Discussion: Suicide, Stigma, And Substance Abuse
Discussion: Suicide, Stigma, And Substance Abuse
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Suicide, stigma associated with accessing services, and substance abuse are real issues for the military. Although military social workers lead the field in these issues, there is always more work to be done. The civilian world is watching as the military works toward assuring access to services that will help their personnel. In fact, many programs developed within the military have been reproduced for a civilian environment. At the same time, there are programs outside of the military that could be tailored to help military personnel. In this Discussion, you consider other steps the military could take in the areas of suicide, stigma, or substance abuse.
To prepare for this Discussion, read the case study, “Working With Clients With Suicidal Ideations: The Case of Denise,” located in the Learning Resources. Discussion: Suicide, Stigma, And Substance Abuse
Post(2 to 3)
- Describe an approach you would take to help the military expand or better address either suicide, stigma, or substance abuse.
- Describe how the situation depicted in the case study could have been handled differently via your approach.
Required Readings
Rubin, A., Weiss, E. L., & Coll, J. E. (Eds.). (2013). Handbook of military social work. Hoboken, NJ: John Wiley & Sons.
Chapter 12, “Assessing, Preventing, and Treating Substance Abuse Disorders in Active Duty Military Settings” (pp. 191–208)
Chapter 14, “Suicide in the Military” (pp. 225–246)
Document: Working With Clients With Suicidal Ideations: The Case of Denise (PDF)
wk8-Case.pdf
© 2016 Laureate Education, Inc. 1
Working With Clients With Suicidal Ideations: The Case of Denise
Denise is a 26-year-old, Caucasian, heterosexual female who initially presented to the
outpatient mental health clinic following a brief inpatient psychiatric facility admission for
having passive suicidal ideations and self-injurious behaviors, which included cutting
her upper thighs with a razor blade. A full biopsychosocial evaluation occurred on the
day of her release from the inpatient psychiatric facility. Denise presented to the clinic in
a moderately agitated manner, voiced her dissatisfaction to the front desk staff that the
appointment was in the afternoon and was with a male therapist, and said that she
wanted to be seen the following morning and only by a female therapist. After
discussing the importance of establishing a solid safety plan and reviewing the clinic
policy that would support her ongoing care with multiple appointments over the course
of the following six weeks, she agreed to be seen “briefly.” This was the first indication
of Denise’s manipulative quality and tendency to demand that others meet her needs.
Overall, Denise was in good physical health with no significant medical findings
or previous specialty care. She did not disclose at the initial intake session that she
received routine opiate prescriptions for a variety of broad-based aches and pains,
which had been prescribed intermittently since the age of 16. Upon review of her
electronic medical record, the therapist discovered a long list of ongoing medical
complaints: chronic migraine headaches, lower back pain, and a host of other physical
pain ailments that had no medical etiology.
From a mental health perspective, Denise revealed having multiple visits to local
emergency departments (EDs) beginning at the age of 15 and continuing to the current
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day. She explained that the primary reasons for the ED visits were “suicide gestures,”
which she explained typically followed an emotionally volatile breakup or argument with
a boyfriend and resulted in engaging in some level of self-injurious behavior (e.g.,
overdosing on pills, cutting, crashing her car, or alcohol intoxication). However, despite
the estimated half-dozen visits to various EDs and brief admissions to various inpatient
psychiatric facilities, Denise never followed through with the recommended outpatient
therapy or psychopharmacology. As explanation for this lack of follow-up outpatient
care, Denise said, “the crisis is over; things are back to normal, so why bring things
back up?” This limited insight into the normalization of pathology appears to have begun
within her family of origin. Denise expressed that her mother was known for her
“explosive tempter” and would display hysterical behaviors and extreme emotional
reactivity on a daily basis; she would then appear happy and cheerful once the crisis
was averted or concluded.
