Vignette - Eeyore PDF

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Running Head: CLINICAL VIGNETTE

Clinical Vignette Jennifer Keil UMKC

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Date of Report: 12.06.17 Patient: Eeyore Referred By: Tigger; family/friend

Assessment Eeyore has suppressed many traumatic childhood experiences. As a result, he has developed severe depression. At the young age of 7, he witnessed the self-inflicted death of both his parents. He went through several foster homes, two of which were abusive. By the age of 12, he had finally had enough. He ran away to live in the Hundred Acre Wood to try to reclaim the last bit of sanity he had left. He now is one of the main characters of Disney Winnie the Pooh series. Since living in Hundred Acre Woods, he is known for suffering extreme depression and social anxiety. He is often found alone in his shack made of sticks, traumatized by his thoughts and currently has no occupation. During our sessions, I noted Eeyore’s slumped posture, droopy eyes, and his remark “thanks for noticing me.” His health compared to other donkeys is slightly underweight, but slender. Eeyore’s sluggish movements are also apparent without any physical cause for movement delay. Eeyore uses little words and sentences to interact with, is very monotone, and quite depicting his stance in terms of emotional expressiveness and excitability. He also arrived in our sessions twice without his tail, telling me that it had run away because it did not like him. Eeyore consistently insist that his tail falls off rather frequently. When his tail is attached, he steps on it often and falls down. Eeyore hates to depend on his friends but when it comes down to his tail falling off, they are right there to help him put it back on. One main difficulty Eeyore has elaborated on is his detachable tail, which seems to cause him several problems.

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Eeyore said many negative things during our session, seeming resigned to the fact that his life was sad and there was nothing he could do about it. He loves sad stories because they make him feel more appreciative of his life and what he has. He also stated that although he tries to force a smile, a real smile has not existed in a long time. I asked what his goals were for therapy was and he indicated that his goals are to remain strong for his friends despite his lack of confidence within himself. He often feels lonely without support from others that he is close to. When he is around his friends, he makes comments about his relative unimportance and travels near the back of the group because he feels empty. Although sleeping habits were not explicitly expressed, Eeyore admitted to having experience a loss of energy throughout the day. I questioned what was he hoping to get out of therapy today and he stated, “I want to become the happiest, soberest donkey in Hundred Acre Wood.” He also stated he needs help with some forms of coping mechanisms, to feel useful in the presence of others, and to find pleasure in his life while sober. I questioned if he was to wake up tomorrow and no longer have his problem, what would his life be like and how would he know his problem was gone and he stated that he would be happy and gleaming with joy and would know if his problem gone by his tail staying attached and not stepping on it when it is attached. Relevant Drug Knowledge Eeyore admitted his habit of drug use. Rabbit offered Eeyore some marijuana to loosen up. Due to negative peer pressure and his depression, Eeyore decided to smoke it. Eeyore claimed felt numb, relaxed, blurred vision, increased appetite, and some dizziness. As soon as he crashes, he’s more depressed. When he’s depressed and stressed, he buys more from his friend Rabbit, hence becoming addicted to marijuana. Marijuana (aka drug of choice); a mixture of derived from the buds, crushed leaves, and flowering tops of hemp plants. Marijuana is a

