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Clinical Teams Mental Health Protocols Manual

Paris Coleman, MacKenzie Mick & Sophie Young

Department of Counseling, Wake Forest University

CNS 770: Classification of Mental and Emotional Disorders

Dr. Farren Stackhouse

28 November 2021
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Clinical Teams Mental Health Protocols Manual

DO A CLIENT MAP

Our client, who we will refer to as Ryan, is conceptualized in the DO A CLIENT MAP

format. This conceptualization will allow us to remain organized and ensure that we are offering

the best care possible.

Diagnosis

● Major Depressive Disorder, Recurrent Episode, Moderate 296.32 (F.33.1)

● Autism Spectrum Disorder 299.00 (F84.0)

● Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Presentation 314.00

(F90.0)

Objectives of Treatment

● Build positive rapport with the client (Reichenberg & Seligman, 2016). Ryan has

expressed problems with their relationships and family of origin in the past - ensuring

there is good rapport will be critical for treatment.

● Reducing the dysfunction from symptoms associated with Major Depressive Disorder

(MDD). The client’s presenting problem is recurrent experiences of MDD, though

several other factors should be considered in their treatment.

○ When appropriate, explore cultural and familial factors, including the family of

origin, potential trauma history, and protective factors.

● Work to improve functioning in social, academic, and work aspects of life.

Assessments
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● The Beck Depression Inventory (BDI). This assessment will inform the counselor about

Ryan’s extent of symptoms and may shine a light on potential coping skills to focus on

(Reichenberg & Seligman, 2016).

● A comprehensive assessment of family history should occur as well (Reichenberg &

Seligman, 2016). Depressive and Bipolar Disorders have a suspected degree of

heritability, so history should be taken into account when designing a treatment plan and

discussing medication with our client.

Clinician Characteristics

● Reichenberg and Seligman (2016) encourage clinicians working with depressive

disorders to be nonjudgmental, supportive, structured, and present-focused.

● The clinician should balance gently challenging distorted cognitions while instilling hope

in the client.

Location of Treatment

● Therapy will be conducted in an outpatient setting (i.e. Guilford College’s Counseling

Center). Due to Guilford’s current COVID-19 safety precautions, counseling services

will be provided via telehealth using the HIPAA compliant platform, Doxy.

Interventions to be Used

● Focus on primary adaptive vulnerable emotions (e.g. fear, grief, anger) regarding Ryan’s

unmet attachment/identity needs. This approach has been found to facilitate productive

emotional processing among disengaged, depressed, and suicidal adolescents

experiencing familial conflict (Tsvieli et al., 2020). The goal with this attachment-based

intervention is to help Ryan make sense of their experience and provide interpersonal
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guidance for how they can express themselves and have their needs met by others in a

healthy, productive manner.

● A 2018 study by Hillier et al. measured the effectiveness of supportive interventions for

university students with Autism Spectrum Disorder. It was found that providing

interventions like academic skills education (e.g. study tips, communicating with

professors, accessing university resources), enhancing interpersonal communication and

relationships (e.g. locating opportunities for meeting other students and setting relevant,

observable goals), and working on time/stress management are linked to enhancing self-

esteem, reducing loneliness, and reducing anxiety among autistic college students.

● Task client with exploring the online resource for self-injury at sioutreach.org (Hasking

et al., 2021).

● Due to the presence of consistent suicidal ideation, hospitalization may be necessary to

ensure the client’s safety.

Emphasis in Treatment

● Treatment will be collaborative, supportive, and fit to match the pacing and stage of

change exhibited by the client. Given that Ryan is hesitant to divulge but is committed to

attending, the clinician will incorporate supportive techniques such as appropriate silence,

open questions, and here-and-now questioning, while primarily working to strengthen the

therapeutic relationship.

Numbers

● It is recommended that Ryan consistently attend individual therapy through Doxy.

● At the beginning of the Spring semester of 2022, Ryan will be encouraged to participate

in an art therapy group for first-year students hosted by the Counseling Center. This
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group will allow Ryan to meet other first-year students, engage with them in a safe,

therapeutic environment, and process their first-year experience in a group setting.

Timing

● Given the nature of Ryan’s disorders and their high prevalence of suicidal thoughts, Ryan

will attend weekly 30 to 50-minute sessions for the entirety of their first year at Guilford

College. Ryan will meet with the clinician once more during the fall semester because

services will be paused during winter break. During the four-week break, Ryan will be

given the option to connect with a clinician from an outside agency for support. Services

will resume in mid-January and will continue for 15 weeks until May of 2022.