Denise did acknowledge that she maintained a long pattern of alcohol misuse,
which appears to have begun during her early teen years. She reported having frequent
parties at her home when her mother would go out of town with a new boyfriend and
leave Denise with full access to alcohol and her mother’s prescription medications.
Denise denied any pattern of misconduct with the law and offered no criminal
history and no documented or disclosed illegal behaviors.
Denise was raised in a large city in the northeastern United States, where she
moved frequently with her mother and two older siblings. Denise’s parents divorced
when she was 6 years old, stemming primarily from both parents having extramarital
affairs and frequent arguments regarding control of finances and overspending on
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luxury items they could not afford. Her socio-economic status could be categorized as
lower-middle class, but Denise’s parents were known to purchase expensive clothing
and items for the kids so they would “feel important.” Denise described her mother as
“pretty cool,” but upon further discussion it became evident that her mother was
emotionally distant and avoidant of setting appropriate limits and boundaries. Denise
later described her mother as very “hypercritical and emotionally volatile.” Following her
parents’ divorce, Denise’s biological father soon remarried and began a new family. Discussion: Suicide, Stigma, And Substance Abuse
Denise reported having very little contact with her biological father, and she did not
consider him a source of support or parental guidance. Denise’s mother moved the
family moved several times over the course of her middle and high school years, usually
due to financial problems, including the inability to pay rent or bills. Discussion: Suicide, Stigma, And Substance Abuse
Denise’s two older siblings were aged 3 (brother) and 5 (sister) years older than
Denise, and they did not interact or provide much oversight into her life. Both older
sister and brother played a minimal part in her childhood and adolescent development,
with each having a different biological father. Both Denise’s brother and sister were
involved in drugs and had considerable legal problems, which took considerable time
away from attending to Denise’s emotional and social needs. Denise reported on
several occasions that she learned to get her needs met by friends and others and that
she could attract attention from prospective boyfriends by “acting flirtatious and getting
them to buy her things.”
Denise recalled that at age 12 she experienced the first of several sexual
molestations and abuses at the hands of her mother’s boyfriend, who lived occasionally
at their residence. She stated that her mother and boyfriend would come home
Discussion: Suicide, Stigma, And Substance Abuse
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intoxicated from a party or elsewhere and that he would sexually molest her at night. He
would then return to the mother’s bedroom and the next morning, would act like nothing
occurred. This reportedly occurred over the course of the next 2–3 years, until there
was a domestic violence incident between the mother and boyfriend that resulted in his
being arrested and the family subsequently obtaining a protection order.
Denise was able to make friends easily, and reportedly was considered popular
by most people. Her relationships were filled with interpersonal chaos, and she focused
most of her time on boyfriends to feel a sense of belonging and self-worth. Intimate
relationships began in her early teen years; these relationships often ended with an
impulsive and emotionally reactive behavior. Female friends were superficially friendly,
and the relationships were often described as a “soap opera.” She described getting
into physical altercations with other female students in her high school due to people
“disrespecting her or trying to take her boyfriend.”
Denise began to engage in self-injurious behaviors at age 13 by cutting her
upper thighs with a razor blade. The cutting began to “numb away” the emotional pain of
being sexually abused by her mother’s boyfriend. Denise stated that she attempted to
report the abuse to her older sister, but she stated that she was rejected and told to “not
make waves,” as the boyfriend financially supported the family. She soon began to
describe the cutting behavior as a “badge of honor” to repress and control her emotional
pain. In addition, Denise stated that she often took pride in being able to “show off her
pain tolerance” and made comments such as, “I wanted to feel my emotional pain
physically.”
