Identifying Data
Date of initial assessment – 8/19/2021
Client’s name: Penny for your Thoughts
Age: 16
Gender: Female
Sexual Orientation: Heterosexual
Race: Black
Ethnicity: Non-Hispanic
Marital Status: Single
Employment Status: Unemployed/Student
Part I: Intake Information
Reason for Referral/Presenting Problem
Penny is self-referred with parental consent. Penny reported that she has been feeling “sad” and “lonely” and isolating herself from family and friends. The precipitating event was her parent’s divorce 2 months ago.
Source of Information
A semi-structured interview was conducted along with DSM-5 level 1 cross-cutting symptom measure, DSM-5 level-2 (PROMIS Emotional Distress—Depression, Beck Depression Inventory-II (BDI-II), and DSM-5 Cultural Formulation Interview (CFI).
Part II: Assessment
Observational Data/Mental Status Exam
Through an MSE, Penny was accurately oriented to person, place, time, and situation. Her thought process and appearance were normal. Her eye contact was limited and was tearful at times. Normal tone, volume, and rate but quiet at times.
Psychometric Assessment
Based on the DSM-5 level 1 cross-cutting symptom measure, the client scored greater than a 2 on the depression domain for the past 2-weeks. From the DSM-5 level-2 (PROMIS Emotional Distress—Depression), the client had an elevated t-score (t = 61) indicating moderate depression in the past 7 days. The elevated items (3 or greater) were “I felt alone,” “I felt sad,” “I wanted to be by myself,” and “It was hard for me to have fun.” She also reported a lack of desire or interest during the clinical interview and confirmed in the PROMIS-Depression instrument, “I wanted to be by myself” and “It is hard for me to have fun.” The Beck Depression Inventory-II (BDI-II) corroborated her depressive state with a score of 23, moderate. Her elevated items (2 or greater on the BDI-II) were “I am sad all the time,” “I feel I have nothing to look forward to,” “I feel quite guilty most of the time,” “I blame myself all the time for my faults,” and “I cry all the time now.”
Biological Assessment
Penny is a 16 year-old single, Black, heterosexual female. The client did not recall her last physical. The client does not report any current concerning physical conditions.
Sleep
Penny stated she sleeps up to 12 hours a day and finds it difficult to awake in the morning.
Diet
The client reports eating a “normal” diet. She does not report any disorder eating. The client drinks two energy drinks per day. One in the morning and one at lunch.
Exercise
Penny does not report any recreational activities as this time. Prior to her depressive symptoms, she did engage in recreational basketball.
Medication
The client does not report any prescription medications. She did not an allergic reaction to penicillin.
Medical History
No clinically significant medical history was reported by the client.
History of Developmental Milestones
Penny reports normal development but did note that she was born premature, 35 week gestations.
Psychological Assessment
The client does not have any previous counseling or mental health treatment. Penny does not report any previous episodes of clinical depression.
Addiction Screening
Penny reports no history of addiction. The client does not consume alcohol or other drugs.
Risk Assessment
Penny did not report any suicidal ideation, attempts current or historical. The client reported no homicidal history or current ideations.
Family Psychiatric History
No family history of psychiatric treatment reported by client.
Piaget’s Theory of Cognitive Development
Penny is in the “formal” stage of development. This is evidenced not only by her age, 16, but supported during the assessment. The client was able to show her ability to think abstractly and think in complexity when describing her feelings, thoughts, behaviors in associated with others (e.g., parents). Adolescent egocentrism may also play a part as she makes meaning of self, others, and the world.
Social Assessment
Cultural Factors
Penny is a young Black female living with her parents who are low-medium socioeconomic status. Her mother and father reported race Black. Both of her parents completed high school. Through the DSM-5 Cultural Formulation Interview (CFI), Penny offered that “I caused my parents’ divorce . . . it is all my fault.” She also declared that “all my friends have divorced parents, us Black kids can’t get a break.”
Family of Origin
Her family system consists of a father, Ron, (45-year-old Black male, employed as a mechanic), mother, Anne, (40-year-old Black female, employed as an administrative assistant) who had their divorce finalized around 2-months ago. Penny now splits her time between her parents’ household. Penny reports being “tired of the fighting” between her parents. The conflict has been an ongoing issue for the past 10 years and she attempts to avoid engaging with either of her parents, generally. The fighting recently escalated once the father discovered infidelity with his wife and a co-worker. This was the second affair in their 20-year marriage. Penny did not report observing or experiencing any physical abuse but did report witnessing potential verbal abuse between her parents. Penny has a 5-year-old sister, Margaret, who attends kindergarten. She reports a close kinship with her younger sister.
