Therapeutic Treatment Strategy for Bipolar II Disorder

Develop one empirically supported therapeutic treatment plan for the client in the vignette. Please make sure you summarize the empirical evidence with appropriate citations to support your treatment choice(s) in working with your client. Be sure to discuss the effectiveness and limitations in working with this particular client, including this client’s background, using the above treatment plans. 

I.                   IDENTIFYING DATA

Ms. Monroe is a 26-year-old, divorced, Caucasian female who is four months pregnant and currently held at the Rappahannock Regional Jail in Stafford, Virginia.  She was arrested on November 5, 2016, charged with trespassing (Class 1 misdemeanor); statutory burglary while armed with a deadly weapon (Class 2 felony); two counts of abduction (parental kidnapping); and contempt of court (Class 6 felony).  Ms. Monroe is facing 20 years to life in prison.  On January 5, 2017, she was court-ordered to participate in a psychological evaluation due to her current mental status as well as her psychiatric history.  Clinical opinion specific to Ms. Monroe’s competence to proceed and mental status at the time of the offense is to be offered to the Court.  

II.                INSTANT OFFENSE

At 6:30am on November 2, 2016, Fredericksburg Police Department received a call from Mr. John Monroe.  He stated that he woke up to find his 1-year-old daughter and 2-year-old son missing. He noticed that the window to his back door was broken which he assumes was the means to unlock and open the door.  He reported that his home security system had been de-activated due to financial strain and that his bedroom is located in an area of his house that is opposite of his children’s room. Thus he was unable to hear any movement.  He denied any property damage (other than the back door window) and anything missing (other than his children). 

Mr. Monroe reported to police that he suspects that his ex-wife entered his home and took the children.  He stated that they divorced 10 months ago when their daughter was 2 months old and, due to his ex-wife’s psychiatric condition and unemployment status, the court awarded him full custody of both children.  He also reported that since the court’s decision, Ms. Monroe would intermittently text or call him for the purpose of threatening to take the kids from him, out of the state, with the intent of him never finding them and with no concern about legal consequences.  She also verbalized the possibility of harming him if he interfered with her taking them.  He suggested that she may be in the Hampstead, North Carolina area, as that is where she was born and raised and always desired to return.  He also made it known that she is severely hearing impaired, wears hearing aids, but primarily relies on lip-reading.  She is fluent in American Sign Language.  He provided identifying information, the make and model of her car, and the license plate number.

On November 5, 2016, after an Amber Alert was issued, her car was identified parked at a McDonald’s.  Ms. Monroe was reported to be sitting inside with both children eating lunch. She was soon apprehended and arrested by the Pender County Sheriff’s Office.  After her first appearance in Court on November 6, 2016, due to contempt of court related to child custody, she was extradited to Rappahannock Regional Jail.

III.             RELEVANT HISTORY

Ms. Monroe was born and raised in affluent area of Hampstead, North Carolina.  She was raised by her biological parents and with two older brothers. Ms. Monroe was born with severe hyperbilirubinemia (jaundice) resulting in a blood transfusion.  The high levels of bilirubin caused damage to the nerves responsible for hearing and, consequently, hearing impairment. Her childhood was free of any abuse, neglect or other trauma. She reported being a happy and social child, despite the limitations of her hearing impairment.  

Ms. Monroe was homeschooled from kindergarten through high school.  She graduated with a high school diploma at the age of 17. Although homeschooled, her parents maintained mainstream opportunities for Ms. Monroe, such as sports and other extracurricular activities, with other children.  Upon receiving her high school degree, she continued to live at home and volunteered in guest services at a church assisting hearing impaired attendees.  She has never been gainfully employed.  She met Mr. Monroe at church at the age of 20, married him at the age of 22, and became pregnant with their son at the age of 24. Within their first year of marriage, they experience severe marital conflict and sought counseling.  She questioned whether she had made the right decision to marry so young.  She thought having children would help the way she was feeling and therefore got pregnant within the next year.  During her second pregnancy, her husband filed for divorce.  They divorced when her daughter was 2 months old.  Ms. Monroe currently resides independently in a one bedroom apartment.  She lives off of Social Security Disability Benefits and money that her parents send her. 

Ms. Monroe has no history of alcohol or drug use.  With the exception her recent arrest, she has no history of arrests or legal issues.

