Mary

Posted: December 11th, 2013

You are a counselor in a community mental health center. At the urging of her friend, Mary has come in for an individual evaluation. Mary is a 24 year old single African American woman who has been living with her boyfriend Max for the last five years. Both Mary and Max have consistently used heroin for the last five years as well. Mary reported that she has never received any substance or mental health counseling before. Mary also denies any criminal history as well as any suicidal or homicidal ideation, intent or plan.
When Mary was 8 years old, her father left her mother and her two younger siblings and she never saw him again. Mary reported that he father was an alcoholic and her mother is a recovering alcoholic. At about 12 years old Mary reported that she started drinking alcohol and smoking marijuana. At 16 years old she dropped out of high school and at 19 years old she moved in with Max. He introduced her to heroin. She reported that she uses about ½ gram of heroin per day just to be able to function and feel comfortable. In order to pay for the heroin and pay her rent, Mary is a prostitute in the evening. Max does not work at all. Mary advises you that she usually drinks four or five beers each night before she goes out to work. If she cannot get heroin she advises you that she will “score” valium, xanax or klonopin to “tide me over until I can score some h.” She reported that she tried cocaine but “did not like the high.”
Mary tells you that alcohol and heroin help to calm her nerves and get her through the day. She also reported that she and Max are not having sex much at all. When they do have sex, he never uses a condom. He says that’s what makes him different from one of her “Johns” and Mary confirms that she will not work without her customers using a condom.
Mary tells you that she notices that lately her breasts have become swollen and tender, and she has not had her period in the last 12 weeks. She is pretty sure that she is pregnant and believes that it is Max’s baby. She reported that she is not sure that she can stop using drugs and alcohol or work to have the baby even though Max wants her to keep the baby if she is pregnant. She has not seen a medical doctor as she has no medical insurance. Her friend who works with her at night told her not to stop using drugs if she’s pregnant because “it would be worse for the baby.” Mary is very confused about what she should do and is asking for your help to assist her in making some decisions.
Answer the following questions with regard to the case above.

1. Provide a DSM-IV-TR 5 Axis diagnosis for Mary and support all of your reasoning.
2. What treatment options would you recommend for Mary and why?
3. What referrals would you give Mary and why?
4. What legal and ethical issues must you consider in this case?
5. Identify any transference or countertransference issues that may impact this case.