Current Living Arrangements
The client reported doing a fifty-fifty split between her mother’s home and her father’s apartment.
Academic History
Academically, Penny, a junior, identified a dip in her academic grades and attendance during the past five months. Historically, Penny reported her status as an “A to B” student. She does desire to go to college, but she is unclear on a degree and how to finance it.
Occupational History
No occupational history to report
Current Social Support
The client stated she has only a few friends. She offered that her primary social support is her friend who is in the hospital. She stated mixed support from her mother and father.
Erikson’s Psychosocial Stages
The client is 16 which aligns with Erikson’s identity vs confusion. During the assessment, the client appears to be in role confusion based on her identity blended within her parents and in particular her ownership of the divorce. Penny may also be process in her identify development as a Black women based on her CFI interview.
Spiritual Assessment
Spiritual/Religious History
Penny remarked that growing up she can recall attending church weekly. She also attended children’s and youth ministry activities. She stated she was baptized when she was 10 years old. She recalls praying during dinner with her family and as she got older praying on her own. She recognized that her parents read the Bible to her.
Present Spiritual/Religious Beliefs
Penny stated she was “spiritual” and attended her local church somewhat regularly with her parents before the divorce but not currently. She continues to pray and read her Bible. She reported her faith being important to her currently but feels embarrassed to attend church because of her parental situation.
Fowler’s Stages of Faith Development
The client appears to be at Stage 3 – “Synthetic-Conventional” Faith. This is evidenced by her adherence to faith system and its associated practices. She appears to have adopted her parent’s tradition and has not individuated her own beliefs.
Integration Assessment
The stated that she desired to have her faith incorporated into clinical work. She stated that prayer and bibliotherapy via scripture are desired.
History of Presenting Problem
Penny does not have a history of counseling but has experienced feeling “sad” a couple of times over the past 2 years and isolating herself from family and friends. The client reported an increase in feeling “sad” daily [frequency] over the past month [onset] and hypersomnia. Both the DSM-5 level-2 (PROMIS Emotional Distress—Depression) and the BDI-II indicate moderate depression [severity] for the past two weeks. The client noted a dip in her grades over the past month. She stated that the continued parental conflict makes “life difficult” and she feels “helpless” toward herself, her parents, her sister, and others. Yet, she perceived the need to “protect” her sister from the parental conflict. When the clinician further inquired about her friend in the hospital, the client changed the subject to her parents. The counselor later inquired about her friend and again Penny resisted the topic during the clinical interview.
Barriers to Treatment/Success
Potential barriers to treatment may be the supportive environment of the family system. The client offered mixed support by her parents. Another potential barrier that needs further investigation is the impact of discrimination. Factors that enhance treatment are her insight, her orientation x4, and her spirituality.
Part III: Diagnosis
F32.1 Major depressive disorder, single episode, moderate (principal)[MSOffice1]
Z63.5 Disruption of family by separation or divorce
Z60.5 Target of (perceived) adverse discrimination and persecution (provisional)
Diagnostic Rationale
Penny is experiencing her first major depressive episode. She has met DSM-5TR [MSOffice2] criteria for major depressive disorder, single episode, and moderate for around 1 month (American Psychiatric Association, 2022). Penny has experienced a depressed mood based on feeling “sad” as well as an elevated score (t=61) on PROMIS-Depression and BDI-II of 23. She marked feeling “sad all the time” and “I cry all the time” on the BDI-II and “I felt sad” on the PROMIS-Depression; this was reported for at least the past month and up to the past 7 days, respectively (Criterion A.1). She also reported a lack of desire or interest during the clinical interview and confirmed in the PROMIS-Depression instrument, “I wanted to be by myself” and “It is hard for me to have fun” (Criterion A.2). [MSOffice3] There was no report of weight loss or gain but Penny (Criterion A.4) reported sleep disturbances – sleeping around 12 hours per day. The client experiences fatigue and less energy as found in the PROMIS-Depression and BDI-II (Criteria A.6). She noted excessive guilt – “I blame myself” and “I feel quite guilty” according to the BDI-II) (Criteria A.7). No reported data pointing to concentration concerns, but the client noted a decrease in her school grades potentially indicating impairment in the school environment. Based on the signs and symptoms, major depressive disorder is suggested for Penny’s current state.
