Composite Case Example Research Articles

Tetradic Model of the Human Psyche Incorporating Active versus Passive Mindfulness with Psychotherapeutic Applications

Three diverse composite case examples are presented which demonstrate how the proposed tetradic model can be applied in psychotherapeutic practice and can also be tested in future empirical research.

Compassionate Care for People with Cancer and Opioid Use Disorder.

Opioid use disorder (OUD) is an important comorbidity to assess and manage in people with cancer. In this article, the authors discuss strategies for safe opioid management in individuals with OUD and cancer-related pain using a composite case example. They highlight core approaches to pain management, including motivational interviewing, harm reduction, and evidence-based treatments, as well as advocacy for person-centered end-of-life care.

Clinical social work practice in organizational settings: a psychodynamic systems approach

ABSTRACT Clinical social work practice in organisational settings is complex and challenging. Effective practice is contingent on knowledge and skills that are particular for systems-based work involving multiple interprofessional mental health practitioners and clients interacting in a relational matrix. Yet, not all social work theories and constructs that were developed for application in individual, group, and family modalities are directly transferable to the practice environment of a treatment system. This paper offers a conceptual framework that synthesises contemporary psychodynamic theory with systems theory – referred to as a psychodynamic systems approach – to inform and advance knowledge of systems-based social work practice. This approach considers the interplay of dynamic processes among the four levels of the socially co-constructed system which constitute the system as a whole. It examines how five key clinical phenomena – transference, countertransference, splitting, projective identification and enactment – are actualised in systems. Definitions of these phenomena formulated from a dyadic perspective and a contemporary psychodynamic systems approach are offered, and their similarities and differences are discussed. A composite case example is provided to illustrate how several of these phenomena manifest in clinical practice.

Perinatal outcomes of synthetic cathinone (“bath salts”) use in pregnancy: a case series

ABSTRACT Background Little is known about the effects of exposure to synthetic cathinone drugs in pregnancy. Methods We report five cases of pregnant women with opioid use disorder who tested positive for α-Pyrrolidinohexiophenone (alpha-PHP), a synthetic cathinone. We describe key characteristics of the course of disease and its treatment, as well as perinatal and treatment outcomes. We present a composite case example demonstrating relevant clinical issues. Results All cases of women with synthetic cathinone use were notable for decreased engagement in care and clinical signs associated with active substance use (difficulty maintaining personal hygiene, disorganized behavior suggestive of psychostimulant intoxication) despite reporting abstinence and testing negative for psychostimulants on standard urine toxicology testing. Four of the five women delivered prior to 38 weeks’ gestation and infants of three of the mothers were placed in foster care at birth. Conclusion It is not known to what degree synthetic cathinone use may have contributed to these adverse perinatal outcomes in these cases. Research on the effects and treatment of synthetic cathinones during pregnancy is needed to guide identification and treatment for women using these substances and to improve outcomes for mothers and infants.

No Soy De Aquí, Ni Soy De Allá: Second-Generation Latinx Youth Belonging Everywhere and Nowhere

ABSTRACT Belonging is a human need, one that is particularly difficult for children of immigrants to achieve. The Second-generation youth hangs in a balance between the culture of their parents and that of their friends and peers. Often these youth feel that they are not heard or seen by those around them, enhancing the feeling of not belonging in their communities, or even in their country. Therapeutic interventions could potentially create a “third space” in which they feel a sense of belonging. This paper explores the complexity in the experience of belonging in second-generation Latinx youth through a review of the literature, psychodynamic theories, a composite clinical case example and the reflections and implications to and from Second-generation Latina therapist.

The Impact of the COVID-19 Pandemic on the Suicidal and Self-Harming Behavior of Young People

The unprecedented use of lockdown and quarantine to combat the spread of coronavirus disease 2019 (COVID-19) severely disrupted young people's social worlds. Both short- and long-term negative consequences were widely predicted for adolescent mental health, which was, however, reported to be deteriorating before the COVID-19 pandemic. By taking a microperspective, exploring in depth the experiences of therapeutic work with young people with suicidal thoughts or behavior, including two composite case examples, this article provides a nuanced understanding of the pandemic's effects. The discussion links the accounts of these cases, firstly, with evidence to date about the patterns that are emerging regarding the effects of the pandemic and, secondly, with theories of the relationship between suicidal thoughts and behavior and the impasse/breakdown in the adolescent developmental processes. In conclusion, it is suggested that the capacity to negotiate loss and change are crucial for sustaining development despite the COVID-19 pandemic and often in the face of overwhelming anxieties. [ Psychiatr Ann . 2022;52(8):318–322.]

