Case Presentation

Case Presentation of Ellie

Jane Doe (Student Name)

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 Jane Doe, 1971 University Blvd., Lynchburg, VA 24515. Email: [email protected]

1

CASE PRESENTATION OF ELLIE 1

Case Presentation of Ellie

Identifying Data

Date of Initial Assessment: 04/11/2023

PSEUDO Name: Ellie

Age: 25

Gender: Female

Sexual Orientation: Heterosexual

Race & Ethnicity: Caucasian/Non-Hispanic

Marital Status: Partnered / Cohabitating

Employment Status: Fulltime

Part I: Intake Information

Presenting Problem

Ellie is self-referred to this private practice. She reported that she has been feeling “anxious”, “sad”, and has had difficulty concentrating for the last 4 months. She reports isolating and withdrawing from her boyfriend, family, and friends, and that “all I want to do is sleep”. About 4 months 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. If I can’t trust him then I can’t trust anyone”.

Confidentiality

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. Ellie signed her HIPAA and informed consent forms and uploaded them to the website prior to her first appointment. As we are utilizing telehealth via Zoom meeting at our center, we reviewed briefly what she had signed and I reiterated that confidentiality would be maintained between her and me with the exception of my supervisor, and would only be broken in the event that she relays that she may be of harm to herself or others, or in the case of known elder or child abuse. Prior to this session, I reminded her of the confidentiality agreement that she had signed for recording and videotaping to use in my class presentations and the deletion of such recordings after the assignment is complete. She verbally expressed that she gave consent to these recordings.

Source of Information

The information in the intake was provided directly from the client herself during a formal intake biopsychosocialspiritual assessment required by the agency. She was assessed during the intake session for her medical, psychological, and other relevant history, including a risk assessment, the GAD-7 (Spitzer et al., 2006), and the PHQ-9 (Kroenke & Spitzer, 2002). Her Likert scale rating of her problem at intake revealed that she feels that her problems are completely interfering with her life, and she is not very optimistic that she can change them.

Part II: Assessment

Observational Data

Ellie was neatly dressed and appeared healthy and relaxed with somewhat fidgety motor activity. Her insight and judgment seemed good, and her affect was appropriate. Her Mood was euthymic. She was orientated to person, place, and time. Her memory was intact. Her attention and concentration were good. Her thought content was appropriate. Her perception and flow of thought were unremarkable. Her interview behavior was appropriate and cooperative, but she was either picking at her nails or biting them throughout the session. Her speech pattern was normal throughout. She was thoughtful and articulate, although she was frequently tearful when discussing her relationships.

Psychometric Assessment

I administered the GAD-7 (Spitzer et al., 2006) to assess Ellie’s anxiety and she scored a 16, indicating severe anxiety. I also administered the PHQ-9 (Kroenke & Spitzer, 2002) to assess levels of depression. Ellie scored a 9 on the assessment, indicating mild depression. A Likert scale was used to assess the level of interference that the presenting problems are causing (0-10, with 0 being not at all and 10 being extreme interference), and Ellie indicated that the level of interference was an ‘8’.

Biological Assessment

Ellie is a 25-yr old, Caucasian, heterosexual female, who is in a committed relationship, cohabitating with her boyfriend. She has no children and has had no pregnancies. Ellie reports her last physical was seven months ago during an annual OBGYN visit. She reports that her menstrual cycle is normal and reports no relevant medical history but notes she did break her arm “a few years back”. Ellie appears to be average height and weight for her age and does not appear to be underweight or overweight.

Sleep

Ellie shares she averages about eight to ten hours of sleep a night but reports recently struggling to fall asleep. Client reports using an herbal tea in the last several weeks to increase her ability to fall asleep, which she noted has been helping her relax. Client reports that “all I want to do is sleep. On weekends, I take a lot of naps and struggle to get up and motivated in the morning.”