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Over the course of several clinical sessions, it became more evident that
Denise’s primary expression of emotions was in the form of extreme volatility of rage
and anger, often followed by a sense of desperation and hopelessness. She reported
difficulties with coworkers and complained about others commenting that she was
“overconfident and cocky.” She also appeared to have minimal insight into fantasy-like
beliefs that bordered on narcissism. Denise often presented to the outpatient clinic in
emotional crisis, usually due to a problem with a personal or intimate relationship. Initial
diagnosis was adjustment disorder with depressed mood, but notably had several key
traits of borderline and histrionic personality disorder. Initially, she refused to comply
with assigned clinical homework and had difficulty establishing clear therapeutic goals.
Denise had “fired” three different therapists and two psychiatrists over a ten-month
period, often lamenting that the therapist didn’t agree or “didn’t understand my situation
well enough.”
From a clinical perspective, Denise was superficially charming and likeable. She
would initially provide praise and gratitude for helping her, but over time she became
contentious and frustrated when challenged to consider altering her own behavior or
thought processes. External attributions for every presenting problem was consistently a
source of clinical concern, but eventually would fracture the therapeutic relationship as
the therapist would attempt to engage in some limit setting or challenging perspective.
Denise seemed to enjoy being a “patient at the mental health clinic,” and she would
often disclose her mental health treatment to supervisors during times of emotional
crisis as a way of avoiding her job duties or responsibilities. Her ego-syntonic
maladaptive behaviors were the primary focus of treatment for the therapist, but Denise
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wanted to maintain focus on the perceived external slights from others and distress from
intimate relationships. After several months of unsuccessful therapy, Denise had again
engaged in another episode of self-injurious behaviors of cutting, combined with an
opiate overdose and alcohol intoxication following a volatile breakup with a boyfriend.
The overdose and self-injurious cutting behavior was discovered by her female
roommate, who took her to the ED, and Denise was subsequently admitted to a local
inpatient psychiatric hospital for three days. Denise returned to the outpatient clinic and
once again requested a change in primary therapist. A critical therapeutic breakthrough
occurred when the new therapist quickly established clinical boundaries and worked
collaboratively to focus on gaining insight to understand the long-standing pattern of
self-destructive behavior. Denise was introduced to several key empirically supported
treatments for borderline personality disorder, and she was provided consistent clinical
structure to follow dialectical behavior therapy modules. Denise begrudgingly
established the clinical goals of eliminating self-injurious behaviors, increasing insight
into her unhealthy emotional reactivity within interpersonal relationships, and improving
her overall sense of self-worth. In addition, Denise agreed to partake in a full substance
disorder evaluation and treatment at an adjoining substance abuse outpatient clinic.
The evaluation revealed an alcohol use disorder-mild and an opiate use disorder-
moderate level, which Denise initially refuted, stating that her alcohol use was “just
normal partying with friends” and that she was taking her medication “as prescribed by
her physician.” She declined to engage in substance use education or follow-up care. A
multidisciplinary team meeting with her primary care provider was held to review the
current case management, and it was determined that Denise would not continue to
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receive opiate medications. She was then referred to a pain management clinic. She
was placed on a sole-provider program to ensure she would not be able to obtain opiate
medications from any prescriber other than the pain management clinic.
A thorough treatment plan was developed, and the clinical interventions included
dialectical behavior therapy to address the negative behaviors and maladaptive
cognitions typical of borderline personality disorder; seeking safety skills to address the
emotional reactivity and distress she experienced during times of crisis; cognitive
processing therapy to address the history of sexual trauma she experienced during her
teen years; and schema therapy (a form of cognitive-behavioral therapy) to address the
negative underlying core beliefs about herself, others, and the world. In addition, a
battery of psychological testing that included the MMPI-RF, MCMI-II, PAI, and Beck
Depression Inventory was utilized to provide an objective assessment of her personality
structure. The results of the psychological testing supported the clinical evaluation and
collateral information that Denise did meet the diagnostic criteria for borderline
personality disorder with histrionic traits. Furthermore, at each session the provider
utilized ongoing clinical assessments, which included the Basis 24, PHQ-9, and the
CAMS risk assessment for suicide. Denise soon became frustrated with the ongoing
use of these measurements and began to intentionally mark the highest levels possible
as a way of disrupting the clinical process and to manipulate the content of the session
to avoid the more difficult clinical trauma work.
