Case Presentation Review

Case Presentation of Jasmine

Jane Doe

School of Behavioral Sciences, Liberty University

Author Note

Jane Doe https://orcid.org/#####

I have no conflicts of interests to disclose.

Correspondence concerning this paper should be addressed to John Doe, 1971 University Blvd., Lynchburg, VA 24515. Email: John.Doe@liberty.edu

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CASE PRESENTATION OF JASMINE 1

Case Presentation of Jane

Part 1 – Assessment and Diagnosis Identifying Information

Identifying Data

Date of Initial Assessment: 9/6/2022

PSEUDO Name: Jasmine

Age: 25

Gender: Cis Gender Female

Sexual Orientation: Lesbian

Ethnicity: Mexican American

Marital Status: Partnered / Cohabitating

Employment Status: Fulltime

Reason for Referral/Presenting Problem

Jasmine is self-referred to this private practice. She reported that she has been feeling “sad” and “angry” for the last three weeks and has been isolating and withdrawing from her girlfriend, family, and friends. About a month ago, the client learned that her father had been cheating on her mother for the past year. She said, “Learning this about my father has been devastating as I always thought he was a good and faithful man. I always looked up to him.” I reviewed confidentiality and the limits therein with the client and received verbal and written permission to videotape our sessions for individual supervision and faculty group supervision.

Source of Information: The information provided was collected during the intake and initial diagnostic evaluation with the client. Additionally, the client completed the DSM-5 Level 1 and 2 Cross-Cutting Measures (Level 2-Depression, Level 2-Anger) and the DSM-5 Cultural Formulation Interview.

Background, Family Information, and Relevant History

The client is a 25-year-old cis gender Mexican American woman in a cohabitating relationship with a Black female partner. She was born and raised in Los Angeles, California with her parents and two younger brothers, ages 23 and 21. She described her father as hardworking, quiet, and even-keeled. He is 55 years old and currently works as a hospital administrator. The client described her mother as a loving, caring, and gregarious woman. She is 54 years old and works parttime at a local coffee shop. Her parents are both Mexican Americans born and raised in California. Jasmine described her upbringing as “normal” and having a “close-knit” family. She shared that they did not experience any abuse or violence in the home.

The client attended public school (K-12) and received a bachelor’s degree in nursing. She described herself as an average student; she graduated high school with a 3.2 GPA and college with a 3.8 GPA. In high school, Jasmine participated in choir and the Spanish club. She currently works at a community hospital as a registered nurse in the intensive care unit. She is satisfied with her career choice and current employment. During college, she worked parttime at a group home for individuals with developmental/intellectual disabilities.

The client described her current health as good. She reported her last physical was six months ago without incident. Further, she does not take any medications and has no medical conditions. She reported that she tries to exercise at least three times per week and maintain a well-balanced diet. The client reported that she only drinks wine at social gatherings about twice a month. Jasmine denied any history of using illicit drugs although she tried marijuana once in college.

Jasmine came out as a lesbian at the age of 18 although she realized it around 14 years old. Her parents were supportive but concerned about her relationship with God. Jasmine is sexually active and satisfied in her relationship with her girlfriend.

The client describes herself as a Christian. She first came to faith at the age of six and was baptized when she was 12 years old. She and her parents attended a Presbyterian church during her upbringing. Jasmine currently attends an LGBTQIA+ affirming and accepting Methodist church with her girlfriend who is also a believer. The client shared that her faith is very important to her, and she believes that God loves her and made her a lesbian. She expressed a desire to integrate her faith into counseling, but she does not want to discuss sin.

Problem and Counseling History

The client reported that she briefly experienced mild depressive symptoms while wrestling to accept her sexuality and some anxiety before coming out to her family. Overall, Jasmine has not experienced any significant mental health concerns until recently. Upon learning that her father had cheated on her mother, she began experiencing sadness, irritability, and anger nearly every day for the last three weeks. Her current symptoms include feeling down at times throughout the day, being preoccupied about her parents’ relationship, anger when thinking about her father, isolating and withdrawing from her loved ones, calling in sick to work a few times in the last two weeks, and general unhappiness. She reported that he has no history of counseling, psychiatric hospitalizations, or any previous mental health diagnoses. The client denied any history of suicidality, homicidality, non-suicidal self-injury, hallucinations, delusions, mania, hypomania, risky behaviors, obsessive-compulsive symptoms, or trauma.

During the intake session, Jasmine was accurately oriented to person, place, time, and situation. She was well groomed and appropriately dressed. She maintained good eye contact, but her motor activity was agitated. Her speech was generally at a regular rate, volume, and rhythm, but her speech was louder and quicker when discussing her father. She described her mood as down and irritable. Her affect was congruent. Jasmine displayed good judgment, impulse control, and insight. Her memory appeared to be intact. Her thought process was circumstantial with some rumination, but her perception was unremarkable.