Prior to the age of 22, Ms. Monroe had never received psychiatric treatment and denied any mental health conditions requiring psychiatric attention.  During her first pregnancy, at the age of 22, she began spending most days sad and tearful.  She began isolating from friends and family and sleeping 12-15 hours per day; and she had thoughts about whether she would be a good mother and if her husband would be better off without her.  She was hospitalized twice due to suicidal thoughts. However, due to the pregnancy, she was not medicated.  At home, during these episodes, her mother-in-law came to stay with them and “watch” her for safety purposes.

After the birth of their son, she grew into her role as mother in a positive and unexpected manner.  She enjoyed her time with her son and appeared happy.  However, periodically, for weeks at a time, day after day, her self-esteem was inflated, she functioned well on only 2-3 hours of sleep, she would talk excessively and over others, and she began spending excessive amounts of money on random, non-essential items.  Her husband attempted to get her back into counseling.  However she refused.  She had numerous episodes of “highs” and “lows” over the course of a year, putting even more strain on their marriage.  When feeling “high”, she felt like the perfect mom and wanted to have more children. Because she thought her husband would attempt to talk her out of having another child, unbeknownst to him she stopped taking birth control.  She was soon pregnant with their second child.  Throughout her second pregnancy, she continued to experience highs and lows and was again hospitalized for expressing suicidal ideation.

Since the divorce 10 months ago and losing her children to her ex-husband, she has been hospitalized after attempting suicide through drug overdose on two occasions.  Although released with medication each time, she refused to fill the prescription as she was adamant against taking medication. In between hospitalizations, when feeling better, she re-engaged in buying sprees but also became carelessly sexually active. She is currently four months pregnant.  She is unable to identify the father due to the number of partners she had.  She denies interest in learning who the father is.

IV.             CURRENT MENTAL STATUS

Due to Ms. Monroe’s hearing impairment, use of an American Sign Language Interpreter was offered for the interview.  However, Ms. Monroe was adamant against using an interpreter stating that she would prefer to read lips and write down her responses as well as any questions she may have. The interview took place in a private room at the Rappahannock Regional Jail.

Ms. Monroe is a 26-year-old, divorced, Caucasian female who is currently four months pregnant.  She appears her chronological age.  She is of average height and slightly overweight.  Her presentation was unkempt, as her hair appeared dirty and tangled, she had poor oral hygiene, and she had food stains on her facility-issued attire.  She maintained poor eye contact throughout the interview.  Although rapport was difficult to establish, Ms. Monroe did appear to become more comfortable about 10 minutes into the interview, as she appeared less apprehensive to write down answers and utilized more nonverbal gestures (i.e., head nods, shrugging shoulders) to assist with the interview process.

Ms. Monroe was alert and oriented to person, place, time and situation.  She did not appear to be having any delusions or perceptual disturbances.  Attention, concentration, and memory recall were compromised, as she was not motivated to perform well during tasks intended to assess these areas.  She indicated inability to sleep well and having no appetite since being in jail.  Reportedly, she lost 15 pounds in 5 weeks.  Her affect was sad throughout the interview, and she became tearful when asked about her mood.  She responded in writing, “I feel like nothing. I have nothing.  I am nothing.”  She presented as lethargic, hopeless, and helpless.  Regarding risk, she wrote that she feels suicidal most days but does not want to tell anyone because she fears what they might do to her.  She also reported that if she thought she could get out of jail and to her kids by hurting someone, she would.  She added, “I don’t care about consequences.  I have nothing to lose.” 

Insight and judgment were poor, as she refused to acknowledge the severity of past and present psychiatric symptoms as well as behaviors, and the need for treatment.  When asked about her charges, she wrote that if she had the chance she would take her kids again.  She continued to write that her kids are all she has and that she deserves to have them because, “I’m the one that wanted them and I’m the one who gave birth to them.”  She stated that she knew that her actions could get her in trouble but she did not care.  When asked about the custody decision, she stated that her mental health and unemployment status should not play a role in the decision process, as she is the mother and should be able to raise her children.  Regarding her family, she replied, “They don’t understand why I did what I did.  They won’t help me.  And I don’t care. I don’t need anyone.” She denied having any contact with her ex-husband.  However, according to jail records, her ex-husband made several attempts to come visit but she repeatedly refuses to put him on the visitation list. With regard to her current pregnancy, she reported, “If I have to live, then at least I will have this child to live for.”  She refused to discuss her pregnancy any further.

Ms. Monroe reported that her faith has always been strong enough to get her through.  However, over the past year, she has begun questioning God and her faith overall.  Since her arrest, she has refused receipt of a Bible, all invitations to attend Chapel, and visits from the Chaplain.