A Sequenced, Relationship-Based Approach to the Treatment of Complex Posttraumatic Stress Disorder (CPTSD): The Hybrid Case Study of "Chloe"

Chronic and repeated exposure to relational and developmental trauma can result in a presentation that differs from posttraumatic stress disorder (PTSD), with a unique cluster of complicated symptoms, and has thus been labeled as complex PTSD (CPTSD). Many such individuals meet criteria for PTSD while also exhibiting additional symptomology not accounted for in a traditional PTSD diagnosis. This case study provides an overview of the differences between PTSD and CPTSD, using empirical evidence to illustrate the necessity of distinguishing between these two differing diagnoses and subsequently the need for differing treatment approaches. The purpose of this case study is to examine the benefits of using a three-phase, integrative model for an individual with CPTSD. Specifically, it explores the delivery of Courtois and Ford’s (2013) sequenced, relationship-based approach to the treatment of complex trauma. This model was chosen due to the emphasis on attachment and because it allows for clinicians to tailor interventions to the unique individual while also providing an overarching structure to treatment. This treatment analysis is demonstrated via the hybrid case of "Chloe,” who serves as a meaningful representation of a psychotherapy patient with a history of chronic relational and developmental trauma who presents to treatment with symptoms concurrent with a CPTSD diagnosis. Chloe’s composite case example is based on the author’s actual, de-identified psychotherapy cases in addition to clinical examples in the relevant literature. Using the format of a pragmatic case study (Fishman, 1999, 2013), Chloe’s case is analyzed through qualitative processes and quantitative measures. An in-depth illustration of this hybrid patient’s course of treatment provides an avenue for describing key clinical issues related to the treatment of CPTSD and the utility of an integrative treatment approach. Chloe’s case study is intended to be a resource for clinicians seeking more knowledge and understanding of the impact of chronic developmental and relational trauma and the implications this has for effective treatment.

Trauma-Informed Restorative Justice Practices in Schools: An Opportunity for School Social Workers

Abstract Restorative justice (RJ) is both a philosophy and a set of practices meant to repair harm and maintain connection in the face of wrongdoing. While RJ is becoming increasingly popular among K–12 educators and in schools, emphasis is typically on its social justice applications, including its use as an alternative to zero-tolerance discipline policies and its role in dismantling the school-to-prison pipeline. However, RJ can also be understood as a trauma-informed mental health intervention allowing perpetrators, who have frequently been victims of past trauma, to regain a sense of voice and control, and to maintain social connection within their community. Social workers in school settings are in a prime position to explore and advocate for its increased use with vulnerable youth populations. Through review of relevant literature and use of a composite case example, this article outlines the harmful impacts of punitive and exclusionary discipline; describes the potential benefit of schools utilizing RJ as a mental health intervention; and recommends further research to understand RJ's effect on self-efficacy, self-regulation, and healthy attachment.

The Challenges of Using Available Practice Classification Systems in Researching Social Work

ABSTRACT Coding social work practice in research studies can present a number of challenges for researchers aiming to break down elements of practice into variables. Using as an example, a completed study that investigated social work interventions in cancer care, the paper explores coding challenges that arose for social work researchers using a national classification system for social work in health. The benefits and limitations of using these codes, and the research design strategies that were used to overcome some of these limitations are discussed. A composite case example from the study is used to illustrate the challenges of capturing case complexity. A concluding critical appraisal of social work practice in health suggests that interpretive, contextual practice can sit alongside bio-psychosocial frameworks. The translation of professional practice for classification systems requires ongoing input that includes cultural and ontological stances to ensure meaningful representation of the social circumstances of patients and social work practice. This paper contains an anonymised, composite case example derived from data collected in a research project. Aboriginal and Torres Strait Islander people should be aware that the case involves a young Aboriginal woman who died in hospital as a result of her cancer. IMPLICATIONS Social work is a profession that is understood through context, values, world views, and critical reflection. Challenges arise for social work researchers when practice is classified in context-free information systems. Opportunities to mould classification systems enable more meaningful conceptualisations of practice that support understandings of the complexities of the work.

Significant Moments in Improvisational Music Therapy

Four composite case examples are presented and discussed as they relate to emotional expression, significant moments in the therapeutic process, and communication using a variety of modalities in music therapy with adults diagnosed with intellectual and developmental disabilities. Building on therapeutic awareness through discussing musical elements, body movement and posture, countertransference, and interactional patterns, the implications of deep emotional connection and processing are approached using primarily nonverbal methods. Composite vignettes from the author’s clinical work demonstrate awareness of these factors in the moment as they impacted the session, therapeutic relationship, and other professionals’ understanding of music therapy in this population. Implications for emotional processing in clinical practice are presented as they relate to the concepts presented in this paper.

