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Complex Case Management

Complex Case Management

Sample Answer 

Complex Case Management

Introduction

H.M. was a 41-year-old Hispanic woman who is being managed for alcohol use disorder and major depression. She presented with a prolonged history of sadness and dejection, sleep disturbances, social withdrawal, poor impulse control, and excessive alcohol use.

Despite 11 weeks of pharmacological and psychotherapeutic treatment, she continues to experience worsening sleep disturbance, overwhelming sadness, and fatigue. She remains cynical about her treatment and recovery. She has also reinitiated alcohol use despite successful initial detoxification therapy.

Biopsychosocial Assessment

Biological Assessment

H.M. has had chronic back pain for 6 months, which has conceivably derailed her quality of sleep. Limited access to treatment because of lack of health insurance jeopardized her access to pain management.

She was recently diagnosed with hypertension. Her latest check-up indicated that she has uncontrolled hypertension. She is on antihypertensive medication (lisinopril).

Her development was normal across all major domains and milestones and across childhood and adulthood.

Psychological Assessment

H.M experiences persistent feelings of dejection, sadness, and loss of control for the past 5 months. These symptoms are related to thoughts of being incompetent as a mother and financial insecurity.

She also experiences persistent self-loathing and self-criticism making her cynical about any attempts to improve her well-being.

H.M has had sleep disturbances for several months, characterized by delayed initiation of sleep that could last for many hours and frequent awakening.

She has also been struggling with recurrent nightmares that have further hindered her ability to obtain refreshing sleep, causing significant fatigue during the day.

Although she has a prior history of experimental alcohol use as a teenager, H.M has been drinking excessively for the past four months. Drinking helps her sleep and cope with the persistent feeling of sadness. She was not using any other psychotropic substances.

H.M has recently become socially withdrawn, avoiding any form of engagement with her friends. She has also become increasingly irritable and experiences anger management and impulse control difficulties.

H.M denies experiencing any suicidal ideation or behaviors. She also has no prior history of psychiatric illness. Family history of psychiatric illness is negative.

Her psychological symptoms meet the DSM 5 criteria for depression, including depressed mood, insomnia, fatigue, reduced interest in friends and activities and self-loathing (Criteria A), and socio-occupational dysfunction, including parenting challenges and a reduced interest in business ventures (American Psychiatric Association [APA], 2013).

Social Assessment

H.M is a single mother who lives alone with her 2 children, a 13-year-old son, and a 7-year-old daughter. Both her children are healthy.

H.M has also experienced a failed relationship. She separated from her husband. She thinks it was her fault despite a history of intimate partner violence. H.M is reluctant to be in another relationship for fear of another relationship failure.

She lives with her two children in a small rental house, for which she had reneged on payments for 4 months. She received an eviction notice 3 weeks ago.

H.M experienced a loss of a relationship because of bereavement. Her mother succumbed to a stroke 1 year ago. She attributes the loss to her current distress. Her only other living close family member is her grandmother, who lives in a different city.

She has recently become emotionally neglectful and hostile towards her children. She verbally abuses them. However, she has never physically abused them.

She is reluctant to pursue any income-generating activity out of fear of failure. She lost her life’s savings in a failed textile business venture within just eight months.

Analysis         

Psychosocial risk factors such as loss of relationships (bereavement and marriage failure), loss of business, and financial insecurity have predisposed H.M to persistent stress and worry. Persistent stress has, in turn, precipitated psychological problems and symptoms, including sadness and dejection, sleep disturbances, and triggered negative coping strategies such as excessive drinking. Persistent psychological distress may have contributed to her medical conditions because of the association between psychological stress, hypertension, and back pain (Liu et al., 2017; Abdallah & Geha, 2017). Behavioral problems such as emotional dysregulation, poor impulse control, and poor anger management may be related to excessive alcohol use, which may also contribute to uncontrolled hypertension (Bradizza et al., 2018).

McLean’s Triune Brain Theory

Neurobiological Basis of Symptoms

H.M experiences persistent sadness, dejection, self-loathing, and sleep disturbances, symptoms which are mainly medicated by neuroanatomical structures within the limbic system, particularly the amygdala (Pantic, 2019) and its connections with areas of the cortex such as the prefrontal cortex. The amygdala is particularly important in interpreting and expressing negative emotions such as sadness, self-loathing, and dejection (Pantic, 2019; Arias et al., 2020). The prefrontal cortex suppresses the stimulation of the amygdala by negative emotions by integrating conscious awareness and logic in the interpretation of emotions. In a persistently depressed mood, the connection between the prefrontal cortex and the amygdala is attenuated, increasing the sensitivity and reactivity to negative emotional input even when the input has dissipated (Ferrari & Villa, 2017). Psychological stressor-related elevation of cortisol levels also augments the reactivity to negative emotional stimuli by suppressing neural activity in the PFC and potentiating the amygdala activation (Pantic, 2019).