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schedule I drug and is considered as “no currently accepted medical use and high potential for abuse.” The effects of marijuana include hallucinogenic, depressant, and stimulant effects. Eeyore’s slow reactions and lack of motivation could be the cause of his marijuana usage. Eeyore smokes marijuana at least five times a day and his high lasts two to six hours after each smoking session, making him a chronic user. Eeyore stated, “End of the road. Nothing to do but get high since there’s no hope of things getting better.” This illustrates the lack of hope experienced by Eeyore using drugs because it restricts his ability to take positive actions toward his goals. Eeyore has reported feeling a lack of interest in activities due to his substance abuse use and feels empty even accompanied by friends. He admits a decreased sense of pleasure in activities started not to long after he first started using marijuana. Withdrawal concerns for Eeyore would be sweating, fever, chills, hallucinations, anxiety, mood changes, nausea, and insomnia to name a few. The patient placement I would place Eeyore in is dimension 3, level 1. Diagnosis 300.4 (F34.1) Persistent Depressive Disorder (Dysthymia) with melancholic features, late onset, severe. 304.30 (F12.20) Cannabis-Related Disorder, Moderate Eeyore shows consistent signs of depression. He has a low self-esteem and isolates himself from his friends, taking little participation in the activities they do. He seems to move slower and his talking is often drawn out, as if he doesn’t have too much energy and his thinking is slightly slower, perhaps from lost sleep due to his depression or from his substance abuse of marijuana. Eeyore claims to be always upset, expects bad things to happen and doesn’t try to be cheerful. He never has a positive outlook no matter the situation. He looks at the negative side of

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things and he accepts his state the way he is. Eeyore recalled a time when it was his birthday and he was getting two presents. He began that day with looking at himself in the river and mentioning how pathetic he was, since his friends always mention how gloomy he always is. Eeyore exhibits five symptoms of a major depressive episode, he also has experienced these for several years, therefore meeting full criteria. Criteria met include depressed mood most of the day, markedly diminished interest or pleasure in activities, fatigue or loss of energy nearly every day, feelings of worthlessness, and diminished ability to think or concentrate were indicated. Overall, Eeyore exhibits severe clinical major depression without psychotic features. Postpartum onset is not a factor. Though I have not heard any thoughts of suicide, his behavior should be watched very closely, in case his depression escalates to a point where his life may be in danger. Persistent Depressive Disorder (Dysthymia) is labeled as a depressive mood disorder. Among other mood disorders are bipolar disorders and manic episodes. Eeyore also shows some symptoms of catatonic schizophrenia and dissociative identity disorder. He has none of these for these reasons: Bipolar I Disorder: people having bipolar disorder have periods of happiness and depression. With Eeyore, he is depressed for most of the time. Dissociative Disorder: when a disturbance occurs when the subject is younger that makes them want to hide or be afraid of their true identity. When this happens, their brain switched and creates multiple personalities to hide the one they are so self-conscious about. Eeyore is always gloomy and doesn’t experience this feeling.

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Catatonic Schizophrenia: patients go from a coma like daze and then talk in a bizarre hyperactive. Where Eeyore is sometimes in a coma like daze, he is not usually in hyperactive mood. Manic Episodes: periods of time in which people feel extremely happy. Eeyore does not have periods of happiness, he is constantly gloomy. Eeyore’s exhibits four symptoms of cannabis-related disorder. Criteria met include cannabis use over a longer period than was intended, craving or a strong desire or urge to use cannabis, continued cannabis use despite having persistent or recurrent social interpersonal problems caused by the effects of cannabis, and cannabis use is continued despite knowledge of having a persistent psychological problem that is likely to have been caused by cannabis. Chronic intake of cannabis can produce a lack of motivation that resembles persistent depressive disorder. Acute adverse reactions to cannabis should be differentiated from the symptoms of panic disorder, major depressive disorder, delusional disorder, bipolar disorder, or paranoid type. A physical examination will show an increased pulse and conjunctional injection. Urine toxicological testing can be helpful in making my diagnosis. Eeyore experiences a consistent object loss, his detachable tail. Eeyore stated, “a tail isn’t a tail to them, it’s just a little bit extra at the back.” This illustrates the importance of a tail to Eeyore. The loss of his tail can cause him to experience worthlessness, incomplete, less of an individual, and undergo low self-esteem. This ongoing problem will eventually lead to a crisis where Eeyore cannot handle the anxiety and stress this object loss creates. Biopsychosocial Conceptualization Behavioral: When Eeyore was 12 years old, he was in his last abusive family. Within that family, he was rarely aloud to talk. They took him strictly for the monthly income they would

