CASE PRESENTATION
Benchmark Case Presentation Paper Assignment
School of Clinical Mental Health Counseling, Liberty University
1
CASE PRESENTATION
Benchmark Case Presentation Paper Assignment
Part I: Intake Information
Identifying Data
Date of Initial Assessment: September 20, 2024 Sexual Orientation: Heterosexual
Pseudo Name Jessica Smith Race & Ethnicity: White
Age: 36 Marital/Relationship Status: Married
Gender: Female Employment Status/Grade Level: College
2
CASE PRESENTATION
Reason for Referral/Presenting Problem
Jessica is a 36-year-old Caucasian female who resides with her husband and three
children. She is a stay-at-home mother to her children, ages 6, 3, and 2 months. She was
referred to our clinic by her OBGYN due to concerns for her well-being following her 6-week
post-natal appointment. She reports that she has recently been feeling very irritable and nervous
to the point where she is distracted and can’t think straight. She also says she has had difficulty
bonding with her newborn. When asked about her relationship with the infant, she responded,
“It’s like he's a friend’s child who I am babysitting. I take care of him and do all of the things
I’m supposed to. But I don’t feel connected to him. I like him a lot and even love him, but not
like I loved my other kids. I want to love him like that so much, but I just don’t know how.”
Jessica reports that she had planned on a natural birth for her son. She had opted to find
out his sex at birth rather than during an ultrasound earlier in her pregnancy. “I had this dream in
my head where I would have the baby, and they would be placed in my arms. Then, after I felt
bonded, I would look and announce to the room whether it was a boy or a girl. It was all
supposed to be so peaceful. But it ended up being a nightmare.” Jessica said that at 41 weeks,
her doctor discovered that her baby was breech. They attempted to turn him, but he ended up
with a decelerating heart rate and had to be delivered via emergency cesarean. Jessica reports
that everything began happening very quickly and she missed out on the first two hours of her
son’s life while in recovery. Jessica told me, “When they took me back to the room, the nurse
said to come see my son. I didn’t even get to look before they told me. I was the last to hold him
and the last to know he was a boy.”
Since returning home, Jessica stated that she has had difficulty coming to terms with the
fact that her son’s birth was so different from what she had imagined. “It’s as if it happened to
3
CASE PRESENTATION
someone else, and I’m still waiting for my child to be born.” She often finds herself
remembering the moments in the operating room before she fell asleep and says it makes her feel
very panicked. Other times, she says, she replays the events in her head trying to think of ways
she could have changed the outcome. “Sometimes I think if I’d only done something to keep him
from turning, or I’d agreed to an induction a week earlier, this wouldn’t have happened.”
Because her OBGYN’s office is in the same hospital where her son was born, she
admitted that even attending her postpartum checkup caused her to feel anxious, and she even
rescheduled it for a time her mother could take her. “I knew if my mother was taking me, I
would have to go. Otherwise, I probably would have rescheduled.” She also reports having
frequent nightmares about the experience and hardly ever sleeps because of it. She says she is
normally a very gentle parent to her children but that lately, she has been very easily irritated by
the smallest things her 6-year-old and 3-year-old do.
Jessica says she has been avoiding spending time with her friends and family because she
worries that they won’t understand. “They think I’m just upset that I didn’t get my ‘perfect
birth’ or that I think there’s something bad about cesareans. But that isn’t the case at all. Yet
some of my friends have even gotten angry when I tried to explain how I felt because they had c-
sections and think I’m judging them. I’m not at all! So, I just don’t want to see anyone now.”
She acknowledges that her family and most of her friends have tried to be supportive and reach
out, but that she still doesn’t want to see anyone. Jessica told me, “I feel like I’m a terrible
mother for feeling like this. Everyone keeps telling me that the only thing that matters is that he
is healthy. I’m so glad he’s healthy! But that doesn’t change the fact that I went through such a
scary birth! Why can’t people understand that?” She said she knew her birth may not be exactly
as envisioned but that it was the events surrounding it that made it so much worse. “Not even
4
CASE PRESENTATION
being awake when he was born, not seeing him for hours, and then having a stranger hold him
before me awhile she cheerfully told me he was a boy are the things that really hurt the most.”
