Case Study
Patient Demographic: Initial Intake: Age: 32 Gender: Female Sexual Orientation: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Community Mental Health Agency, state-run Type of Counseling: Individual and family
Mental Status Exam: Shania is disheveled, has tangential and fast rate speech and is fidgety with twitching in her motor movements. Shania makes consistent eye contact and leans in close when she becomes upset and begins to cry. Shania admits to having suicidal thoughts and attempt behaviors in her past, but says she no longer feels suicidal. Shania denies homicidal ideations, hallucinations, or delusions. She shares how when she was heavily using drugs and alcohol, she would become paranoid and frequently experience delusional thinking with manic presentation but only while actively on psychoactive substances. Shania has an extensive physical and emotional abuse history since childhood but is a poor historian with the timeline of events. She attributes her anxiety to her trauma as she remembers feeling anxious around her parents since she was a child. She tells you she has no desire to use drugs again but is frequently worried about her temptations to drink when she is stressed or around members of her extended family who drink. Shania’s depression and anxiety have increased more recently due to her family being evicted from their rental apartment and having to stay in a hotel room for the past few weeks.
Presenting Problem: Diagnosis: Major Depressive Disorder, recurrent, unspecified (F33.9), Anxiety Disorder, unspecified (F41.9), Alcohol dependence, uncomplicated, in early remission (F10.20), Cocaine Use Disorder, unspecified with cocaine-induced mood disorder, in remission (F14.94)
 

You are an intern providing mental health counseling sessions to adults and children struggling with economic and legal issues and are given a referral to conduct an evaluation for Shania, a 32-year-old woman with three children. Shania has temporary guardianship of her youngest two daughters but is undergoing a custody battle to win back full custody of all her kids. Her oldest, age 12, is under guardianship of her parents in another state. Shania tells you in the intake session that her father beats her 12-year-old with his belt and her mother verbally abuses her, but that she isn’t taken seriously when reporting. Shania says because of her legal and substance use history, and due to her reports often being vague on details and directly attempting to influence her court hearing results, officials do not follow through on investigations. Shania further shares that her youngest daughter is struggling with psychiatric and behavioral issues, has used violence against her when angry and cannot sit still, most nights only sleeping for two or three hours. She can no longer afford medications and no longer has health insurance.
Other Contexts: Substance Use History:
Shania has been in long and short-term treatments several times in her 20s for alcohol dependency and cocaine use. She had all her children while under the influence or in remission from using substances and has had minimal contact with their fathers. The man she is currently living with is not the biological father of the children but has taken to caring for them as his own while he is in a relationship with Shania.
 
Work History:
Shania has never been able to keep a job for long because of her substance use, which has contributed to her depression and has caused suicidality in her past. Shania has worked in several retail, food and other merchandising chains but has just recently become unemployed again. This is what contributed to her inability to pay rent and eviction. She asks you for help with getting government assistance as she has no family she can rely upon for support.

Question: You discuss with Shania how trauma is a psychological injury that continues to harm one's cognitive and emotional state, often rendering them helpless to recurrent patterns of maladaptive behaviors. She agrees to begin trauma work. In what order would you attempt the following interventions?
(A): coping skills, TF-cognitive therapy, order for EMDR and/or neurofeedback
(B): cognitive therapy, teach coping skills, EMDR
(C): neurofeedback, prolonged exposure therapy, cognitive therapy, teach coping skills
(D): EMDR, teach self-soothing techniques, TF-cognitive therapy

Correct Answer: coping skills, TF-cognitive therapy, order for EMDR and/or neurofeedback
Explanation: It is crucial that prior to having a client address their trauma they learn to master coping skills, both during exercises in session as well as at home in real life situations. Concurrent to teaching coping (self-soothing techniques included) you should engage your client in cognitive interventions, such as Cognitive Processing Therapy approach and trauma-focused Cognitive Behavioral therapy. Once they have thoroughly discussed their traumas and become comfortable managing their reactions and emotions in counseling sessions, they should continue interventions such as neurofeedback operations or EMDR (eye-movement desensitization reprocessing) techniques. Neurofeedback machines are not commonly found on most agency sites and technicians must be specialty trained to administer the resource; but they have been found to drastically reduce emotional complications from trauma, anxiety, and depression often in a single session. EMDR is a specialty intervention requiring licensure and/or certification and training. As a counseling intern in a state-run facility, you would have to order a referral for this service. EMDR interventions may seem like the first line of defense in treating trauma, however without first feeling comfortable with approaching traumatic content in therapy and having confidence in one's ability to self-soothe resultant anxiety, it is possible for EMDR to be too challenging. Prolonged exposure therapy is effective if relatable to certain traumas where one can control the reduction of fear response associated with the trauma (ie, driving over the bridge where they had a car accident, or taking a shower after being attacked in water). It would not be appropriate for Shania who has a history of physical and verbal abuse by her parents. Therefore, the correct answer is (D)
Competency: treatment planning