Case Study Crystal Smith, a 33-year-old African American homemaker, came to an outpatient clinic seeking “someone to tal

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Case Study
Crystal Smith, a 33-year-old African American homemaker, came toan outpatient clinic seeking “someone to talk to” about feelings ofdespair that had intensified over the previous 8–10 months. She wasparticularly upset about marital conflict and an uncharacteristicmistrust of her in-laws.
Ms. Smith said she had begun to wake before dawn, feeling downand tearful. She had difficulty getting out of bed and completingher usual household activities. At times, she felt guilty for notbeing her “usual self.” At other times, she became easily irritatedwith her husband and her in-laws for minor transgressions. She hadpreviously relied on her mother-in-law to assist with the children,but she no longer entirely trusted her with that responsibility.That worry, in combination with her insomnia and fatigue, made itvery difficult for Ms. Smith to get her children to school on time.In the past few months, she had lost 13 pounds without dieting. Shedenied current suicidal ideation, saying she “would never dosomething like that,” but acknowledged having thought that she“should just give up” and that she “would be better off dead.”
Two months previously, Ms. Smith had seen a psychiatrist forseveral weeks and received fluoxetine. She reluctantly gave it atry, discontinuing it quickly because it made her feel tired. Shehad also dropped out of therapy, indicating that the psychiatristdid not seem to understand her.
Ms. Smith lived with her husband of 13 years and two school-agechildren. Her husband’s parents lived next door. She said hermarriage was good, although her husband suggested she “go seesomeone” so that she would not be “yelling at everyone all thetime.” While historically sociable, she rarely talked to her ownmother and sisters, much less her friends. A regular churchgoer,she had quit attending because she felt her faith was “weak.” Herpastor had always been supportive, but she had not contacted himwith her problems because “he wouldn’t want to hear about thesekinds of issues.”
Ms. Smith described herself as having been an outgoing, friendlychild. She grew up with her parents and three siblings. Sherecalled feeling quite upset at age 10–11 when her parents divorcedand her mom remarried. Because of fights with other kids at school,she met with a school counselor with whom she felt a bond. Unlikethe psychiatrist she had recently consulted, Ms. Smith felt thecounselor did not “get into my business” and helped her recover.She said she became quieter as she entered junior high school, withfewer friends and little interest in studying. She married herhusband at age 20 and worked in retail sales until the birth oftheir first child when she was 23 years old.
Ms. Smith had not used alcohol since her first pregnancy anddenied any use of illicit substances. She denied past and currentuse of prescribed medications, other than the brief trial of theantidepressant medication. She reported generally good health.
On mental status examination, Ms. Smith was a casually groomedyoung woman who was coherent and goal directed. She had difficultymaking eye contact with the white middle-aged therapist. She wascooperative but mildly guarded and slow to respond. She neededencouragement to elaborate her thinking. She was periodicallytearful and generally appeared sad. She denied psychosis, althoughshe reported occasionally feeling mistrustful of her family. Shedenied confusion, hallucinations, suicidality, and homicidality.Cognition, insight, and judgment were all considered normal.