Part II: Client’s Biopsychosocialspiritual Assessment
Biological Assessment
Jessica is a 36-year-old Caucasian female who resides with her husband and three
children. She is a stay-at-home mother to her children, ages 6, 3, and 2 months. She reports that
she only sleeps for a couple of hours at a time, getting a total of 4 hours a night, and may take a
short nap during the day. Her diet consists mostly of quick snacks throughout the day and one
good dinner in the evening. She has not been getting much exercise since the birth of her infant
son, but before this, she was walking about ½ of a mile daily through her neighborhood. She
was on Zoloft (sertraline) for anxiety before her pregnancy but was weaned off of it when she
discovered she was pregnant. She has discussed the possibility of taking it again but is
concerned about the effects it may have on her breastfeeding relationship with her son.
Psychological Assessment
Jessica has a history of anxiety, for which she took Zoloft previously. She has never had
any psychiatric-related hospitalizations or other diagnoses. She does not have a history of
trauma up to this point in her life and has no history of illegal substance abuse. She drank
socially before her recent pregnancy and also smoked about 10 cigarettes per day, both of which
she stopped immediately upon becoming pregnant. Jessica scored an 8/10 on the Trauma
Screening Questionnaire (TSQ) indicating a high risk for post-traumatic stress disorder (PTSD).
Jessica does not have a family history of stress or trauma-related disorders but does report having
a sister with anxiety and a grandmother who was diagnosed as having bipolar disorder.
Social Assessment
5
CASE PRESENTATION
Jessica has no reported cultural factors that may be a source of her symptoms. She has a
strong relationship with her family of origin, including her mother, father, older sister, and
younger brother. Her family all live locally and normally spend a lot of time together.
Jessica and her husband have been married for seven years and have three young
children. Their oldest, a daughter, is 6. They also have two sons, ages 3 and 2 months. They
live in what Jessica describes as a “happy home with two cats and a dog.”
Jessica obtained her bachelor’s degree in education 14 years ago. She reports that she
was a good student and excelled in her field of study. After school, she began teaching at a small
Montessori school in Hawaii, specializing in Special Education. She enjoyed her work greatly
and said she felt very fulfilled. She met her husband, who was stationed in Hawaii, and left her
job to get married when they discovered he was going to be returning to the mainland. Soon
after, they discovered they were having their first child, so Jessica opted to become a stay-at-
home mom rather than return to her teaching career. She mentioned that she still misses it but
that she would not trade this time with her children for anything.
Spiritual Assessment
Jessica was raised in a Catholic household. Her husband was raised in a non-
denominational environment. She said that they have decided to attend a non-denominational
church, but they still incorporate Catholic traditions within their home. They attend their church
weekly and previously participated in a small group that included other young families. Their
group ended just before her youngest was born and they have not joined another as of the date of
this assessment.
Jessica states that faith is important to her. She mentions that she is currently feeling a bit
angry with God over how everything happened with her son’s birth, but that she isn’t entirely
6
CASE PRESENTATION
sure what part of it she is mad at Him about. She would like to have religion incorporated
somehow so that she can regain her trust in God.
Part III: Mental Status Exam
Appearance
Jessica is a 5’8” female of average weight. She came to our session today dressed in a
casual, comfortable outfit. She appeared to be well-groomed and with good hygiene. She was
visibly tired with drooping eyes and persistent yawning, for which she apologized profusely.
Manner and Approach
Jessica seemed very willing to take part in the assessment. She had a friendly and open
personality and was willing to answer all questions fully. She was able to maintain appropriate
eye contact without instances of staring or avoidance. Her speech was normal without delays or
deficits. She chose words that properly expressed her thoughts and feelings, indicating good
semantics. She was coherent and able to comprehend all questions. When asked to recall three
unrelated items (green, computer, lion) she was able to name them after a 15-minute interval.
Alertness and Thought Process
Jessica did struggle with alertness due to her obvious lack of sleep, though she was able
to demonstrate orientation x 4 (stating her name, where we were located, the date, and why she
was here). She did seem to have trouble with her concentration, seemingly becoming distracted
and having to ask me to repeat a couple of questions. Her thought flow was clear and sequential
when responding to questions. When asked if she had a history of hallucinations, she stated that
she had never experienced them.