Diet

The client reports “I eat mostly good” but reports skipping several meals a week that usually includes “breakfast and lunch” due to feeling overly anxious. She states, “sometimes my stomach is just in knots, so the thought of eating makes me feel worse”. Client reports no history of eating disorder or time when overweight/underweight was an issue. The client reports that she usually has one cup of coffee in the morning, but otherwise she does not consume caffeine “except for the occasional specialty coffee, but that’s less than once a week”.

Exercise

Ellie shares regularly exercising 3-4 times a week up until she learned about her dad’s affair. She reports “no longer having energy to go to the gym”. Client notes being “mad at myself for being so lazy”. She reports that she also used to enjoy taking her dog to the park and walking, but she mostly just lets him out in the backyard now.

Medication

The client reports no medication history other than birth control that she has been on since 15years old and reports no known side effects. She reports also taking a women’s daily multivitamin.

Medical History

Client reports no medical history. She reports that her last physical exam was seven months ago where she received a clean bill of health.

History of Developmental Milestones

Ellie reports that she met all her developmental milestones at the appropriate ages. She reports that her parents described her as a “motivated” baby and that she crawled and walked early and that she taught herself her ABC’s “when I wasn’t even two-years-old”.

Psychological Assessment

Client reports having no previous counseling or mental health treatment. She reports having a previous time where she felt depressed, but that she did not receive any counseling or help for it.

Addiction Screening

Ellie reports no history of addiction. She reports consuming alcohol “on occasion socially” and that she never has more than two drinks. Ellie reports no use of illicit drugs. She reports that she smoked marijuana a few times as a teenager, but that she never liked it and doesn’t do it anymore.

Risk Assessment

The counselor assessed the client’s risk by asking if she has ever been a harm to herself or to anyone else as well as whether she has current suicidal or homicidal ideations. The client reports that she has no suicidal attempts in her history or current suicidal ideations. The client also reports no homicidal history or current ideations.

Family Psychiatric History

Ellie reports that her father does not have any mental health diagnoses that she knows of, but she reports that her mother has what she describes as undiagnosed depressive disorder and that “she’s always been a worrier”.

Piaget’s Theory of Cognitive Development

Ellie is in Piaget’s fourth stage, the formal operational stage. This was evident by how Ellie described how her father’s affair has now made her question whether she can trust anyone, including her boyfriend. She stated, “If my own dad can fool me and my mom, then anyone can fool me. I’d never know if he was cheating on me”. Ellie’s occupation also confirms her stage of cognitive development as she is a project manager who manages a small team of individuals.

Social Assessment

Cultural Factors

Ellie is a young Caucasian female with a medium socioeconomic status who was born and raised in New Jersey. She reports that her father is Italian-American and her mother is German. She reports that her father’s Italian background was important in her upbringing and that “family was everything”, which is partially why she can’t believe that her father cheated on her mother. She reports her parents “doing well for themselves” financially and that they always expected their kids to work hard.

Family of Origin

Ellies mother and father live approximately 30 minutes away and her 28-year-old brother lives with his wife and child on the other side of the state. She reports that she and her brother talk a couple times a month. When describing her relationship with her parents, Ellie states that growing up they had a typically warm and loving relationship. She reports being very close with her mom whom she talks to several times a week. She reports that she used to be close with her father, but that she’s not talking to him right now because she’s “so angry with him, I can hardly stand to look at him.” Ellie reports thinking that she was not “enough” for her father to be loyal to her mom and that if he loved her more than he would have been faithful because he would have seen how his actions would hurt Ellie. Her maternal grandparents are a few miles away and have always been very supportive of her.

Current Living Arrangements

Ellie lives with her boyfriend and several pets (a dog, and two cats) in an apartment. She reports that her and her boyfriend have been in a committed relationship for three years and that they have lived together for the last year. She reports that her relationship with her boyfriend is good, but that he’s noticed her withdrawing from some of the fun things they typically do together. She reports that they usually go on one or two dates a week and that she “hasn’t been interested”. She also reports “struggling to trust him lately”.

Academic History

Ellie has a bachelor’s degree in business management. She reports that she was always a straight-A student and that she graduated high school when she was 17 and college at 20 years old. She reports loving school and that she was good at it, but that she took it very seriously.

