Part I: Reason for Referral

1. What was the reason for the referral?

The rationale for the referral is related to the behavior of Ms. Smith and he once boyfriend Frank. She seems to be exposing her erratic and often volatile behavior to others. This erratic behavior has a history of being self-destructive to both Ms. Smith and the individuals she is often involved in relationships with. Ms. Smith also appears to be exhibiting poor judgement as it relates to her behavior towards others. She appears to have very low self-confidence as indicated by her aggressive sexual behavior towards others, her ability to shift her emotions to anger quickly, and her ability to harm others or herself. This my particularly stem from her childhood which relative normal standards was very tough. As a result, she may have experienced very traumatic events that ultimately impacted her ability to diagnose situations correctly while having proper emotional intelligence.

2. What sources of data do you have and need?

As far as data source currently available, we have the childhood history of Ms. Smith. We have a clear understanding of her background and her upbringing. We can draw some connotation between her upbring as a child and her desire for love and relationships now. As a child Ms. Smith longed for a loving relationship which was ultimately denied to her over 18 years. She now desires this love and affection from Frank. After he denied her, she lashed out, not only at him but in response to many years of emotional abuse. We also have the data from her altercation with Frank and how she perceived their relationship. We have data related to the education, occupation, and socio-economic status of Ms. Smith. Finally, we also we have data related to many of the symptoms she feels immediate before and after committing self-harm. These symptoms which oscillate between joy and sadness, show some signs of bipolar disorder. We, need more information related to recent events in Ms. Smiths life and her emotional stability. We need more information on the frequency of the self-harm and if she has sought treatment.

Part II: Background Summary

1. Family/Social, (supports) Include ethnic/racial/cultural

As noted in Part 1, Ms. Smith has a heavily troubled social and family background. First her parents both suffered from drug addictions which heavily influenced Ms. Smith. Her mother, Ms Taylor, who is former heroin addict did not want to Ms. Smith mother. As a result, she gave her to her dad, who also was a heroin addict. This created a tumultuous and unstable environment in which Ms. Smith had to grow up in. For one, her dad was unpredictable in both his mood swing and his ability to take care of the family. He was lower on the socio-economic status rung and therefore could not provide many of the basis necessities many young girls would like. For example, growing up Ms. Smith only had one pair of shoes, one pair of jeans and four shirts. As a student she was heavily picked on and emotional abused by other students (Berger, 1995).

This constant cycle of abuse took its tool on Ms. Smith. For one she had to live within an unstable family knowing that her mother did not want her. Then once she is able to leave that environment she must endure abuse from other students for 5 days a week. This manifested itself in her behavior towards Frank. Here, she simply wants to feel appreciated and given the affection that she was denied for so long as a child. Her stop mother was not any help in this regard as she too...

Part V: Treatment Recommendations

To begin the treatment recommendation should first leverage education. Ms. Smith should know exactly what the disorder is and how the treatment plan will function to help medicate any adverse circumstances. She should also look to leverage close friends and/or family who can help her through this disorder as community involved is positively correlated to treatment success. Next, the treatment plan will look to promote regular patterns of sleep, anticipating stressors, identifying new potential episodes and lower the likelihood of impairment related to drugs and alcohol. As it relates medications, Lithium, is the most widely used and studied medication as it relates to bipolar disorder. As a result, the treatment plan will leverage the use of lithium within its implementation. This medication is particularly well suited for Ms. Smith as it helps limit the severity and frequency of both mania and depression. This will help Ms. Smith better cope with the inevitable stressor that will occur in her life as a waitress (Goldberg, 1999).

Part VII: Conclusion

In conclusion, Ms. Smith seems to exhibit the symptoms of an individual suffering from bipolar disorder. She appears to be experiencing large episodes of both mania and depression as it relates to her dating relationship, therapist observations, and other aspects of her personal life. Much of this disorder may stem from a very harsh and difficult childhood environment where she was exposed to a litany of verbal and emotional abuse. This emotion abuse consisted of a mother her abandoned her shortly after birth, two parents that were addicted to heroin, as step mother who ignored her accomplishments and peers who ridiculed her for her lack of finances.

Part…