Through the DSM-5 Cultural Formulation Interview, Jasmine offered that she may be the reason for her father’s infidelity. She said she has always been the apple of her father’s eyes and brought peace and happiness to their home, but when she left home at the age of 23, she fears her parents grew apart. She also shared concern that her parents may divorce because it has “become the American way” although Christian Hispanics have traditionally been opposed to divorce.

Jasmine was open during the intake evaluation and appeared to be ready to confront her emotional pain. She has the support of her girlfriend and employer to attend counseling at this time in her life.

Diagnostic Impression

F43.21 Adjustment disorder, With depressed mood, Acute (principal diagnosis)

Differential Diagnosis: Major depressive disorder

Discussion of Diagnostic Impression

Jasmine’s symptoms of sadness, anger, and irritability emerged within days of learning her father had cheated on her mother. She also began withdrawing and isolating from others, sleeping more than usual, being preoccupied and ruminating about her parents’ relationship, and calling in sick to work a few times. These symptoms are consistent with Criteria A and B of adjustment disorder as described in the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR; American Psychiatric Association [APA], 2022). Moreover, her symptoms do not meet diagnostic criteria of another mental disorder (Criterion C) or bereavement (Criterion D; APA, 2022). Additionally, the consequence of the stressor has not ended (Criterion E; APA, 2022). The specifier “With depressed mood” is appropriate as her symptoms are depressive in nature, and “Acute” since symptoms have been persistent for less than six months (APA, 2022). Jasmine’s baseline scores on the DSM-5 Level 2 measures indicated mild depression (T-score of 56.2) and mild anger (T-score of 58.8).

Currently, Jasmine has some symptoms consistent with major depressive disorder, including a depressed mood, hypersomnia, and some concentration problems for more than two weeks; however, she does not meet the full criteria of five or more symptoms. Furthermore, her symptoms are better accounted for as an adjustment disorder with the stressor of father’s infidelity. Ongoing assessment is warranted. The following Z-codes were considered but ruled out since the client is an adult: (Z62.820) Parent–Biological Child Relational Problem and (Z62.898) Child Affected by Parental Relationship Distress.

Part 2 – Case Conceptualization: Inverted Pyramid Model (IPM)

STEP 1: IDENTIFY AND LIST CLIENT CONCERNS AND ANY OTHER PROBLEM AREAS

Father’s infidelity

Worry about parents getting divorced

Sadness

Unhappy

Agitation

Anger

Irritable

Guilt

Avoiding emotion

Withdrawing from others

Isolation

Hypersomnia

Rumination

Calling in sick

STEP 2: ORGANIZE CONCERNS INTO LOGICAL THEMATIC GROUPINGS

Descriptive-Diagnostic

F43.21 Adjustment disorder, With depressed mood, Acute –

Learning of father’s infidelity, sadness, unhappiness, anger, irritability, guilt, withdraw, isolation, hypersomnia, rumination

STEP 3: THEORETICAL INFERENCES:

ATTACH THEMATIC GROUPINGS TO INFERRED AREAS OF DIFFICULTY

Maladaptive thoughts (CBT)

Maladaptive thinking in the following areas: guilt about parents’ relationship (e.g., “I caused my parents’ problems, it’s all my fault”; personalization)

Maladaptive behaviors (CBT)

Maladaptive behaviors in the following areas: Withdrawing from relationships (isolation), avoiding emotion, sleeping more, calling in sick to work

STEP 4: NARROWED INFERENCES AND DEEPER DIFFICULTIES

Deepest Negative Distortion (CBT)

Worthlessness, a maladaptive core belief: “I’m a bad daughter”

Narrative of the Case Conceptualization

Using a cognitive behavioral lens, Jasmine’s core maladaptive belief of worthlessness drives her maladaptive thoughts and behaviors resulting in some of her current problems (Beck, 2021). Jasmine has expressed sadness after learning of her father’s infidelity, which can be healthy, but much of her sadness, anger, and avoidance are driven by cognitive and prediction errors of reality (Beck, 2021). These cognitive errors, or automatic thoughts (e.g., “I caused my parents’ problems, it’s all my fault”), are motivated by faulty core beliefs or interpretations of the world based on Jasmine’s belief that she is the source of her parent's conflict (Beck, 2021). Jasmine uses several cognitive distortions. For example, she engages personalization by taking on the responsibility of her parent’s problems, and she applies control fallacy and overgeneralization to limit her perceived control (Beck, 2021). This may be her rationale for avoiding her girlfriend, family, and friends; she is powerless, so why try.

Further, Jasmine attempts to evade triggering her core belief of worthlessness by using avoidance behaviors such as withdrawing from relationships (isolation), sleeping more, and calling in sick to work; 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 defective; Beck, 2021). Internal or external reminders of her father elicit further avoidance (e.g., excessive sleep) leading to increased isolation, sadness, anger, and irritability. The client may also have perceptions of cultural shame that need to be further investigated.