Exploring Modifications to Individual Trauma-Focused PTSD Treatments in a Routine Care Setting: An Examination of Medical Records at a Veterans Health Administration PTSD Clinic

Clinicians in naturalistic settings regularly modify the delivery of trauma-focused treatments to enhance client engagement and retention. However, what types of modifications are made in clinical settings, why, and when, and their impact on client outcomes has seldom been examined. As an initial step to address this, the current study applied elements of the updated Framework for Reporting Adaptations and Modifications—Expanded (FRAME; Wilstey Stirman et al., 2019) to examine content-level modifications documented in the delivery of posttraumatic stress disorder (PTSD) treatment to veterans via medical records review in an urban PTSD clinic. Results indicated that the updated FRAME suited the data well, and that modifications occurred in most veteran–clinician pairs over the course of treatment. The four most common modifications documented were spreading (27%), repeating (24%), drift with return (22%), and integrating (21%). Three composite case examples are discussed that describe the application of the most common modifications observed in medical record documentation. This is an important first step toward understanding the real-world modifications of evidence-based trauma-focused interventions that in turn will lead to critical recommendations for improving treatment implementation.

Elements of Suffering in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: The Experience of Loss, Grief, Stigma, and Trauma in the Severely and Very Severely Affected.

People who are severely and very severely affected by Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) experience profound suffering. This suffering comes from the myriad of losses these patients experience, the grief that comes from these losses, the ongoing stigma that is often experienced as a person with a poorly understood, controversial chronic illness, and the trauma that can result from how other people and the health care community respond to this illness. This review article examines the suffering of patients with ME/CFS through the lens of the Fennell Four-Phase Model of chronic illness. Using a systems approach, this phase framework illustrates the effects of suffering on the patient and can be utilized to help the clinician, patient, family, and caregivers understand and respond to the patient’s experiences. We highlight the constructs of severity, uncertainty, ambiguity, and chronicity and their role in the suffering endured by patients with ME/CFS. A composite case example is used to illustrate the lives of severely and very severely affected patients. Recommendations for health care providers treating patients with ME/CFS are given and underscore the importance of providers understanding the intense suffering that the severely and very severely affected patients experience.

Digital Technologies and Coercion in Psychiatry.

Psychiatry has a contentious history of coercion in the care of patients with mental illness, and legal frameworks often govern use of coercive interventions, such as involuntary hospitalization, physical restraints, and medication over objection. Research also suggests that informal coercion, including subtle inducements, leverage, or threats, is prevalent and influential in psychiatric settings. Digital technologies bring promise for expanding access to psychiatric care and improving delivery of these services; however, use and misuse of digital technologies, such as electronic medical record flags, surveillance cameras, videoconferencing, and risk assessment tools, could lead to unexpected coercion of patients with mental illness. Using several composite case examples, the author proposes that the integration of digital technologies into psychiatric care can influence patients' experiences of coercion and provides recommendations for studying and addressing these effects.

A Cognitive-Behavioral Family-Based Protocol for the Primary Presentations of Avoidant/Restrictive Food Intake Disorder (ARFID): Case Examples and Clinical Research Findings

Avoidant/restrictive food intake disorder (ARFID) is a feeding and eating disorder with evidence for distinct but overlapping presentations characterized by avoidance of eating or narrow dietary range related to poor appetite, selective eating, or fear of aversive consequences of eating. The current paper describes a flexible, cognitive-behavioral, family-oriented treatment approach that has been applied to each of these ARFID presentations within a larger partial hospitalization program (PHP) for eating disorders. We provide composite case examples for the presentations and retrospective outcome data on a sample of 81 patients treated with the protocol. Overall, patients with ARFID exhibited significant increases in body weight and the number of foods accepted, and significant decreases on measures assessing food fears, oral control behavior, anxiety, and depression. At baseline, patients with co-occurring poor appetite and selective eating exhibited significantly lower body weight than those with fear of aversive consequences, while the latter group of patients were eating significantly fewer foods and feared a larger number of foods according to parent report. Patients with the fear of aversive consequences presentation also experienced greater increases in the number of foods they were willing to eat and greater decreases in the number of foods they feared over the course of treatment relative to the other two groups. Our findings provide preliminary support for the effectiveness of our family-centered, cognitive-behavioral PHP for children and adolescents with ARFID. Future studies with more sophisticated methods, including randomized controlled designs and ARFID-specific measures, are recommended to help establish evidence-based psychosocial interventions for this clinical population.

