Discussion: Suicide, Stigma, And Substance Abuse-Wk8-6212

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.

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)

Pietrzak, R. H., Johnson, D. C., Goldstein, M. B., Malley, J. C., & Southwick, S. M. (2015). Perceived stigma and barriers to mental health care utilization among OEF-OIF veterans. Psychiatric Services, 60(8), 1118–1122. doi:10.1176/appi.ps.60.8.11

Document: Working With Clients With Suicidal Ideations: The Case of Denise (PDF)

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



© 2016 Laureate Education, Inc. 2

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



© 2016 Laureate Education, Inc. 3

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.

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.

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



© 2016 Laureate Education, Inc. 4

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




© 2016 Laureate Education, Inc. 5

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



© 2016 Laureate Education, Inc. 6

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



© 2016 Laureate Education, Inc. 7

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



© 2016 Laureate Education, Inc. 8

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



© 2016 Laureate Education, Inc. 9

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



© 2016 Laureate Education, Inc. 10

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.

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