Tiffany Case Study (Client History & Background Information)…
Tiffany Case Study (Client History & Background Information) Tiffany, age 16 years, was diagnosed with major depressive disorder (MDD) 3 years ago. She was admitted to a women’s & children’s shelter 3 days ago as a walk-in. At intake, Tiffany told staff members that she ran away from home 4 weeks ago, was out of money and hungry, and had no safe place to go. She completed intake paperwork on her own. Tiffany identifies as white Hispanic and lists her preferred pronouns as she/her/hers. English is her first language. Tiffany acknowledged understanding that this shelter allows people to stay for a maximum of 30 days and that residents must follow the rules/get along with other residents during that time. Mental Health History: Tiffany was diagnosed with depression at the age of 13. She reports that she felt a lot of anger and hostility toward her friends and family during this time. In addition, she stopped doing her homework, began to fail classes, stopped hanging out with friends, and lost interest in after-school activities like choir and Spanish club. At her mother’s request, she was evaluated by a psychiatrist, who diagnosed her with depression and prescribed Lexapro (escitalopram). Tiffany reports that she did not like taking Lexapro because it made her feel tired and restless. She also noted that she attempted suicide by taking a bottle of acetaminophen during her freshman year of high school. Following the suicide attempt, she was hospitalized for two weeks. Her psychiatrist discontinued her prescription for Lexapro and prescribed 20 mg of Prozac (fluoxetine) daily. Tiffany reports that she has not taken any medication or been seen by any mental health professional in over 6 weeks. Before that time, she had only received counseling and therapy during her 2-week hospitalization following the suicide attempt and once-per-month check-ins with a counselor assigned to her at school. She also indicated that she is not sure if medication even helps. She identified that she has used Vicodin (acetaminophen/hydrocodone) and ecstasy recreationally. At the time of intake, Tiffany was slightly disheveled & had some redness/enflamed scratches and cigarette burns on her arms. She denied any current suicidal or homicidal thoughts but admitted occasional self-harm. She denied being under the influence of any illicit substances and presented with a stable mood. Medical History: Unremarkable. Does not list a current Primary Care Provider (PCP) on intake forms. Tiffany has medical insurance from her mother’s employer and says she “doesn’t know what that looks like” now since she is no longer living at home. Family History: Before running away, Tiffany lived with her mother and older brother. Tiffany’s parents separated when she was 5, and she spends every other weekend at her father’s house in the neighboring town. Tiffany’s mother is white non-Hispanic and Tiffany describes her as “super Catholic.” Tiffany’s father is a “Christmas & Easter Catholic” (per Tiffany) and immigrated to the US as a teenager from Colombia. Tiffany’s father is a car salesman and her mother works as a bank teller. Her brother is a student at the local community college and spends most of the time at his girlfriend’s house. Tiffany describes her parents as being “too conservative,” “too controlling,” and rarely affectionate with her. In addition, Tiffany reports that she had been fighting with her mother about dropping out of school during her junior year, shortly before running away. Tiffany was close with one male first cousin who is similar in age but reports that they have grown apart in the last 2 years. She reports feeling like she is the “black sheep” of the family. Educational History: Tiffany completed the 10th grade and dropped out of high school in the first semester of her junior year. Tiffany indicated that she “hates” school and is particularly upset with her ninth-grade math teacher, who spoke to her mother about changes she had observed in Tiffany’s behavior. Tiffany also reported that she was an honor student in elementary school and during the first 2 years of middle school. She does not regret dropping out of high school and has no interest in returning. However, Tiffany is aware that she will likely need a GED in order to get a job. Occupational Profile An occupational profile was initiated by the occupational therapy assistant (OTA) on the 3rd day after Tiffany arrived at the shelter. Although Tiffany responded with “I don’t know” for most of the questions during the interview, she did provide information about a typical day. Tiffany is more irritable today than the initial intake and the OTA notes increased redness/skin picking and a new cigarette burn on her arm. Tiffany reported that she typically (when still living at home) slept until noon or later and spent most of her time in her bedroom. When asked why she sleeps until noon, she noted that she “hates the mornings.” She usually showered once every 3 days, which had become a point of contention between her and her parents. Unless her mother makes tacos or a favorite food for dinner, Tiffany often makes peanut butter sandwiches and eats them in her bedroom alone. When asked why she came to the shelter, Tiffany said she was fearful of being physically harmed by some of the strangers with whom she had been “hanging out.” She shut down and did not want to discuss details, but shared that she had sexual encounters with a few guys and had been verbally assaulted by a woman who was in a relationship with one of them. She describes herself as “useless” and indicated that she did not think that anyone really cared about her except her grandmother, who lives more than 300 miles away. Tiffany initially stated that she was not good at anything, but after rephrasing the question, she told the OTA that she is good at sketching. She did not elaborate on what she likes to sketch. She reports that she has not completed a sketch in a long time because she gets too distracted by all of the things on her mind. When asked about her current goals and priorities, Tiffany was unable to identify anything more specific than “finding a place to live.” She was adamant that she did not want to return home or go back to school. New Information: Tiffany is now on her 5th day at the shelter. You’ve identified self-regulation during daily routines and initial steps toward housing stability as her most urgent short-term goals. Using the occupational profile, trauma-informed principles, and psychosocial OT models, in the next few questions you will create a 30-minute treatment plan that supports these goals. Additional Case Information: In one of your future sessions, Tiffany shares that she once cut her mom’s favorite shirt into tiny pieces because she was so mad that her mom forced her to go to church that morning. When Tiffany becomes overwhelmed or fearful—such as when discussing her past experiences or facing uncertainty about her housing situation—her body may enter a state of fight, flight, or freeze. During an OT session, Tiffany appears physically agitated, speaks quickly, and becomes verbally defensive when asked to participate in a planning task related to housing. The OT suspects she is in a state of hyperarousal and outside her window of tolerance. Which of the following intervention strategies would be MOST appropriate to support co-regulation and down-regulation?