Occupational History

Ellie describes “always having a job from the time I was 15-years old”. She reports being offered a position at the hospital in administration directly after college. She reports that she has quickly “climbed the ladder” which is how she got to her current position as a project manager. She describes herself as a “go-getter” at work and that she is “very organized, maybe to a fault”. Ellie reports that despite not wanting to get out of bed, she has been able to continue going to work even though she “doesn’t feel like it” most of the time.

Current Social Support

Ellie reports having a strong social network with some friends from college. She also states that she is close with her community group at church. She feels that she has many good friends but that she has not had any interest in hanging out with them for the last several months. She reports that her friends have noticed that she’s been “on-edge”, “down”, and “not myself” lately.

Erikson’s Psychosocial Stages

Ellie is in Erikson’s stage of Intimacy vs. Isolation (McLeod, 2023). When talking about her teenage years, Ellie seems to have established her identity, as it relates to Erikson’s Identity vs. Identity Confusion. This was evidenced by Ellie stating that “I never really cared about what others thought of me. I always had a drive to achieve my own dreams and I set out to do that. Whoever supported me was welcome to walk with me”. She now seems to be struggling in the current psychosocial stage since learning of her father’s affair because she states that she “doesn’t know if I can have a relationship and expect it to actually last”.

Spiritual Assessment

Spiritual/Religious History

Ellie reports that she was raised Catholic and her family was very strict going to mass every week (sometimes more than once a week) and following strict rules. She reports that her parents are still practicing Catholicism but that they “are saved”.

Present Spiritual/Religious Beliefs

Client reports that she “believes in God” and attends the same church that she found when she was in college. She reports that she stopped going to her parents’ church because her roommate in college invited her to the campus ministry service which she liked better than the traditional Catholic mass. The client reports that she considers herself very spiritual and believes in God. She reports being non-denominational and attends a local Bible church.

Fowler’s Stages of Faith Development

I believe that Ellie would fit under Fowler’s fourth stage of faith development, called “individuative-reflective faith. Fowler (Armstrong, 2020) describes this stage as a time when the individual makes their faith more personal and can challenge some of their old beliefs. This was evidenced by Ellie describing the change she went through when she left the Catholic church and attended church with her college roommate. She reports that she has learned how to have a more personal relationship with Jesus which has been more spiritually meaningful to her than following the sacraments of the Catholic church.

Integration Assessment

The counselor assessed whether the client wants her spiritual beliefs incorporated into the counseling process. The client stated that she would like her beliefs and spiritual disciplines to be incorporated into counseling, specifically by praying, referencing Scripture, and discussing spiritual things, if applicable.

History of Presenting Problem

Ellie reports that she always considered herself “a little high strung” regarding her academic and work performance, but that she never experienced anxiety that was debilitating like it is now. She reports that it seemed to help her get things accomplished in the past, but that it is now making life and her relationships much more difficult. She reports that although she’s still able to work, she would rather stay home and sleep. Ellie reports that she experienced a time where she felt depressed for approximately two months in college (about six years ago) and she recalled barely leaving her dorm during that time, “except to go to class and work”. She reports that she remembers feeling better after going on a Spring break vacation with her friends. She reports that the anxiety has been present for about four months and the depressive symptoms have been for the last “month or two”.

Barriers to Treatment/Success

Barriers to treatment include the stigma of mental health treatment. Ellie reports that her parents have always been “do it yourself” people and that they rarely seek help from others. She reports that she does not plan to tell her parents that she is in counseling because she doesn’t want to hear any disapproval from them. This current barrier to treatment is low at this point.