The primary case conceptualization is that Denise manifested a long history of
self-destructive behaviors due to family dynamics of being emotionally distant and
hypercritical, combined with recurrent sexual abuse that resulted in a very poor sense of
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self-worth. In addition, Denise modeled her mother’s emotionally reactivity and limited
insight. The resulting emotional volatility and self-injurious behaviors were positively
reinforced, as others would quickly respond with cursory support or nurturance. Denise
developed about herself and others core beliefs (schemas) of emotional deprivation,
mistrust/abuse, defectiveness/shame, and entitlement.
Denise’s family of origin was detached, rejecting, withholding of emotional
nurturance, unpredictable, and abusive. Therefore, the core belief of emotional
deprivation that Denise maintains is that a normal degree of emotional support and
belonging will not be adequately met by others. She was deprived of vital nurturance
and empathy at an early age; she therefore subconsciously expects all people will not
meet her emotional needs, and subsequently she engages in a self-fulfilling prophecy
that evokes this situation to sabotage close relationships. Denise also continues to hold
the schema of mistrust/abuse, which creates the expectation that those closest to you
will eventually hurt, abuse, manipulate, or take advantage of you. This perceived
intentional and malevolent harm by others negates any establishment of genuine trust.
This often manifests as quick and destructive emotional reactions of anger and
rejection. A primary schema related to her sense of self is defectiveness and shame, as
it related to Denise’s low self-esteem and sense of inferiority to others. She often
revealed her belief that if people became too close to her personally, they would
eventually reject her and discover her fundamental flaws. Lastly, as a compensatory
schema of entitlement, Denise developed this counter-response that she should be
entitled to special rights and is justified in acts of demanding and controlling behaviors.
Her appearance of being cocky and selfish was this manifestation to overcompensate
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for the internally perceived low self-image and flaws that can only be “made right by
getting what she deserves.”
Denise had been in treatment for approximately one year when she began to
exhibit a return to her maladaptive behaviors. She started an intimate relationship with
someone she had met during her inpatient psychiatric admission earlier that year, and
she soon began to display emotional volatility and self-injurious behavior when the
boyfriend returned to his hometown over the holidays. Her overwhelming feelings of
abandonment and mistrust resurfaced when she was unable to contact him one
evening, and she took an overdose of Tylenol and alcohol that left her in a coma for
three days. She was fortunate to have been discovered by a friend, who called
emergency services. She did not suffer any long-term medical complications, and she
was released back to the outpatient clinic to resume her individual therapy and
psychiatric psychopharmacology.
From a clinical perspective, there are existing challenges that will likely persist
due to the pervasive personality structure that has been engrained to the degree that
Denise still enjoys the interpersonal chaos and energy that she derives from the
unhealthy conflict with others close to her. A particularly difficult driving force to maintain
pathology is the primary and secondary reinforcement for Denise, including the
immediate gratification of obtaining sustained attention from peers and co-workers, the
manipulation of intimate relationships to meet her emotional needs, and establishing
self-identification as a “patient” so that she is not held to the same occupational or
professional standards due to her clinical diagnosis. It is unclear if she will resume her
misuse of opiate medication to suppress her emotional turmoil. A sign of optimism is
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that Denise continues to engage in outpatient mental health treatment, and she has
developed a sound therapeutic relationship and is making gradual, albeit slow, progress
in the areas of cognitive insight and decreased emotional reactivity. The establishment
of a comprehensive safety plan if and when Denise becomes suicidal again has been
helpful in creating a healthier support system. However, it remains uncertain if Denise
will sustain the motivation to remain in therapy to genuinely work through the various
levels of trauma and develop healthier schemas that will help guide her through future
stressors without resorting to impulsive suicidal behaviors.