Z63.5, disruption of family, was assigned because of the continued parental conflict and the divorce of her parents. Penny reported, “I caused my parents’ divorce” which may be associated with the disruptive family system. Finally, Penny remarked, “Black kids can’t get a break” which may connect with experienced discrimination, but further information is required therefore a provisional diagnosis Z60.5 Target of (perceived) adverse discrimination and persecution was given.
Part IV– Case Conceptualization
Theoretical Orientation
The theoretical orientation of the counselor is cognitive behavioral therapy [MSOffice4] (CBT, Beck, 2021). The major tenets of CBT focus on how cognitions impact emotions and can lead to maladaptive behavior. Further, it is theorized that patterns in behavior derive from an unhealthy clinical core belief – helplessness, worthlessness, or unlovable (Beck, & Beck, 2020).
Narrative of the Case Conceptualization
Using a CBT lens (Beck, & Beck, 2020; Murdock, 2017), Penny’s core maladaptive belief is helplessness which is driving her maladaptive thoughts and behaviors resulting in depression and the associated z-codes[MSOffice5] . Penny has expressed sadness, which can be healthy, but sadness, crying, avoidance as well as other maladaptive activities are driven by cognitive and prediction errors of reality. These cognitive errors or automatic thoughts (“It’s all my fault”) are driven by faulty core beliefs or interpretations of the world based on Penny’s belief she is the one who is the source of her parent’s conflict and divorce and helplessness to change her circumstances. This may be the rationale for the avoidance of her friend and the hospital as well; she is powerless so why try. Penny attempts to evade triggering her core belief of helplessness by using avoidance behaviors such as shunning parents, hospital, school, and engaging in hypersomnia; the client is using her compensatory behaviors based on her conditional assumptions e.g., if I avoid, then I am in control and I will not feel helpless.
Part V– Treatment Plan
| Problems |
| Major depressive disorder– feeling sad, fatigue, avolition, hypersomnia, low self-worth, avoidance, helplessness, and false guiltDisruption of family by separation or divorce – parental divorce 2 months ago, high conflict, affair, joint custodyTarget of (perceived) adverse discrimination and persecution (provisional) – “Black kids can’t get a break.”[MSOffice6] |
| Goals for Change |
| 1. Major Depressive Disorder Understand the relationship between cognitive errors, maladaptive core beliefs, and depression.Increase engagement in non-depressed activities to reduce avoidance behaviors.Increase realistic relational schemas within the family system to reduce conflict and depression symptoms.Reduce or eliminate depressive symptoms and return to prior level of functioning. 2. Disruption of family by separation or divorce Understand the impact of divorce on the perception of self, others, and the world. Eliminate the faulty core beliefs around the guilt of divorce. Decrease family dysfunction to reduce the negative impact on the client’s relationship with parents. 3. Target of (perceived) adverse discrimination and persecution (provisional) Understand how discrimination may influence negative thoughts of self, others, and the world. Eliminate [MSOffice7] faculty core beliefs associated with adverse discrimination and persecution.Increase resiliency to cope with perceived discrimination. |
| Objectives & Therapeutic Interventions |
| The client will engage in 10 to 15 weekly, individual and family sessions of CBT (Beck Institute, n.d.; Schwitzer and Rubin, 2015; Murdock, 2017). 1. Major depressive disorder The client will learn about depression, factors that influence its development and continuance. The counselor will provide psychoeducation about major depressive disorder and CBTs conceptualization and treatment for MDD. The client [MSOffice8] will identify, challenge, and replace her maladaptive automatic thoughts, intermediate beliefs, and maladaptive core beliefs. The counselor [MSOffice9] will educate and assist the client in applying the Test Your Thoughts worksheet.The counselor will educate client on reframing and assist the client in applying. The counselor will use Socratic questioning and downward arrow to assist the client in identifying her intermediate and core beliefs. The counselor will use behavioral experiments with the client for cognitive restructuring of maladaptive thoughts and core beliefs. The client will identify, challenge, and replace maladaptive behaviors with effective ones. The counselor will provide the client with the pleasure/mastery scale and assist the client in completing it. The counselor assists the client in completing an activity schedule that could include self-care, exercise, and social events.The counselor will provide psychoeducation on good sleep hygiene.The counselor will conduct a sleep questionnaire. The client will identify and engage in actions to prevent relapse. The counselor will assist the client in identifying potential relapse risks.The counselor will assist the client in identifying actions to prevent and limit relapse. 