Part III: Diagnosis

Principal Diagnosis: (F43.23) Adjustment disorder with mixed anxiety and depressed mood, acute

Rule out: (F41.1) Generalized anxiety disorder; (F33.1) Major depressive disorder, recurrent episode, mild severity

Diagnosis Rationale

Ellie’s symptoms of sadness, anger, and irritability emerged within days of learning her father had cheated on her mother. This is consistent with Criterion A 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). She also began withdrawing and isolating from others, sleeping more than usual, being preoccupied with and ruminating about her parents’ relationship. These symptoms are consistent with Criteria B of adjustment disorder. 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 mixed anxiety and depressed mood” is appropriate as her symptoms include both depression and anxiety, as expressed through her fidgeting, restlessness, irritability, worry, sadness, tearfulness, hypersomnia, and difficulty concentrating. The specifier “Acute” is used since symptoms have been persistent for less than six months (APA, 2022). Ellie’s baseline scores on the PHQ-9 (Kroenke & Spitzer, 2002) indicated mild depression (score of 9), and her scores on the GAD-7 (Spitzer et al., 2006) indicated severe anxiety (score of 16).

Currently, Ellie has some symptoms consistent with major depressive disorder, including a depressed mood, loss of pleasure in activities, hypersomnia, and concentration problems for more than two weeks; however, she does not meet the full criteria of five or more symptoms. Since she is close to meeting five criteria, the counselor will continue to assess to rule out Major Depressive Disorder, recurrent episode, mild severity. The recurrent episode specified would be used if Ellie meets all five criteria because she described a time approximately six years ago where she experienced a 1–2-month episode of depression.

Additionally, Ellie is experiencing some anxiety symptoms that are consistent with Generalized Anxiety Disorder (GAD), which include excessive worry, difficulty controlling the worry, restlessness, easily fatigues, difficulty concentrating, and irritability. However, her symptoms do not meet Criterion A, which states that the anxiety is present for at least six months. Ellie’s anxiety symptoms have been present for four months. Furthermore, her symptoms are better accounted for as an adjustment disorder with the stressor of father’s infidelity. Ongoing assessment is warranted, and diagnoses will be changed if necessary. 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 IV: Case Conceptualization

Theoretical Orientation

The theoretical orientation of the counselor is Cognitive Behavioral Therapy (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 core belief. When using CBT, the counselor educates on the theory and teaches the client how to challenge their thoughts and core belief, leading to adaptive coping behaviors (Beck, 2021). CBT has shown efficacy in treatment of anxiety disorders, including GAD (Borza, 2017; Kaczkurkin & Foa, 2015).

Narrative of the Case Conceptualization

While most of Ellie’s symptoms seem to be connected to her psychological health and maladaptive beliefs related to social contributions (her father’s affair), biologically, Ellie has discontinued exercising and has a poor diet, which is likely a small contributing factor to her depressed mood and anxiety. Further, Ellie has withdrawn from her faith community which could be a protective measure against anxiety and depression as well.

Using a cognitive behavioral lens, Ellie’s core belief of ‘unlovable’ drives her maladaptive thoughts and behaviors resulting in some of her current problems (Beck, 2021). Ellie 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 can’t trust anyone. Everyone will betray me”), are motivated by faulty core beliefs or interpretations of the world based on Ellie’s belief that she was “not enough” for her father to be loyal to her mother (Beck, 2021). Ellie 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 boyfriend, family, and friends; she is powerless, so why try. Additionally, the psychosocial stage that Ellie is currently in (intimacy vs. isolation; McLeod, 2023) is threatened due to her maladaptive thoughts about all romantic relationships being mistrustful since her father’s affair. This could lead to future problems for Ellie in later stages of her life.

Further, Ellie attempts to evade triggering her core belief of unlovable by using avoidance behaviors such as withdrawing from relationships (isolation) and sleeping more; 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 unloved; Beck, 2021). Internal or external reminders of her father elicit worry, feeling out of control, mistrust, anger, and irritability. The client may also have perceptions of cultural shame that need to be further investigated.

Part V: Spiritual Integration

Personal Integration Approach

I operate from an “Allies” model based on Integrative approaches to psychology and Christianity (Entwistle, 2015). This view supports a biblical worldview as the foundation for counseling, namely that the truth comes from the Scripture. 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 that all truth is God’s truth, which includes truths from psychology (Entwistle, 2015).