McLean’s Triune Brain Theory

McLean’s Triune Brain Theory divides the brain into three layers, namely the reptilian, mammalian, and primate brains (MacLean, 1952). These layers are functionally distinct but interconnected, an organization that is reflected in human cognition, emotional expression, and behaviors. The innermost layer of the brain is the reptilian brain which consists of structures of the brainstem, including the medulla, pons, midbrain, cerebellum, and globus pallidus. This layer is concerned with the control of physiological elements such as blood pressure, heart rates, and breathing (MacLean, 1988). The mammalian brain is analogous to the limbic system and its constituent structures, such as the amygdala, hippocampus, and adjacent cortices, and the hypothalamus and adjacent nuclei. This layer mediates emotional regulation (MacLean, 1952; MacLean, 1988). The primate brain consists mainly of the cerebral cortex and some subcortical structures, such as the basal ganglia, and is concerned with higher functions such as reasoning, motor activities, and social capacities. This layer also controls emotional expression in the mammalian layer by appraising emotionally-charged stimuli (MacLean, 1988).

McLean’s Triune Brain Theory and the Complex Case

According to McLean’s Triune Brain Theory, emotional responses and their salience in human behaviors and experiences are mediated in the mammalian brain (MacLean, 1988). H.M experiences negative emotions, including sadness, dejection, self-loathing, and associated sleep disturbances which originate in the mammalian layer. According to the Triune Brain Theory, this layer has a lower accuracy in conceiving stimuli and therefore relies on input from the primate layer, which is analogous to the cerebral cortex for modulation in the normal brain (MacLean, 1988). In the case of H.M, her tendency to experience sadness and dejection in response to emotionally charged negative experiences represents the absence of modulatory input from conscious awareness (primate brain) or errors in cognition that allow the output from the mammalian brain (limbic system), such as sadness and self-loathing to remain dominant. In the absence of cognitive modulation, initial stressors such as bereavement, loss of a relationship, and loss of business continue to elicit negative emotional responses. Fatigue is the physiological output from the reptilian brain, based on the emotional responses arising from the mammalian brain.

Prior interventions failed to elicit symptom reduction and improvement of function because the integrity of the modulatory connection between the primate and mammalian brains was not restored. H. M’s treatment plan consisted of initial detoxification at the agency’s crisis center and counseling and antidepressant treatment with Citalopram. While these interventions may potentially alleviate symptoms, they failed to address the dominance of the mammalian layer resulting from cognitive distortions in the interpretation of emotionally charged negative experiences such as the risk of eviction, financial insecurity, and limited social support following the loss of relationships. An effective intervention, such as cognitive behavior therapy, should target the negative thoughts and cognitions that maintain these negative emotional responses.

Intervention

            An intervention that may be more effective in the management of H.M. is cognitive behavior therapy (CBT). The intervention emphasizes the role of negative thinking patterns in the persistence of psychological disturbances such as depression Corey, G. (2017). As such, in order to effectively manage psychological disturbance and maintain the remission of symptoms, these negative schemas should be identified and restructured (David et al., 2018). CBT is an evidence-based psychotherapeutic technique that is consistent with McLean’s paradigm of the human mind.

Cognitive Behavior Therapy

            CBT operates on the basic assumption that an individual’s belief system, emotional response, and behaviors are mutually interlinked. As such, the occurrence of a change in one area, precipitates a change in the other areas. In negative emotional states such as morbid sadness, entrenched cognitive schemas result in the unrestrained perception of experiences as catastrophically distressful (Corey, 2017). Core beliefs developed through initial negative experiences provide the templates for appraising future experiences, even when they are dissimilar (Wenzel, 2017). For instance, in depression, an individual who perceives themselves as a failure will be reluctant to take on any challenge because of the tendency to anticipate failure. CBT seeks to minimize such self-defeating tendencies and emotional responses by imparting a more logical schema. Therefore, the goal of the therapist is to guide the client to learn to distinguish between genuine and irrational emotional phenomena (Corey, 2017; Wenzel, 2017). The client eventually learns to avoid maladaptive emotions and associated behaviors. A change in the client’s belief system and thinking patterns can potentially elicit permanent changes in morbid emotional responses and behaviors (Corey, 2017).

In practice, CBT has some key attributes that increase its effectiveness in the treatment of psychological disturbances such as morbid sadness and underlying causes such as depression and adjustment disorder. One such attribute is the reliance on a positive and collaborative relationship between the psychotherapist and the client. The client plays an active role in their therapy through practices outside the therapy setting, such as completing behavioral assignments (Corey, 2017). The technique assumes that psychological disturbances are maintained by enduring cognitive patterns (Wenzel, 2017). CBT is also mainly oriented to the present, focusing on helping the client to positively construct their present situation. As such, the intervention does not focus on the formative aspects of a client’s psychological distress unless they have actual therapeutic value (Corey, 2017). Notably, the therapist has a proactive role in the treatment, directing and guiding the client as an expert in cognitively-maintained psychological distress (Wenzel, 2017). According to Corey (2017), CBT also relies on psychoeducation, aimed at helping the client to understand the origin of their negative emotions in cognitive distortions and imparting strategies for redressing these distortions to mitigate or eliminate their impact on emotions and behavior.