2. Disruption of family by separation or divorce The client will process grief/loss of family system and associated grief. The counselor will provide psychoeducation on divorce.The counselor will apply Socratic questioning. The counselor and client will apply Test Your Thinking worksheet.The counselor will offer bibliotherapy, The divorce helpbook for teens.The counselor will refer the client to family therapy to conjointly process the divorce.The counselor will refer the client to grief “teen” group counseling. 3. The target of (perceived) adverse discrimination and persecution (provisional) The client will identify and engage in resiliency efforts for adverse discrimination experiences. The counselor will offer the client distress tolerance tools The counselor will assist the client in identifying “normative” discriminatory perceptions leading to problem-solving actions through Socratic questions. The counselor will provide assertiveness skills training. The counselor will use role-play to practice skills. The counselor will provide modeling for coping with adverse discrimination events. The counselor will assist the client in identification of her “strength” and “values”The counselor will assist the client in identifying and engaging in social support resources. The client will engage in cognitive restructuring of maladaptive thoughts and core beliefs. The counselor will provide psychoeducation of the CBT triad (feelings, thoughts, behaviors) to perceived discrimination. The counselor will conduct an ABC evaluation to assist the client in understanding the antecedents, behaviors, and consequences. The counselor will assist the client in the identification of maladaptive automatic thoughts and core beliefs about self, others, and the world through Socratic questions. Counselor and client will engage in the cognitive restructuring of maladaptive thoughts and core beliefs as needed via Testing Your Thoughts worksheet. |
| Outcome Measures of Change |
| Improved self-worth, improved mood, increased engagement in pleasurable activities, and increased support seeking.[MSOffice10] The client reported reduced maladaptive thoughts and behaviors along with increased pleasure and mastery activities.Pre-post measures on the Beck Depression II Inventory.The Counselor observation of improved mood via signs, symptoms reduction, and change talk around automatic thoughts, assumptions, and core beliefs. The Client reported reduced family disruption.The Client [MSOffice11] reported increased distress tolerance of perceived adverse discrimination. |
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
Beck, J., & Beck, A. T. (2020). Cognitive behavior therapy: Basics and beyond (3rd ed.). Guilford Publications.
Berghuis, D. J., Peterson, L. M., McInnis, W. P., and Timothy J. B. (2014). The adolescent psychotherapy treatment planner: Includes DSM-5 updates, John Wiley & Sons, Incorporated.
Murdock, H. L. (2017). Theories of counseling and psychotherapy: A case approach (4th ed.). Pearson.
Rubin, A. M., & Switzer, L. C. (2015). Diagnosis & treatment planning skills: A popular culture casebook approach (2nd ed.). Sage.
[MSOffice1]Not this is here only as a reminder. If you have more than one disorder, then required to put “principal” for inpatient or “reason for visit” for outpatient.
[MSOffice2]Only use the DSM-5TR
[MSOffice3]Be specific (A2) on offering a criteria plus data that shows others that it is met.
[MSOffice4]Note – APA requires that theories, diseases, and disorders be lowercase unless proper noun
[MSOffice5]The purpose of a case conceptualization is to “explain” the clients problems that are diagnosed above.
[MSOffice6]Note the problems here are mirror of the diagnosis. Additionally, you do not have to offer all z-codes but only the ones that need to have separate goals, objectives, and interventions. The clinical thinking is if you treat the principal disorder and it takes care of the z-codes, then no need to offer the z-codes in the treatment (tx) plan. If the principal diagnosis does not resolve the z-codes, then create separate goals, objectives, and interventions.
[MSOffice7]Note the progression of goals from early to middle to late of treatment.
[MSOffice8]This is an objective. It is what you want the client to do to reach the goals you created. Make sure there are enough objectives and interventions to reach the established goals.
[MSOffice9]These are the interventions. It is what the counselor will do to achieve the objective.
[MSOffice10]Offer the outcomes you are assisting the client to reach.
[MSOffice11]Note the varying measures to monitor success.