Implicit Integration

By using the truth of God’s works through Psychology, I can implement psychological theories and interventions with my clients and still be practicing within God’s truth without mentioning His name (Entwistle, 2015). 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 my client is not a believer, I will solely integrate implicitly. 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” (American Counseling Association [ACA], 2014, p. 5).

Explicit Integration

If the client is a fellow believer, at their consent, I will utilize whichever spiritual disciplines they wish to be included in their sessions. Christian interventions, such as prayer, scriptural bibliotherapy, meditation, silence, solitude corporate worship, discussion of Scriptural concepts, and service may be used. In Ellie’s case, she is very open to discussing spiritual things including Scripture and praying together. I integrate these spiritual conversations into the CBT interventions by asking Ellie, “how do your spiritual beliefs impact what we are discussing?”. I am careful when discussing Ellie’s spiritual beliefs that it remains client-centered and that I am never imposing my own beliefs and values (ACA, 2014).

Part VI: Treatment Plan

Treatment Plan

Problems

1. F43.23 Adjustment disorder, with mixed anxiety and depressed mood, Acute – Learning of father’s infidelity, sadness, unhappy, anger, irritability, worry, withdraw, isolation, hypersomnia, rumination

Goals for Change

1. F43.23 Adjustment disorder, with anxiety and depressed mood, Acute (Jongsma et al., 2014) · Recognize current maladaptive thoughts and behaviors contributing to depressive and anxiety 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. · Alleviate anxiety 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. F43.23 Adjustment disorder, with mixed anxiety and depressed mood, Acute Objective – Client will learn about Cognitive Behavioral Therapy. · Counselor will provide psychoeducation on CBT. · Counselor will provide psychoeducation about the relationship between negative self-talk, avoidance behaviors, and mood. Objective – Client will practice challenging maladaptive automatic thoughts and core beliefs, incorporating spiritual beliefs when appropriate. · Counselor will teach the client how to complete a thought record. · Counselor will introduce coping cards. · Counselor will use downward arrow technique to identify core belief. Objective – Client will learn and practice adaptive coping behaviors, · Counselor will provide psychoeducation on Objective – Client will identify and engage in good sleep hygiene. · Counselor will provide psychoeducation on good sleep hygiene. Objective - Client will engage in activity scheduling (e.g., self-care, exercise, and social events every week). · Counselor will provide psychoeducation on the benefits of self-care, exercise, and social support to mental health. Objective – Client will identify and meditate on Scripture that combats core belief. · Counselor will use guided meditations to teach the client how to meditate. Objective – Client will identify and engage in actions to prevent relapse. · Counselor will provide booster sessions as needed.

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 GAD-7 · Pre-post measures on the PHQ-9

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.

Armstrong, T. (2020, June 12). The stages of faith according to James W. Fowler. American Institute for Learning and Human Development. https://www.institute4learning.com/2020/06/12/the-stages-of-faith-according-to-james-w-fowler/

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

Borza, L. (2017). Cognitive-behavioral therapy for generalized anxiety. Dialogues in Clinical Neuroscience, 19, 203-207. https://doi.org/10.31887/DCNS.2017.19.2/lborza

Entwistle, D. N. (2015). Integrative approaches to psychology and Christianity (3rd ed.). Wipf and Stock Publisher

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

Kaczkurkin, A. N., & Foa, E. B. (2015). Cognitive-behavioral therapy for anxiety disorders: An update on the empirical evidence. Dialogues in Clinical Neuroscience, 17, 337-346. https://doi.org/10.31887/DCNS.2015.17.3/akaczkurkin

Kroenke, K. & Spitzer, R.L. (2002). The PHQ-9: A new depression and diagnostic severity measure. Psychiatric Annals, 32, 509-521.

McLeod, S. (2023, April 25). Erik Erikson’s 8 stages of psychosocial development. Simply Psychology. https://www.simplypsychology.org/erik-erikson.html

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

Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Löwe, B. (2006). Generalized anxiety disorder 7 (GAD-7) [Database record]. PsycTESTS.