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Identifying Information/Reason for Referral
A patient is a 48-year old, married, employed American female who currently lives at home with her husband and who has a history of depression, and drug dependence. The patient was brought in by her husband who was concerned with his wife’s increased feeling of anxiety combined with apathy to external stimulus. The patient herself states that she has an overwhelming feeling of despair because of her father’s death. She also states, “I do not feel support and sympathy on the part of her family. I am alone in front of the problem”. She currently expresses the need to “receive support and assistance” and help her “to get rid of drug dependency”. The patient, however, does not express active suicidal intent.
Evaluation and Summary
The patients confessed concerning her current mood, “I feel at a loss because nothing brings me pleasure and joy. I am in despair because neither my husband nor my son provides me with sufficient support. I feel horrible because the only joy I found is drug use that helps me just forget about the problems.” The effect was blunted, which is congruent with the expressed mood because her answers were not saturated with splashes of emotions.
The patient was first hospitalized two years ago, right after her father’s death, and diagnoses with a drug overdose. The patient underwent three months of treatment for drug abuse. The patient took a behavioral treatment, which involved counseling – both individual and in groups – combined with medications (buprenorphine). The treatment was at first voluntary, but later the patient expressed no desire to take one more course. However, the patient took the second course in 3 months, upon her husband’s request because there were significant complications in terms of normal physical and behavioral functioning.
Despite the two sessions conducted, the patient is still dependent on drugs. She can take one dose of the drug three or four times a day, despite her husband’s prohibitions and disapprovals. She prefers taking morphine, which was initially taken to relieve headaches. Hence, the patient has started taking morphine since her father’s death and never given it up to the current moment despite treatment sessions. During the first session, the patient states that she was clean for half a year after the session. The second session, however, was not as effective as the first one and the patients restarted taking morphine. She felt even worse because the feeling of despair deepened and now she feels apathy to the surrounding people.
There is also evidence of taking medical treatment for depression. The patient took antidepressants and underwent psychotherapy. However, the course has worsened the situation because the patient became more dependent on drugs.
Developmental History
The patient was born to a traditional American family in San Francisco. She was born on time and the delivery was normal. The medical report reveals that her mother’s pregnancy was normal. Before the patient lost her father, she never felt depressed. Her family was happy enough and she felt especially strong support from her father. She states that her father was the main person who was able to give the right pieces of advice and she was not afraid of making the wrong decision. The patient’s parents lived happily and in accord with each other. At the age of 29, she married her husband and two years later, she gave birth to their son.
Being in a marriage with his husband, the patient often referred to her fathers’ advice and support, if there were some family problems. Professional choices were also considered with her father, but not with her husband. So, she decided to become a social worker just because her father believed it was the best decision she would make, but not because this was what she wanted. The patient confesses that she dreamt of the profession of a lawyer. The decisions about her son’s future education and profession, asset purchases, and other minor problems were always discussed with her father. She seems to be reluctant to talk about the decision made by her husband.
Currently, the patient is under psychiatric counseling because she in urgent need of constant support. The loss of her father made her irresponsible; the client considers it impossible to make decisions independently as she always needs someone to approve of her actions. The patient is now not able to act without assistance and, therefore, the further intervention of the counselor is necessary. The actions should be based on several sessions (approximately 1 session per week) where a counselor and a patient can discuss the issues of the greatest concern.
The patient does not have a detailed religious history because she rarely attends church and she does not attain much importance to religion. Nevertheless, family traditions play an important role in her life. Because the patient is American, there were no significant cultural and ethnic constraints about the treatment methods because she belongs to the majority ethnic group.
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