Application of CBT

The cognitive model provides a framework for identifying the schemas that maintain H. M’s negative emotions and behaviors. H.M has never met her father, a developmental event that may have influenced how she perceives herself. H.M.’s self-loathing attitude may have arisen from perceiving herself as unwanted and undeserving of the love of her absent father, which may explain her tendency to respond to distress with social withdrawal. This schema has potentially led her to interpret other losses of relationships, such as her deceased mother and estranged husband, as her fault. H. M’s other negative schema is the belief that she is a failure, shaped by other experiences of failure, including her failed marriage and business venture and the potential loss of housing. She may therefore be perceiving other efforts, including her treatment goals, as failures in waiting. Losing her mother is the critical incident that precipitated further negative automatic thoughts of being a failure, the thought that she would not be sad and dejected if her mother was alive and that drinking relieves her psychological distress. Excessive drinking, hostility towards her children, and self-isolation are negative coping behaviors that help her deal with the negative emotions. Fatigue is the physiological consequence of persistent stress.

Psychoeducation should be tailored to help H.M. identify and correct her negative schema (being a failure and unwanted) and negative automatic thoughts. Collaborative treatment goals for therapy sessions should include helping H.M to identify her various core beliefs, and negative schemas, teaching her to recognize her automatic thoughts and training her on strategies for challenging irrational automatic thoughts by weighing the evidence that supports against the evidence that refutes the automatic thoughts. Strategies for addressing these automatic thoughts would include thought stopping, daily thought recording, thought validation, Socratic questioning, and consideration of alternative thoughts (Corey, 2017). Deconstructing H. M’s negative schemas and teaching her new schemas for interpreting her experiences and relationships may help her to attain enduring remission of symptoms of depression. Behavioral experiments can be used to help H.M. implement the acquired cognitive strategies. For instance, H.M and the therapist could collaboratively agree on a project, anticipate the challenges and address the associated negative thoughts.

Conclusion

  1. M’s negative mood symptoms failed to improve despite 11 weeks of pharmacotherapy and counseling. Based on McLean’s Triune Brain Theory, her treatment failure can be attributed to failure to address the cognitive distortions that underlie her symptoms. Cognitive behavior therapy provides a suitable technique for encouraging and maintaining symptom remission.

References

Abdallah, C. G., & Geha, P. (2017). Chronic pain and chronic stress: two sides of the same coin? Chronic Stress1, 2470547017704763.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Arias, J. A., Williams, C., Raghvani, R., Aghajani, M., Baez, S., Belzung, C., … & Kemp, A. H. (2020). The neuroscience of sadness: A multidisciplinary synthesis and collaborative review. Neuroscience & Biobehavioral Reviews111, 199-228.

Bradizza, C. M., Brown, W. C., Ruszczyk, M. U., Dermen, K. H., Lucke, J. F., & Stasiewicz, P. R. (2018). Difficulties in emotion regulation in treatment-seeking alcoholics with and without co-occurring mood and anxiety disorders. Addictive behaviors80, 6-13.

Corey, G. (2017). Theory and practice of counseling and psychotherapy. Nelson Education.

David, D., Cristea, I., & Hofmann, S. G. (2018). Why cognitive behavioral therapy is the current gold standard of psychotherapy. Frontiers in psychiatry9, 4.

Ferrari, F., & Villa, R. F. (2017). The neurobiology of depression: an integrated overview from biological theories to clinical evidence. Molecular neurobiology54(7), 4847-4865.

Liu, M. Y., Li, N., Li, W. A., & Khan, H. (2017). Association between psychosocial stress and hypertension: a systematic review and meta-analysis. Neurological research39(6), 573-580.

MacLean, P. D. (1952). The triune brain, emotion, and scientific bias. The neuroscience second study program, 336-349.

MacLean, P. D. (1988). Triune brain. In Comparative neuroscience and neurobiology (pp. 126-128). Birkhäuser, Boston, MA.

Pantic, I. V. (2019). Neurophysiological and Neurobiological Basis of Emotions and Mood. In Chronic Stress and Its Effect on Brain Structure and Connectivity (pp. 73-89). IGI Global.

Wenzel, A. (2017). Basic strategies of cognitive behavioral therapy. Psychiatric Clinics40(4), 597-609.

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Question 


Complex Case Management

Assignment 1: Assessment and Interventions Paper with a Complex Client

  1. Identify a client (or group, family, couple) with whom you have worked but who has not responded in the way that you (or they) would have liked to their treatment (a client that you have not written on in any prior assignment);
  2. Provide a concise biopsychosocial assessment;
  3. Briefly describe the previous intervention used with the client and using the theory of the triune brain, justify why it may not have been effective;
  4. Define, describe, and apply one bottom-up or one top-down intervention that may have been more effective.

    Complex Case Management

    Complex Case Management

  • 6-8 pages (not including title or reference pages)
  • Minimum 6 references outside syllabus
  • APA 7th Edition, 12-point Times New Roman Font, 1” margins
  • Class lectures and PowerPoints should not be referenced
  • Writing style includes proper grammar, syntax, sentence structure, and spelling
  • Writing includes clarity of concepts and ideas (articulation), as well as integration of the assigned readings and/or recommended readings and/or independent research
  • -1 point for each day late

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