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receive from fostering him. They had him locked in a room, with no way out. They neglected him, fed him only when he was at his worse health conditions. If Eeyore spoke, cried, or even made the slightest noise, his foster parents would do unimaginable things to him, which is the reasoning his tail only has a nail to hold it up. This explains somewhat of why Eeyore talks slow, quietly, and if at all today. Sociocultural: Growing up, Eeyore was a constant target for bullies at school. Tormented for his looks caused him to develop social anxiety. Eeyore doesn’t like to leave his shack often. When he does, he prefers small social settings with close friends as opposed to large gatherings. When Eeyore is around too many people the he doesn’t know, he is known to have panic attacks. Eeyore said many of his friends have stated “It’s his fault. He never has been to see any of them. That he just stays in one corner of the Forest waiting for others to come to him.” This phrase shows Eeyore’s friends have observed his isolation for long periods of time due to his depression and drug use. When he socializes, he feels ashamed, which is seen in both his appearance and actions. Biological: Eeyore’s parents are a big reason to his depression. Both his parents suffered from depression, assuming that depression runs in the family. Even if Eeyore’s life wasn’t as traumatic, he probably would have developed depression because of his genetics. Heritable factors contribute between 30% and 80% of the total variance in risk of cannabis use disorders. Humanistic: Eeyore got into drugs soon after he started living on his own. He would spend days on end abusing illicit substances and would never leave his shack. He stated “not much of a house. Just right for not much of a donkey.” His friends noticed his behavior and would try to help Eeyore, but he refused the help.

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Cognitive: When Eeyore was in abusive homes, he knew he was in trouble when heard his foster parents yelling his name. To this day, whenever his friends call his name. he gets flashbacks of when he would get beat. He gets very anxious whenever he hears his name. He copes with his anxiety by reminding himself that he is no longer under their abusive power. Eeyore doubts and struggles with low-confidence by believing he cannot handle the challenges in his life. Therapeutic Approach/Topics to Explore in Therapy I believe Eeyore is in the Contemplation stage of change. He has made a commitment to make a change and knows he’s got to do something about his way of living. He has taken steps to enter counseling and wants to know what needs to be done to change his behavior. This will impact my therapeutic approach by accepting that the change process is cyclical, and Eeyore may move back and forth between the stages and cycle through the stages at different rates. Eeyore may move quickly through stages, maybe even so rapidly that it could be difficult to pinpoint where he is because his change is a dynamic process and he may linger in the early stages. Eeyore’s defense of the status quo diminishes he’s the likelihood of change, confrontation can cause him to defend the problem behavior, therefore I need to help him become the change agent. My first priority would be to use a decisional balance technique by having Eeyore assign the pros and cons of how his behavior influences decisions about his behavior changes. By getting Eeyore to a place where he can begin to take a good look at his behaviors, can be huge and an uncomfortable journey. In motivational interviewing, I would not assume an authoritarian role and would seek to create a positive atmosphere that is conducive to change. I would match intervention to his stage of change.

CLINICAL VIGNETTE Therapist: What is it about marijuana that makes you feel good?” Eeyore: “Numbs the pain and lets me escape reality.” Therapist: “How do you handle situations that cause you a lot of stress, for example, losing your tail?” Eeyore: “I ask my friends to find it and put it back on.” Therapist: “Tell me more about that?” Eeyore: “I hate to rely on my friends for everything, but it seems easier for me when they do things for me.” Learning cognitive restructuring would help Eeyore view situations from more of a realistic perspective. One method of confronting this cognitive distortion could be to acknowledge a double standard. Eeyore isn’t necessarily as harsh on others as he is on himself. Recognizing this double standard might help him treat himself with more compassion. He could also survey other perspectives. Therapist: “It seems to me that are the type of donkey that likes to keep to himself?” Eeyore: “Yep, that’s me.” Therapist: “I’m wondering if at times, you have difficulty feeling accepted by your friends?” Eeyore: “Yeah. I never feel like I fit in with them…I tend to stay by myself. When I think about it too much, I just start to feel really sad.” Therapist: “When you were a young donkey, did you have lots of friends to play with? Any siblings? Eeyore: “Nope…Before my friends in the Hundred-Acre Wood…well there wasn’t really anyone…” Therapist: “I think this is the root of your problem along with your marijuana use.”