Medications Needed

● Dexmethylphenidate/Focalin for ADHD

● Bupropion/Wellbutrin for MDD and ADHD

● Fluoxetine/Prozac for Depression

● Amitriptyline for Depression

The client needs to be referred to another psychiatrist or physician to update their

medication needs of the treatment plan. The client reports insignificant change following the

self-administering of medication over the last 4 years. The medication cocktail should either be

adjusted or substituted altogether.

Following the client accepting possible new suggestions for medication management,

these drugs must be taken consistently for at least 4 to 8 weeks before the client will experience

maximum benefit. The client should be attending recurring appointments to closely monitor the

development of side effects during this time and to determine the effectiveness of treatment

(Sanchack, 2016). The client should check in biweekly during the initial stages of medication
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reevaluation. Once an effective medication cocktail is developed for the client, they should

check-in at the end of the 6 and 12-month period to prevent a relapse of depression.

Adjunct Services

● The client needs to be referred to another psychiatrist or physician to update their

medication needs of the treatment plan because they report insignificant change

following the self-administering of medication over the last 4 years.

● The client also needs a referral to a nurse practitioner (NP) on campus for consistent

medication management (Greydanus et al., 2021).

● The client could benefit from engagement with a mindfulness group to encourage the

enhancement of coping mechanisms, social support structures, and inner wellness.

● The client could benefit from engagement with a first-year process group to enhance

social skills and create connections for expression.

● The client could also benefit from a processing group that focuses on difficulty with

families. This could provide corrective experiences, support, and other tools and

suggestions for engaging with unhealthy family behavior (Elder et al., 2017).

Prognosis

● The prognosis for Major Depressive Disorder is good. With proper medication

management, talk therapy, increased support in academic settings (Lee et al., 2019), and

social connections the client is more likely to reduce the impact of depressive symptoms.

An increase in mental health literacy for the client and their family could also create a

healthy, supportive environment for growth (Godfrey Born et al., 2019).

● The prognosis for Autism Spectrum Disorder is good. Research on change in autism

symptoms is still emerging on the reduction of symptoms outside of talk therapy and
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medication management. Based on the Autism Diagnostic Observation Schedule (ADOS)

the client should be able to work toward an improved outcome, functioning, and well-

being (Bieleninik et al., 2017).

● The prognosis for Attention Deficit Hyperactivity Disorder is good. Medication

management (Gökten et al., 2018) and behavior modification using Cognitive Behavioral

Therapy (Lopez et al., 2018) present opportunities for symptom management. Addressing

attachment style could also be a useful tool to reduce the comorbidity of the disorders

(Darling Rasmussen et al., 2019).

Cultural Considerations

Our client, Ryan, has many intersecting cultural factors to be aware of in our counseling

sessions. First, they have a complex familial history. Their family of origin includes a biological

mother and her same-sex partner, who adopted Ryan when they were a child. The client’s

adoptive mother has exhibited mental health concerns since the client was in middle school; our

client often finds themselves caring for the adoptive mother. The client has reported very little

about other family members. As we work with Ryan we must understand the social and cultural

factors that may influence the experience of a child raised by parents in the LGBTQ+

community. Same-sex parents report feeling more stress around parenting and experience higher

rates of depression and anxiety than heterosexual parents do (Boz et al., 2016). Additionally,

emerging research suggests that depressive symptoms in adoptive parents may influence

internalizing behaviors in children (Hails et al., 2019). Further, while the biological factor may

not be at play, adoptive parents’ depression may put adopted children at a higher risk for

developing MDD and ADHD (Hails et al., 2019). Exploring family history, and what it meant to

grow up in their family, may be a critical point of broaching for Ryan.

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Second, Ryan has been to counseling before becoming our client. They arrived at our

sessions already diagnosed with autism spectrum disorder (ASD), major depressive disorder

(MDD), and attention-deficit/hyperactivity disorder (ADHD). However, the client reports that

they identify with the diagnosis of “Aspergers,” and “ADD.” In the revamping of the DSM-5,

Aspergers was removed and replaced with the broad language of autism spectrum disorder.

Similarly, ADD was removed and replaced with the predominantly inattentive presentation

specifier of ADHD. The language we use matters, and can deeply affect our rapport with clients.

We must broach the idea of diagnosis, language, and identity with Ryan to ensure the client feels

heard, understood, and safe in counseling (Vivanti, 2019).

In a similar vein, Ryan also uses she/they pronouns. It will be imperative to ensure that

Ryan feels affirmed in the counseling space. Counselors should utilize broaching and

intersectional advocacy when working with Ryan (Astramovich & Scott, 2020).

