Mary Catherine Collins

Case Study: Peggy

CNS 771 SU 2015
06/27/2015

CASE STUDY: PEGGY

After meeting with Peggy pertaining to the purpose of counseling, I shared my attached
Professional Disclosure Statement and also discussed the Informed Consent, which Peggy
signed. We then conducted intake which includes a biopsychosocial assessment.
IDENTIFYING INFORMATION: 65 year old female, retired public school teacher, married to
her husband (40 years) with two adult children who live 500 miles from home. Seeking treatment
to deal with feelings of isolation, anxiety, depression and hopelessness.
PRESENT PSYCHIATRIC ILLNESS/SYMPTOMS: Client reports episodes of crying daily,
memory loss, isolation, anxious feelings (especially surrounding driving), and hopelessness.
Client has noticed a significant decline in energy and disposition. She has dropped out of social
activities and is also having difficulties sleeping. Suicidal ideation; client reported to her husband
that, she no longer has a purpose in life and wishes that she could just go to sleep and not wake
up.
PAST HX OF TREATMENT: Client has not reported any past or prior symptoms related to the
ones presenting currently. In addition, client has no past history of treatment or counseling. Her
husband is the one who encouraged the appointment, scheduled the appointment and brought her
to the office. The only prior symptoms the client reports is insomnia after going through
menopause. Her insomnia is now present and she has to use medication to fall and stay asleep. It
seems like the client agreed to the appointment simply to appease her husband, Roger.
MENTAL HEALTH MEDICATIONS: Client is currently taking Ambien each night to help
her with her insomnia. Client is not taking any other mental health medications, nor has she
taken any in the past.
MEDICAL CONCERNS: Client has reported symptoms of forgetfulness (keys, day of the
week, conversational), insomnia, and her recent car accident (client was at fault).
CURRENT MEDICATIONS: Client is currently taking an Ambien each night to help her
sleep.

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Mary Catherine Collins

Case Study: Peggy
CNS 771 SU 2015
06/27/2015
DEPENDENCY/ADDICTION HISTORY: Client reports that shortly after menopause she
started taking Ambien to help with her insomnia; client reports that she started abusing the
medication and took three times her prescribed amount every so often. Other than
the misuse of her prescription, the client does not report using or abusing any other over the
counter medications, alcohol or illegal drugs. Client reports drinking 2-3 alcohol beverages per
month. Client does not smoke and has 1-2 cups of coffee per day. No current abuse or
dependency issues suspected.
FAMILY HISTORY OF PSYCHIATRIC/ADDICTION ILLNESS: Client reports that her
mother and father divorced at a very young age. She indicated that her mother often drank wine
daily and ended up in the hospital numerous times. She also indicated that her mother was very
depressed and anxious after the divorce for the rest of her life. Her mother died in her late 50s
due to her alcoholism. The client lived with her mother and lost contact with her father after the
divorce, so she is unsure about the illness history of her father.. The client has two sisters and
they are both healthy without any symptoms of addiction or psychiatric illness.
SPIRITUALITY: Client was raised in a non-religious home, but likes to attend church weekly
with her husband. Recently she has not been attending church because she has not felt, up to it.
When her children were younger, they would attend church almost regularly as a family. Client
reports inability to be very involved in her spirituality recently; reading the bible, praying, church
social groups, etc. The church is very supportive of Peggy and they have been praying for her
and wishing she would come back to church.
PERSONAL HISTORY: Client is the oldest of three children whose parents divorced when she
was age 5. The parents did not remain in the same town and she (and her mother) lost contact of
her father after the divorce. The client does report some feelings of guilt and confusion
surrounding her parents divorce. Since she was the oldest she felt responsible for their divorce
and that she could have done more to take care of her younger sisters to relieve the stress from
her parents. Her mother and father were both overworked and stressed. Client also reports that
her mother was an alcoholic and often had crying spells, panic attacks with symptoms of
depression and anxiety. Her father supported the family from a far financially which allowed the
mother to stay at home. The client reports that her mother was often isolated and upset. She also
recalls that her and her two sisters spent a lot of time at their grandparents home in the next town
over right after the divorce. The clients grandparents and mother are now deceased and she still
does not speak to her father. She sees her younger sisters a few times a year, but recently missed
their last get together.

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Mary Catherine Collins

Case Study: Peggy
CNS 771 SU 2015
06/27/2015
EDUCATION: Client completed high school and went on to obtain a degree in teaching
specializing in early childhood development.

