Client Name: Helen Stonewall
Age: 32 years old
Ethnicity: African American
Marital Status: Married
Children: Sonya, age 5
Background Information You are a caseworker in the emergency room of a large urban hospital. You work the day shift from 8 a.m. to 5 p.m. Several hours before you came to work, the police brought the client to the emergency room in restraints.
The following information was gathered from the police at intake.
The police state that Helen Stonewall, a 32-yearold African-American woman, was found dancing half naked in the middle of a busy intersection in the center of the city at approximately 2 a.m. She appeared to be high on drugs when the police approached her. She told the police that she hadn’t taken any drugs and that she was “just high on life.” She said she wasn’t doing anything wrong, just “having a party.” Witnesses stated that Helen had started the evening at a local restaurant and bar. She had been with a couple of gentlemen who seemed to know her. She began telling jokes and buying everyone at the bar drinks.
At first, she seemed like a person just having fun, but she kept getting louder and more rowdy as the night progressed. The two men left, but she stayed at the restaurant telling them loudly, “I’m just getting warmed up here.” She sang and danced and finally ended up shoving all the glasses onto the floor and standing on the bar talking as fast as she could. Customers got irritated, and the bartender asked her to leave. She ignored his request and started singing at the top of her lungs. Finally, the bartender had to force her off the bar and push her out the door. At that point, she began dancing and singing in the street. The bartender told police that she had no more than two drinks throughout the evening. When the police attempted to get Helen out of the road, she became belligerent and began swearing at the officers. They had to take her out of the middle of the intersection by force and handcuff her to get her into the police car. Lab tests indicated no evidence of excessive alcohol or other drugs. The physician on duty had prescribed a sedative, and Helen went to sleep at approximately 5 a.m.
Based on the intake information alone, which psychiatric disorders seem most likely?
What type(s) of information will you be interested in during the initial interview to help you narrow down the choices of diagnoses?
You go to see Helen at 9:30 a.m. She is lying in bed quietly staring at the ceiling. She seems very subdued in comparison to the description of the previous night. Helen glances at you as you enter the room but makes no attempt to sit up. You tell her who you are and your reasons for wanting to talk to her. Helen makes no response to your introduction. You ask Helen if she has any relatives you could call for her.
Helen looks over at you and says, “I just want to die. If it weren’t for my baby, I’d’ve been dead a long time ago.”
“What’s your baby’s name?” you ask.
“Sonya,” Helen replies. “I’m such a lousy mother lying here like this. I should be home taking care of her.”
“Where is Sonya now?” you ask.
“She’s with my sister. She stayed with my sister last night,” Helen responds. “I knew I was racing so I took her over to my sister’s house.”
“You were racing?” you query.
“Yeah, you know, I start racing sometimes, feeling real good and full of energy like nothing can stop me,” Helen says. “But not now; I feel lousy now, like I just want to be left alone to die.”
“Can you tell me what happened last night?” you ask.
“It’s like living on a roller coaster,” Helen tells you. “One minute you’re way up there, and the next minute you’re in the blackest hole you can imagine.”
“And last night, you were way up there?” you query.
“Yeah, I was just feeling good and having a good time. It’s like you’re racing and you can’t slow down. Like you’re high or something, but I didn’t take any drugs. I don’t do drugs. This just comes over me sometimes, and I feel like I could take on the world.”
“Have you ever felt this way before?” you ask.
“Oh yeah, up and down, that’s how I am,” Helen says.
“So, sometimes you feel really good and up, and then, sometimes you feel really down. Is that right?” you ask.
“Yeah, I’m scared I’m beginning to crash now. It’s bad when you come down. It feels real bad,” Helen says. “It lasts for weeks and weeks . . . just down all the time.”
“How often does this happen, going from one extreme to another?” you ask.
“Once a day or once a week or once a month?” “See, for a few weeks I feel great. I can do anything—stay up all night having a good time. I don’t sleep or eat or slow down. I just keep on going for a week, maybe two. Then, I begin to crash.”
“Do you hear voices or see things when you’re feeling high?” you ask.
“No, except for my own voice. I can’t stop talking either. Gets me into trouble, sometimes,” Helen admits.
“What else happens when you’re feeling high?” you ask.
“I want to party. I can party all night when I’m high. I’m the life of the party,” Helen says glumly.
“Have you ever gotten in trouble before, like you did last night?” you ask.
“Oh yeah,” Helen agrees. “I’ve gotten thrown out of places lots of times, but I usually just move on down the street.”
“Are you employed?” you ask Helen.
“I’ve tried to keep a job. Just can’t seem to stick with it,” Helen replies.
“How are you feeling right now?” you query.
“Feel like hell,” Helen tells you. “This is a rotten way to live, I’m telling you.”
“How long does the crashing last?” you ask Helen.
“Sometimes a few days, sometimes a few weeks,” Helen says bleakly.
“Describe for me what these down times are like for you,” you ask.
“It’s like I’m a balloon and someone stuck a needle in me. I’m so sad that nothing looks good. It’s hard to get out of bed and face the world . . . I sleep and sleep and sleep. When I do get up, I’m so tired that it feels like I’m carrying around invisible weights.”
“What kinds of things go through your mind when you feel like this?”
“I can’t think of anything I want to do,” Helen tells you. “I can’t seem to make myself think anything all the way through. Like making a decision about something no matter how trivial is just impossible. Sometimes, I just wish I were dead.”
“Are you wishing you would die now?” you ask.
“Not yet . . . but it usually does get to that point when I crash.”
“Have you ever seen a doctor for these changes in your mood?” you ask.
“One doctor told me it was just a female thing,” Helen states.
“Maybe it’s more than a female thing,” you suggest. “Maybe there’s some medication that could help even out your moods. Would you be willing to talk to a doctor about how you’ve been feeling?” you ask.
“Okay. I guess it wouldn’t hurt,” Helen says.
To what extent do you think Helen may be a danger to herself?
What other information would be useful in determining her risk?
What would you like to know about Helen’s social support system?
Are there any steps you would take (given the client’s permission) to assure that her support system stays intact?
What internal and external strengths do you see in Helen’s case?
What is your primary diagnosis?
What specifiers would you include with your diagnosis?
What psychosocial and cultural factors could impact your diagnosis?