatigue has been present for at least 12 months. Anna has been struggling to sleep for the past 18 months.  She stated that in the past 12 months she has struggled to get to sleep nightly, laying in bed awake worrying for at least 1-2 hours every night and waking up worrying after 5-6 hours of sleep.  Prior to her retirement Anna slept 7-8 hours a night. Anna reported all these difficulties have occurred daily for the past 12 months.  She stated that prior to a year ago “Some of these things like sleep and being fatigued happened two to three days a week. And then two to three days a week I would feel really wound up and tense. It's like they would trade off with each other, two of them visiting me and then going away and then two others coming to visit and then going away. These past 12 months I feel like they all have moved in with me forever.”

When Anna discussed her husband, she smiled at the memory of their relationship and then appeared sad as she recounted his death. Anna stated that she and her husband were married when she was 30 years old. She stated they had a very positive relationship and she had always been happy in the marriage. She reported that her husband was diagnosed with cancer two years prior to his death. “For the entirety of that two years, I juggled working full time, taking care of my mother who had just moved in with us and caring for my husband. And I never felt overwhelmed like I do now. Even when I knew that he was not going to live much longer, I didn't worry like I do now.” Anna stated that she felt very sad and cried a lot the year after her husband died. She stated “Every day I will think of him and miss him and some days I still feel sad.  Now I think more about the good times I had with him and laugh with others when we tell funny stories about him.  He had a great sense of humor and kept everyone around him laughing!”

Anna stated that she retired 3 years ago.  She worked full time as an elementary school teacher in various grades and school districts since she was 24 years old.  She stated that she decided to stay at work an extra year after her husband died. She reported “It gave me a sense of normalcy and a reason to get up in the mornings.” Her school district has a mandatory retirement age, and Anna stayed until she was forced to retire.  She considered applying for another job in a different school district, but that would have resulted in her having to move.  Because she depends on her daughter’s help with her elderly mother, she did not feel like she had the freedom to move.

Anna stated that after she retired from her job, she did feel sad for about six months. She stated that she worried what she would do with her time and had moments where she felt like her usefulness might be over. She reported that currently she doesn't feel sad about leaving her job but worries about things like finances. When questioned about her financial situation, Anna stated that her husband left a significant amount of money when he died, and she has a substantial retirement account. She stated that she makes more money per month now than she ever did while working. Anna acknowledged that her worries about money are completely unfounded, but she will find herself consumed with worrying about finances several times per week.

Anna stated that she does miss her coworkers and that was the hardest part of leaving her job. A lot of her social network was formed from coworkers. She stated that after she retired, she kept in touch with some of them but over the last 18 months has lost touch with everyone but two friends. Her friends have confronted her about her constant worry and have expressed that they enjoyed spending time with her much more prior to her increase in worry. Currently Anna spends most of her time caring for her elderly mother and helping her oldest daughter with her children. Anna reported that she enjoys being with her family but worries about them all the time. Anna's daughter reported that she desires to have a good relationship with Anna and that she wants her children to have a close relationship with her grandmother. She stated that this has become harder and harder recently due to all the worry. She reported that her children have started to notice how difficult it is to be around their grandmother and have started asking to be excused from family gatherings that involve their grandmother. And her daughter has informed her of this situation. Anna stated that it made her cry for several days when her daughter said her grandchildren did not want to be around her. “I am now worried that no one would ever want to be around me again and that I will die alone in the streets, forgotten and rejected by my friends and family.”

Anna reported that prior to her husband’s death they would have 1-2 glasses of wine 2-3 days per week.  She stated that for a year after her husband died she stopped drinking altogether: “I already felt really sad and I had read that alcohol is a depressant, so I figured if I wanted to start feeling better I should not drink.“ About six months after her retirement Anna began to drink wine again, approximating that she drank 5 to 6 glasses per week. In the past 12 months Anna stated that her wine consumption has increased to having two glasses of wine five days per week, more like prior to her husband’s death. She stated that the wine does “help take the edge off me a little bit and makes me feel somewhat relaxed. A little bit!  But I know what happens when people start to self-medicate… and I am not going there!  Too many in service trainings about alcoholism and teachers.” Anna stated that she does not feel like her alcohol consumption has not gotten out of control and that the same amount of alcohol has the same effect on her. Anna's older daughter reported no concerns about Anna's alcohol use and stated “Sometimes I wish she would drink more so she would just calm down. Not really, but you know, anything to get her to stop being so anxious.”