WORK HISTORY: Client is currently retired, but worked as a public school teacher for 25
years.
LEGAL HISTORY: Client has no history of legal involvement and no pending legal action. She
was involved in a car accident three weeks ago, however no legal action was taken against her
and no one was injured.
MARITAL/RELATIONSHIPS: Client is currently married to her husband Roger. They have
40 years of happy marriage together with two adult children. The couple were high school sweet
hearts and have never experienced any marital discord. The client did not have any other
relationships before Roger.
MENTAL STATUS: Client appears casually dressed, neatly groomed and is friendly/
cooperative. She is anxious and a bit preoccupied. Client is also tearful and hopeless. Suicidal
ideation is present. No evidence of tremors, tics, or muscle spasms. She could not recall the day
of the week and I had to repeat some of the questions on the assessment. Her affect is appropriate
to the conversation and her mood is depressed. Her speech is soft, but somewhat breathy and
anxious in tone. Her thoughts do not flow logically, thought blocking seems to be present in
addition to forgetfulness. She is oriented to time, place and person.
SUMMARY IMPRESSION: Peggy, 65 y/o married caucasian female, was referred by her
husband to seek counseling and discuss her symptoms of depression, anxiety and passive suicidal
ideation. Likely hereditary component with possible contributing factors related to her memory
loss and age.
SHORT-TERM GOALS:
1. Refer to primary care physician to address ongoing memory loss and insomnia which seems
to be worsening over time.
2. Develop a safety plan in case thoughts of hopelessness/death escalate to active suicidality.
3. Get client to engage in self-care plan discussed and written during the session.
4. Develop treatment plan during next session.

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Mary Catherine Collins

Case Study: Peggy
CNS 771 SU 2015
06/27/2015

CASE CONCEPTUALIZATION: I think the primary issue is Peggys symptoms of depression

and anxiety. I am worried about her memory loss and insomnia which may be causing some of
her symptoms of depression, isolation, etc. After Peggy consults with her primary physician to
see what is causing/potential treatments for her memory loss, then we will better be able to seek
treatment for her depression, anxiety and feelings of hopelessness. Suicidal Ideation seems to be
passive at this point, but we have created a safety plan to help if suicidality becomes active.
TREATMENT PLAN: Newsome & Gladding (2014 p. 215) interprent R.M. Mitchell (2007, pp.
22-23)
Problem Statement: Memory loss, depression, anxiety and feelings of hopelessness (passive
suicidal ideation).
Goal Statement and Expected Date of Achievement: Keep a journal describing thoughts,
feelings, and behaviors for the next 4 weeks. In addition, try to go back to church or one of your
previous social activities twice in the next 4 weeks. Try to involve Roger in your journaling
process and social events.
Treatment Modality: Meet once weekly for individual counseling with a licensed professional
counselor. In addition, meet once weekly for senior group counseling for individuals with
depression. The group will be led and facilitated by a licensed professional counselor.
Clinical Impression or Diagnosis: 296.22 Moderate Major Depressive Disorder Single
Episode. 300.29 Specific Phobia (driving) DSM-V. The DSM-V has listed disorders also known
as International Classification of Disease codes (Newsome & Gladding, 2014) and is used to
classify a clients condition numerically and specifically.
Names and Credentials: Mary Catherine Collins, BA Psychology, Current Masters Student at
Wake Forest University Clinical Mental Health Counseling. June 27, 2015 at 8:42 PM EST.

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Mary Catherine Collins

Case Study: Peggy
CNS 771 SU 2015
06/27/2015

SLAP METHOD-SUICIDALITY ASSESSMENT: Newsome & Gladding (2014 p. 215)

interprent Sommers-Flanagan & Somers-Flanagan, (1995)

Specificity: The client has no specific plan for suicide; I just wish I could fall asleep and not
wake up.
Lethality: The clients lethality is pretty deadly. She has access to sleeping medications
which could cause an overdose in addition to very sharp kitchen knives.
Access to Means: Client does not have access to fire arms or hunting knives. She does have
access to everyday household items like (knives, scissors, etc.) and Ambien sleeping
medication.
Proximity of Social Support: Client has her most direct support which is husband who is
available daily to her. She also has her two adult children who are available by phone daily
and her church group (contact numbers are in her phone and at home in the address book). In
addition, she has her two younger sisters who are in the next town over and are available by
phone and can meet her within a 45 minute drive.

LEVEL OF RISK: I think that Peggys risk is at Stage 1. She has not planned out her suicide
and has very passive suicidal ideation. She does have access to means that could be potentially
fatal, but has not indicated those items as means to commit suicide. My next step would be to
make a safety plan in case her passive suicidality becomes active. I would want Peggy to remove
any potential dangerous items from her home for the time being.

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Mary Catherine Collins

Case Study: Peggy
CNS 771 SU 2015
06/27/2015

References
Newsome, D. W., & Gladding, S. T. (2014). Clinical mental health counseling in
community and agency settings (4th ed.). Upper Saddle River, NJ: Merrill/
Pearson Education. ISBN: 978-0-13- 285103-9

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