Mental Health Case Presentation
Clt is a 41 year old single African American female. She is presently unemployed and receives SSI. She is residing at the LSSI, Kenmore Center The Women's Residence. Before this she was homeless. Clt is mandated by TASC (Treat Alternatives for Safe Communities) for Tx. Clt was mandated for solicitation and possession of crack cocaine. Clt has a Dx. of Bipolar Disorder which is under control at this time with medication. Clt was admitted to detox at LSSI for alcohol, cocaine, and heroin dependence. After detox Clt was admitted to passages, which is a 28 day program, at LSSI Kenmore Center. Clt started using alcohol at the age of 9, cocaine at …show more content…
Axis V - The writer believes that the Clts GAF score at this time is 49
Solicit Feedback 1. Working with this Clt I find it difficult to keep her engaged while counseling her. I’ll ask an opened ended question and most of the time I get a shrug or an "I don’t know". I had to cut our hour sessions once a week to three 20 minute sessions three times a week. I determined, with supervision, this to be the best for the Clt because after 30 Minutes the Clt would start to move and twitch in her chair constantly asking "Is it time to go yet?" 2. A clinical question that still remains unanswered is does the Clt have a TBI (Traumatic Brain Injury) and with her obvious lack of cognitive skills why hasn’t she been tested for a developmental disorder.
It would be helpful to know more about her arrest record. To know how many times she has detoxed, if so, or did she ever use in jail, if she was in jail.
It would help to know more about her childhood abuse. Clt revealed that she was molested by her "mother’s brother". Clt did not go into further detail. Clt said she "doesn’t care about that anymore" the Clt was tearing up and it is evident that this issue needs to be addressed.
It would help to know more about her family life, and her children and how not knowing her