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Along with individual and group treatments, I would initiate for family/friend treatments because substance abuse disorder has strong ties to a patient’s social environment. Since depression is the leading cause to suicide, it can be terminal if untreated. I think his depression will not go away by itself and it will get worse over time. Depression is a very serious illness which demands treatment and requires more than just a drug. The root of the problem must actually be solved, not just covered up by antidepressants. Treatment Planning/Recommendations for the Client/Relapse Prevention Strategies Two short-term goals to work that we decided together would be to provide temporary housing for when his house gets demolished and unemployment assistance since he is unemployed. Two long-term goals would be individual and group counseling and support groups. The three recommendations I would have for Eeyore is to remind him that recovery is his first priority, encourage him to maintain balance and perspective with respect to the type and intensity of activities that are undertaken, and assist him in understanding that there will be time to address past mistakes once recovery is solidly underway. Some aspects of relapse prevention I would discuss with Eeyore is to educate him and his family/friends about addiction and recovery, conduct an early assessment of specific relapse triggers, develop a relapse prevention plan immediately, provide intensive monitoring and support, evaluate and review all slips and lapses, use the behavioral contract with clients, and introduce the stages of change. The reason behind Eeyore facing challenges when applying goals physically to his problems and life is due to his current mental health and relevant marijuana use. Eeyore would benefit greatly from an antidepressant, combined with individual therapy. Various treatments could include, interpersonal therapy to help Eeyore focus on relationships with other people and how it affects him, or problem-solving therapy would focus on his specific

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problems he may face and help him find solutions. I would recommend 18 sessions of psychotherapy and cognitive behavioral therapy, in addition to medication. Antidepressants can also increase the chances of suicide tendencies and can also have withdrawal problems after the treatment is ended, if only treated with drugs. I would suggest Citalopram, Paroxetine, or Fluoxetine because they act on the chemical imbalance in the brain and are useful treatments for depression. Fluoxetine might even help Eeyore see the humor in him losing his tail many times. Regarding cognitive behavioral therapy, it is important that Eeyore first understands the relationship between events, emotions, and cognitions. As mentioned, he must first realize that if his tail falls off that he is not less of an individual. He must also realize that the need to be of worth can be self-induced and that he does not need to rely on others to find this feeling. CBT will aim to mitigate the strongly reinforcing effects of substances of abuse by either increasing the contingency associated with non-use or by building his skills to facilitate reduction of use and maintenance of abstinent and facilitating opportunities for rewarding non-drug activities. Eeyore was curious if he should attend a support group. I responded by informing Eeyore that support groups not only provide emotional support, but they share concrete information and recovery tips. Eeyore would benefit from the guidance of other experienced substance use abusers. Besides the sharing of experiences, Eeyore can identify with others who are recovering and can begin to feel hope for his own situation. Treatment would then be followed by instructing Eeyore on identifying, evaluating, and modifying automatic negative though patterns that exist. Understanding this thought pattern can also improve Eeyore’s depression, as he will begin to have a more optimistic view on problems, thus emotions such as sadness and hopelessness can be decreased. He does acknowledge his feelings of worthlessness, so by having the tools to evaluate his negative thoughts as something

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he can control, should enable him to eventually take control over his thoughts. Psychotherapy can help him to externalize and receive more support upon problems and issues he faces as this is an important factor behind his illness; depression and substance abuse. Stress management, social skills, activities training, and relapse prevention will then follow to give Eeyore a path to improve his well-being by being able to optimally connect with others and join in on activities that spark his interests while sober....