Polyamory - a romantic solution to wanderlust?

ABSTRACTThis paper will explore what is meant by polyamory, why it is presenting more frequently in recent years in the media, on online forums and in therapy rooms, and what might be considered the benefits and drawbacks of this way of relating. Challenges for the therapist working with polyamorous clients will be explored and a composite clinical case example will be given as will an example from a recent television documentary on polyamory. Both cases will be discussed using the lens of a psychoanalytic couple psychotherapist and psychosexual therapist

Trauma Informed Practice and Care: Implications for Field Instruction

This article summarizes the evolution in thinking about trauma and its impact on those who have experienced it. The nature of trauma-informed (TI) practice and care and implications for field instruction are then explained. This discussion is based upon the assumption that skills of social work field instruction that already have an evidence base lay the foundation for TI field instruction. Composite case examples drawn from the author’s experiences as a field liaison, a practitioner who works with trauma survivors, and an instructor in the generalist practice curriculum illustrate methods and skills of field instruction from a trauma informed perspective.

Medical Transition without Social Transition

Abstract People who want gender-affirming surgery without a change in social role represent a range of unique perspectives and use a range of self-descriptive terms, including transgender, transsexual, genderqueer, gender nonconforming, TGNC, nonbinary, and cross-dresser. They may seek surgery to reduce gender dysphoria or to enhance gender euphoria. Professional literature and medical protocols such as the World Professional Association for Transgender Health's (WPATH) Standards of Care, version 7 (SOC-7), have been developed to reflect the needs of people who want to change their social role as well as their body. Medical protocols including SOC-7 recommend a period of “real-life experience” as a criterion for some surgeries, which is not appropriate for people who want medical without social transition, who may want a private expression of gender, and who are at high risk for self-treatment and self-injury. This article describes the many factors that may affect transition and surgical choices. A composite case example is presented to illustrate how surgery without social transition might enhance the life of a female-identified person who lives socially as a man. Medical and mental health providers do provide treatment for people who want medical transition without social transition, but the practice has yet to be well documented.

Intimate Strangers? Working with Interfaith Couples and Families

Although intercultural couples are increasingly the norm there is a paucity of systemic literature on working with interfaith couples and families. This paper, based on composite case examples, attempts to address this gap. I use two examples of couples where one partner is South Asian Muslim, to illustrate four inter‐related themes that emerged in the process of the work. The themes were: therapists’ positioning, the importance of the wider socio‐political context, honour, shame and gendered beliefs, and the family life cycle. I also highlight how embodied and non‐verbal representational systemic techniques can be used when working with interfaith couples to access domains of relationality, which may be inaccessible to exclusively verbal strategies.

A Critical and Maternal Narrative Approach to Practice, Enhancing Recognition and Solidarity with Ambivalent Representations

This is a conceptual paper that uses a critical practice approach to how a social worker’s interpretive lens may transform after they become a parent. With a composite case example, I reflect on my own biographical maternal narrative, which aims to enhance the recognition and solidarity with ambivalent representations in the journey of motherhood. I conceptualise maternal narratives with Fook’s critical approaches to practice framework (2016). I interweave a composite case example that I had direct experience and privilege of working with, along with my own biographical experience of mothering. The central themes that have emerged from my critical reflective analysis are; ambivalence, imperfection and guilt. This open ended inquiry outlines a new way of knowing. The primary data are biographical. For the purpose of this critical reflective article I am a mother, and hence I refer to my gendered experience. The article attempts to explore how my social work practice is afforded a new interpretative lens and reconstruction after my own transition into motherhood.

Treating Depression Among Adolescent Perinatal Women With a Dialectical Behavior Therapy–Informed Skills Group

Depression is a prevalent and impairing problem affecting both women and offspring during the perinatal (pregnancy and the postpartum) period. Despite this, few studies have examined treatments for perinatal adolescents with depressive symptoms. The present study examined the feasibility and preliminary outcomes of a dialectical behavioral therapy (DBT) informed skills group among depressed adolescent perinatal women (N=25) recruited from both a public health parent education program and an adolescent obstetric clinic. A brief composite case example is included to illustrate how DBT skills were taught, practiced, and applied. Findings suggest the intervention was credible, acceptable, and associated with improvement in depression. Challenges with feasibility of enrolling and retaining adolescent perinatal women were evident, as approximately half of the enrolled participants did not complete the study. This study provides preliminary evidence that a DBT-informed skills group may be a promising intervention for depressed adolescent perinatal women and points to important directions for clinical practice and research, including treatment engagement and retention.