Part 3 – Treatment Planning/Integration/Counseling Theory

Treatment Plan

Problems

1. F43.21 Adjustment disorder, With depressed mood, Acute – Learning of father’s infidelity, sadness, unhappy, anger, irritability, guilt, withdraw, isolation, hypersomnia, rumination

Goals for Change

1. F43.21 Adjustment disorder, With depressed mood, Acute (Jongsma et al., 2014) · Recognize current maladaptive thoughts and behaviors contributing to depressive and anger symptoms. · Decrease maladaptive thoughts of self, others, and world. · Increase engagement in adaptive coping activities to reduce avoidance behaviors. · Alleviate depressive symptoms and return to previous level of effective functioning.

Objectives & Therapeutic Interventions

The client will engage in 10 to 12 weekly, individual sessions of CBT (Beck, 2021; Jongsma et al., 2014; Schwitzer & Rubin, 2015). 1. F43.21 Adjustment disorder, With depressed mood, Acute · Provide psychoeducation about the relationship between negative self-talk, avoidance behaviors, and mood. · Provide psychoeducation on good sleep hygiene. · Identify and engage in good sleep hygiene activities. · Learn and practice adaptive coping behaviors. · Engage in activity scheduling (e.g., self-care, exercise, and social events every week). · Identify maladaptive assumptions, poor coping strategies, and maladaptive core beliefs in session using a thought log. · Challenge negative automatic thoughts connected with core beliefs by completing using coping cards. · Use behavioral experiments for cognitive restructuring of maladaptive thoughts and core beliefs. · Identify and engage in actions to prevent relapse. · Provide boosters sessions as needed to prevent and recover from relapse.

Outcome Measures of Change

Improved self-worth, improved mood, increased engagement adaptive coping responses, and increased support seeking. · Self-report reduced maladaptive thoughts and behaviors along with increase in adaptive coping. · Counselor observed improvements in mood via signs, symptoms reduction, and change talk around automatic thoughts, assumptions, and core beliefs. · Pre-post measures on the DSM-5 Level 2 measures (Depression and Anger).

Integration

I operate from an “An Integrated View” based on the Five Views of integration of counseling and Christianity (Jones, 2010). This view supports a biblical worldview as the foundation for counseling, namely that the truth comes from the Scripture (i.e., special revelation). The truths that guide my Christian counseling practice are that humans are made in the image of God; sin impacts all of creation; a fallen state of the mind, body of humans exists; that a human is both body and soul; the Holy Spirit works upon nonbelievers and within believers; and general revelation (God’s common grace to all His creation) exists. From this concept of general revelation, I see that science, in particular the science of counseling, allows a counselor to have a greater understanding of God, His creation, and ways to bring about healing (Jones, 2010).

As a counselor, I pray before, during, and after each session for my clients. I ask God not only for the fruit of the Spirit during session but also for wisdom not of this world (1 Corinthians 2:6) to help me assist my clients grow and heal. If the client is a fellow believer, at their consent, I will utilize Christian interventions, such as prayer, scriptural bibliotherapy, meditation, silence, solitude corporate worship, and service. In Jasmine’s case, she is very open to discussing spiritual things and praying together, but she does not wish to discuss sin. To this aim, I must be cognizant of the ethical principles of autonomy and nonmalefcence (American Counseling Association [ACA], 2014). Furthermore, it is essential for me to be intentional about A.4.b. Personal Values, which states “Counselors are aware of—and avoid imposing—their own values, attitudes, beliefs, and behaviors” (ACA, p. 5).

Personal Model of Counseling

Currently, I am working towards CBT proficiency. After my counseling in theories course, I have repeatedly returned to my course textbooks to retain the foundations of CBT. This includes conceptualizing a client based on maladaptive thinking and behaviors that drive emotional responses leading to states of anxiety, depression, etc. (Beck, 2021). I am also able to use Socratic questioning to collect data on automatic thoughts leading to a clear understanding of assumptions and core beliefs (Beck, 2021).

I can use CBT based interventions with clients like a thought record, yet my process is truncated. I specifically need to continually review the CBT therapeutic process, concepts, and interventions before planning a session. I often refer to handouts such as the Cognitive Conceptualization Diagram and others because I am not able to easily recall the information. Moving forward, I plan to take further training courses in CBT, seek supervision by a supervisor who specializes in CBT, and seek consultation. I will prepare for each session by reviewing the CBT process, interventions, and terms so that they are more easily recalled and applied.

References

American Counseling Association. (2014). ACA code of ethics. Author.

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). Author.

Beck, J. (2021). Cognitive behavior therapy basics and beyond (3rd ed.). The Guilford Press.

Jongsma, A. E., Peterson, L. M., & Bruce, T. J. (2014). The complete adult psychotherapy treatment planner (5th ed.). Wiley.

Jones, S. L. (2010). An integration view. In E. L. Johnson (Ed.), Psychology and Christianity: Five views (2nd ed., pp.101-148). IVP Academic.

Rubin, A. M., & Switzer, L. C. (2015). Diagnosis & treatment planning skills: A popular culture casebook approach. Sage.