Anna reported no preexisting medical conditions and no medication prior to the doctor prescribing her Paxil four weeks ago. She stated she entered menopause around 60 but did not notice the decrease in anxiety like was observed in her mother. She stated that she has taken the Paxil daily and has not started feeling any less anxiety. She stated the doctor did explain to her that it could take multiple weeks for the Paxil to work and she could need an increase in the dosage in the next 6 to 8 weeks. She also reported an understanding that Paxil may not be the medication that works for her and she may have to go through several trials to find one. “I really hope this one works because I don't want to damage my relationships any more than they have been. But if the doctor tells me to try something different because my worry doesn't decrease, I'll do it! I don't want to live like this anymore!” Anna reported no history of any other mental health diagnosis and has never been to a counselor before.   Her daughter stated “There are many times I wished my mom would get help, but she never did.  Counseling was not an option in her family growing up and you always kept family problems in the family.  I am so glad she is taking this step now!” Anna reported that she is Hindu and would be interested in integrating the teachings of her religion into counseling.

When asked about her motivation for counseling, Anna stated that she has to continue to care for her mother. “It would be so much shame on my family. Both my mother and father still have lots of family in Asia and I would never be able to face any of them again if I allowed mother to go to a nursing home. And I need my daughter’s help to care for my mother. I also deeply value my relationships including my children, grandchildren, extended family and friends. I think my daughter telling me that her children didn't want to be around me anymore was a bit of a wakeup call for me.”

Case Study Assignment Instructions

Overview

This Case Study Assignment is designed to help you make application of course content to a counseling situation. In this Case Study Assignment you will have the opportunity to think through a clinical case, identify and prioritize key issues involved, consider and clarify relevant diagnostic issues, provide one assessment to clarify the case and formulate treatment recommendations that are most likely to be helpful to the client. This Case Study Assignment will directly apply to your work in COUC 667 and with clients when you begin practicum.

Instructions

For this assignment you will read the case study then generate a report that uses the following outline.  Each section should be separated by the appropriate APA headings (level 1, level 2…)

1. Key Issues: Determine the key issues presented. Using Level 2 APA headings, you will break the key issues into Biological, Psychological, Social and Spiritual
2. Assessment: Provide one assessment that will be used to clarify the diagnosis. Make sure this is a valid assessment that a counselor can use. Give a short (3-5 sentences) overview of the assessment, what it would help you learn about the client and why you chose it over other assessments (example: Beck Depression Inventory, identifies clinical depression, strong research base, short, easy to administer and score). Provide one peer reviewed journal article reference to support the use of this assessment.
3. Diagnostic Impressions: Provide diagnostic impressions based upon the DSM-5. Include the ICD-10 codes and full name of each diagnosis. Be sure to consider secondary disorders in addition to the primary disorder. Is there more than one diagnosis? Provide the following for all diagnoses.
4. Signs and Symptoms: List the signs (clients report) and link them directly to the symptoms (criteria you find in the DSM). You may do this in bullet point or table form to make sure you have linked every client sign to every DSM symptom you will use to support the diagnosis. If there are client reported signs that do not fall into the DSM diagnosis, make note that you considered them, but they did not align with the DSM.
5. Other DSM Conditions Considered: List other DSM conditions you considered and the process you went through to decide they were not the correct diagnosis.
6. Consideration of Theories and Factors: Be sure to consider theories of normal and abnormal development, and systemic and environmental factors that affect human development, functioning, and behavior.
7. Multicultural or Social Justice Considerations: Document multicultural or social justice considerations that went into your diagnostic thought process.
8. Treatment Recommendations: Develop treatment recommendations.
   1. Key Issues: List in order of importance the key issues you believe are involved in the case study. Identify the top 2-3 issues that you will provide recommendations for in order of importance so that you can clearly delineate what you believe will be of most help to your client. Consider recommendations that will be motivating to your client and reflective of a collaborative approach. Be mindful of multicultural, ethical and social justice considerations. This can be done in a bullet point list.
   2. Recommendations for Individual Counseling: Utilizing the professional literature and your textbooks, find at least two treatment recommendations for individual counseling. You will need to cite these recommendations, focusing on the treatments a counselor would provide.  Medication or referral to another type of therapy may be a recommendation, but since these are case management, they do not count towards the two required recommendations. Approach this part of the assignment as your exploration of what you would do with this type of client in individual counseling.
9. Specific Considerations

For each case study you will have one specific consideration.  You will need to provide one paragraph on how this consideration affected your diagnostic impression and your treatment recommendations.

Anna – Case Study 1: How important of a role does cultural background play in this case?  What additional information would you need about her culture?  What kinds of values conflicts might you experience due to the client’s culture?  How would you manage your personal values while working with this client?

Case Study Assignment is to be 3 - 5 pages in length.  This excludes the title page and reference page. Use current APA format.  The Case Study Assignment does not require an abstract.

This Case Study Assignment requires a minimum of 3 resources from peer reviewed journals or professional literature. This can include the maximum of one textbook reference. All resources need to be less than 10 years old.