Neurobiological Perspectives

Counseling stands at a unique intersection between several disciplines. Our experience is

linked closely to our biology, and the biological impacts of stress, trauma, and disorders. Ryan

reports experiencing depressive symptoms for at least the past five years, and reports a major

depressive episode (MDE) every two weeks. Emerging research in neuroscience indicates that

long-term experiences of depression can alter the grey matter density in parts of the brain related

to pleasure and rewards. These changes can diminish the experience of pleasure and rewards for

a long time and may become more entrenched after each MDE (Blank et al., 2020). This

underscores the need for research-informed treatment for Ryan, to aid in restoring their normal

brain area functions.

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Autism is another budding area of research in neurobiology that is extremely informative

and applicable for the counseling profession. First, it has long been recognized that ASD is a

neurobiological disorder that is affected by brain structure and function as much as

environmental factors and brain chemicals. However, the cause of ASD, and exact biological

markers, remain hidden (Eyring & Geschwind, 2021). For counselors, it is important to note that

ASD is commonly misrepresented in the media and scientific disinformation; this may impact

our client’s sense of identity and relationship with their diagnoses (Vivanti, 2019).

Finally, ADHD is another neurologically implicated disorder. It is thought that ADHD is

influenced by disrupted patterns of neuron communication in specific parts of the brain linked to

higher-order thinking and decision making (Knott et al., 2021). However, emerging research is

investigating the link between ASD and ADHD because both diagnoses manifest in similar ways

biologically (Knott et al, 2021).

Interactions Between Developmental History and Symptoms

Ryan arrived at counseling with a long history of diagnosis, but also a complex history of

family dynamics. We have explored the biological, neuroscience, and personal experience of

Ryan’s symptoms, but it’s also important to consider how their developmental history may be

affecting these experiences. First, Ryan reports having to take care of their adoptive mother

during her mental health challenges, which may have impacted the development of their MDD.

Second, Ryan speaks bluntly, which may be a symptom of their ASD but may also have played a

role in how they engaged with their family of origin, friends, and colleagues. It will be important

to explore Ryan’s developmental history with them, as it could provide great insight into factors

that impacted the development of their symptoms. Finally, Ryan’s affect in counseling may be

due to having a trauma history, more so than ASD, or the normal developmental process of being
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a young adult. Ryan’s counselor and future counselors should stay aware of developmental

trends in emerging adulthood, and work to balance the impact of that as well as Ryan’s

diagnosable mental health concerns.

Stage of Change

Ryan is presently in the contemplation stage of change. This is evidenced by their ability

to recognize the intensity of their depression symptoms (i.e. reporting how difficult their week

has been, describing negative mental and physical changes, and recalling persistent suicidal

thoughts). Ryan states that although it was their friends and family who urged them to seek

counseling services, they believe they could benefit from the extra support of a counselor.

Ryan’s symptoms have not hindered their ability to complete day-to-day responsibilities since

they still attend all of their classes, complete all of their assignments, and are engaged in some

extracurricular activities. However, during a depressive episode, Ryan notes that they experience

very frequent intrusive suicidal thoughts regularly throughout the day, isolate themselves, and

struggle to remember to take care of basic needs like eating. Ryan has expressed a desire to work

on improving their functioning during a depressive episode and to learn coping skills to prevent

symptoms from worsening.

By meeting Ryan where they are, the clinician will continuously work to strengthen the

therapeutic alliance and begin encouraging Ryan towards behavioral change actions by starting

in small steps. This can be done by helping Ryan establish their intentions for change as well as

collaboratively creating small, measurable goals for them to complete between sessions.

Examples of these small steps could be making sure they eat at least one meal a day during an

MDE or briefly practicing mindfulness amid an intrusive thought.

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A 2021 study by Lueck provides insightful guidance for different communication

strategies to use depending on a client’s current stage of depression. In Ryan’s case of moderate

to severe depression, it is noted that individuals at this stage can have lower intentions to seek

help than those with minimal depression symptoms. Lueck (2021) notes that framing treatment

using positive language and highlighting the gains to be made can encourage readiness towards

change among clients. For this reason, the counselor must be cognizant of their language

choices, especially when helping Ryan identify intrinsic motivators to continue treatment.

