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Case Study: Mental Health Assessment and Treatment Plan


Talaihla was brought to a local emergency department on an emergency examination authority (Queensland) after consuming a quantity of pills from the bathroom cabinet. She lives with her mother, Karen, and younger brother, Zane, who is nine years old, has behavioural problems and is probably on the autistic spectrum. Talaihla’s parents separated when she was nine years old. Her father re-partnered and moved interstate with his new family. Talaihla doesn’t hear from him often but does spend holidays with him. The night of the overdose was unexceptional. Karen finished up at 5pm from her disability support job and picked up Zane from after school care. Talaihla was in her room when Karen and Zane got home, which was not unusual. She refused to come out for dinner. Talaihla was still angry that her mother had refused to allow her to go a party on a school night earlier in the week. She did come out of her room at 9pm and had a snack. Talaihla posted a picture of a handful of pills and a goodbye message on Instagram around 10pm, and a concerned school friend rang Karen.

Talaihla acknowledged she had taken an overdose, and Karen rang the ambulance. Talaihla refused to talk to the ambulance crew. Whilst Talaihla was medically cleared by toxicology, she was not cooperative with the triage nurse. She was more forthcoming with you, the acute care team worker. She disclosed that she had started cutting herself on the thighs some six months ago after an incident at a party, which she didn’t want to discuss. She said that life really sucked since she started high school. She volunteered that she really hated her body and that everyone thought she was fat and ugly. She won’t eat lunch at school and frequently skips dinner. She has recently started making herself vomit after she sneaks out to the refrigerator late at night and eats too much. She said that a boy had asked her to a party earlier in the week, and she wasn’t allowed to go. She saw a picture of him kissing another girl on social media, and then, she decided to kill herself.

She occasionally thinks about suicide as everyone talks about it, and a girl who used to be her best friend earlier in the year told her she should go and do it. She hadn’t, however, formulated any clear plan. Karen was aware that Talaihla had fallen out with her best friend from primary school. She was surprised by the overdose. She said that Talaihla used to be her best friend and was warm and affectionate, but since starting high school and hitting puberty, Talaihla didn’t want to talk to her. Talaihla does, however, have a warm relationship with a grandfather and has a small network of girlfriends whom she hangs out with. She is academically OK, and she continues to go to piano lessons every week. She used to play netball but stopped that this year as she said she is too busy with school. This year, she wants to go out to parties, but Karen says she will only let her go out on weekends with a strict curfew. She says Talaihla doesn’t ask very often. Lately, says Karen, Talaihla has been “a bit of a drama queen” but will laugh and giggle when they all watch a movie together. Talaihla says that it was all a silly mistake, and she thinks she should go home soon. You need to write up your plan for discharge, discuss your formulation with the Consultant and write a letter recommending follow-up

Background Succinctly describe the key mental health issues and relevant background information in this case. Outline what additional information you would like to obtain and from whom.

Formulation Construct a succinct psychosocial formulation that will explain and guide treatment and follow-up in language that both the individual and family will understand. Outline the salient and important issues that you have considered in arriving at this formulation with reference to developmental theory. Describe how you would assess and mitigate risk of self-harm, suicide or other risks.

Treatment plan • Outline a plan that will enable the individual to be safely discharged and include recommendations for follow-up and support. • Outline a prescription for lifestyle advice to enhance the young person’s wellbeing.

Letter • Write a letter to the individual’s general practitioner (cc appropriate agencies), provide a discharge summary and summarise your follow-up plan

Task You have been asked to provide a treatment report on a client (a child or adolescent) that can be used in referral or handover. The report can either be based on a previous or current child or adolescent client with whom you have worked. Alternatively, you can utilise the case study in Appendix A. The report must contain the following sections (an example of a template is included in Appendix B): 1. Background 2. Formulation 3. Treatment plan 4. Letter to GP (Note the letter should clearly and briefly outline 1,2 & 3) Note that this is a report. However, your formulation should cite appropriate literature to support your formulation.

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