Working Alliance

A unique facet and important consideration of Ryan’s case is the impact that autism

spectrum disorder (ASD) can have on the ability to form bonds, namely with the clinician. A

2020 study by Brewe, Mazefsky, and White notes that the strength of the therapeutic alliance can

influence treatment outcomes for young adults with ASD. Specifically, those with increased

ASD symptom severity and depression predicted a weaker alliance in the beginning stages of

treatment as well as throughout. Overall, empirical findings suggest that it is common for the

alliance to fluctuate throughout the therapeutic process with this population, but establishing a

strong working alliance is both possible and essential (Brewe, Mazefsky & White, 2020).

Establishing a warm, collaborative bond between the clinician and client is crucial for

ensuring that the client feels comfortable, supported, and motivated to participate in treatment.

With Ryan’s existing ASD diagnosis, it will be helpful to note that the bond may feel more or

less solidified at different times in treatment. However, given that the bond in itself can be one of

the most healing aspects of counseling, it is imperative that the clinician continuously works to

maintain this.

Emergency Protocols
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If there is a crisis during business hours, Counseling Center staff will work to rearrange

their schedules so that a clinician can see the individual in crisis as soon as possible. Individuals

requesting a crisis walk-in appointment are asked to complete a Triage Form so that the

counselor who meets with them can gather information about the nature of the crisis and can help

them resolve the crisis effectively. Crises are resolved after the counselor helps the individual

problem solve or develop calming and coping strategies.

If the individual is experiencing suicidal ideation, and the counselor determines that the

individual is at low to moderate risk of suicide, the counselor helps the individual develop a Plan

for Living. The counselor schedules a follow-up appointment as soon as possible with the

individual. Once the individual is stable, the counselor may continue to meet with them or

facilitate an appropriate referral. The Guilford College Counseling Center recommends that

clients attend sessions once every two to three weeks. If the symptoms of the depressive episodes

create a need for an increase in scheduled appointments, the client will need to be referred into

the community.

Psychiatric hospitalization is only pursued when all other safety options have been

exhausted and the individual is unable to remain safe. If the individual agrees to go to the

hospital voluntarily, the counselor may call 911 and request a non-emergency transport to the

Wesley Long Emergency Department (2400 West Friendly Avenue). The counselor may meet

the individual at Wesley Long to remain with them throughout the hospital intake process. The

individual may also contact family members or other loved ones to meet them at the hospital. If

the counselor determines it is appropriate, the family member or loved one may transport the

individual to Wesley Long.

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If a student is unable to plan for safety and is unwilling to go to the hospital voluntarily,

the counselor may pursue involuntary hospitalization. The counselor requests that Public Safety

remains with the student while the counselor completes the hospitalization paperwork and

arranges transportation to the Wesley Long Emergency Department.

If a member of the Guilford College community is experiencing a crisis when the

Counseling Center is closed, they may call campus Public Safety at 336-316-2909. The

responding officer gathers identifying information about the student and their crisis. The

responding officer calls the Director of Counseling Services (or their designee) and relays

information about the crisis. In most cases, the Director of Counseling Services can help the

student resolve the crisis over the phone by helping them problem solve or teaching them coping

or calming strategies.

If the student can resolve the crisis by phone and there are no immediate safety concerns,

the Director of Counseling Services schedules the earliest available follow-up appointment with

the student before hanging up the phone. If the student does not show up for the agreed-upon

appointment, Counseling Center staff reach out to the student to check on them. If staff are

unable to reach the student, they may contact Public Safety to initiate a wellness check if there

are safety concerns.

If the student is unable to resolve their crisis by phone and there are immediate safety

concerns, the Director of Counseling Services (or their designee) relays relevant information to

the Public Safety officer and calls Therapeutic Alternatives Mobile Crisis Management at 1-877-

626-1772 to come to assess the student in person. A Public Safety officer remains with the

student until Therapeutic Alternatives completes their assessment or gives an all-clear.

Therapeutic Alternatives may pursue psychiatric hospitalization, in which case Public Safety
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remains available to assist and to relay information to the Director of Counseling Services (or

their designee) as well as the Administrator on call.

Follow-Ups and Case Closures

The planned procession of case management includes 5 more months of talk therapy with

the current Counselor Sophie Young. The talk therapy will conclude in 5 months due to the

ending of Counselor Young’s internship with the Guilford College Counseling Center. At that

time, Ryan will be transferred to another clinician at the Guilford College Counseling Center or

be transferred to another clinician in the community that can better suit their needs. The client

will need continuous assistance addressing non-suicidal self-injurious behaviors. Once those

behaviors and other risks have been eliminated and goals from the Case Plan have been

achieved, clinicians should begin preparing the client for transition out of mental health services.
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