When asked how she would handle a situation where she had more tasks to do than time
allowed, Jessica responded that she would prioritize what was most important, and once those
7
CASE PRESENTATION
were completed, she would work on the quickest tasks first so she could get as much done as
possible. This demonstrated sound judgment skills and also insightfulness. She then performed
multiple tasks including a simple puzzle and mathematical questions, demonstrating normal
intellect.
Mood and Affect
Jessica seemed to be in a pleasant mood at the beginning of our session but also showed
signs of distress when discussing her experience during her son’s birth. She tended to smile,
even when discussing the distressing events. When asked about this she responded that she
didn’t even notice she was smiling, but that she guessed it was because she felt she was supposed
to be happy when talking about her son being born.
Jessica has no history of suicidal or homicidal ideations and was very clear that she had
no desire to harm her child or herself. She restated that she cares for him and is always sure to
meet his every need. She said that she is a very non-violent person and considers herself a
“gentle parent” to all of her children.
Part IV: Answer Key
DSM-5 Diagnostic Criteria:
Post-Traumatic Stress Disorder, acute
(F43.11
Client’s Reported Symptoms:
Criterion A: Exposure to actual or threatened
death, serious injury, or sexual violence in
one (or more) of the following ways:
A1: Directly experiencing the traumatic
event(s).
Traumatic childbirth event happened directly
to the client.
A2: Witnessing, in person, the event(s) as it
occurred to others.
A3: Learning that the traumatic event(s)
occurred to a close family member or close
friend. In cases of actual or threatened death
of a family member or friend, the event(s)
must have been violent or accidental.
A4: Experiencing repeated or extreme
8
CASE PRESENTATION
exposure to aversive details of the traumatic
event(s)
Criterion B: Presence of one (or more) of the
following intrusion symptoms associated with
the traumatic event(s), beginning after the
traumatic event(s) occurred:
B1: Recurrent, involuntary, and intrusive
distressing memories of the traumatic
event(s).
Client reports that she finds herself
preoccupied with memories of the operating
room before falling asleep.
B2: Recurrent distressing dreams in which
the content and/or affect of the dream are
related to the traumatic event(s).
Client reports having frequent nightmares
about the event.
B3: Dissociative reactions (e.g.,
flashbacks) in which the individual feels or
acts as if the traumatic event(s) were
recurring.
Client says she has had difficulty coming to
terms with her son’s difficult birth.
Client states that it feels like her son is not
hers, and like she is still waiting for her son to
be born despite knowing he is, in fact, hers.
B4: Intense or prolonged psychological
distress at exposure to internal or external
cues that symbolize or resemble an aspect of
the traumatic event(s).
B5: Marked physiological reactions to
internal or external cues that symbolize or
resemble an aspect of the traumatic event(s).
Criterion C: Persistent avoidance of stimuli
associated with the traumatic event(s),
beginning after the traumatic event(s)
occurred, as evidenced by one or both of the
following:
C1: Avoidance of or efforts to avoid
distressing memories, thoughts, or feelings
about or closely associated with the traumatic
event(s).
C2: Avoidance of or efforts to avoid
external reminders (people, places,
conversations, activities, objects, situations)
that arouse distressing memories, thoughts, or
feelings about or closely associated with the
traumatic event(s).
Client reported feeling anxious about her
OBGYN checkup because it was at the
hospital where she gave birth. She admitted
having to have her mother take her just so she
would go.
Criterion D: Negative alterations in
cognitions and mood associated with the
9
CASE PRESENTATION
traumatic event(s), beginning or worsening
after the traumatic event(s) occurred, as
evidenced by two (or more) of the following:
D1: Inability to remember an important
aspect of the traumatic event(s) (typically due
to dissociative amnesia and not to other
factors such as head injury, alcohol, or drugs).
D2: Persistent and exaggerated negative
beliefs or expectations about oneself, others,
or the world.
Client says she feels like a terrible mother
because of how she feels.
D3: Persistent, distorted cognitions about
the cause or consequences of the traumatic
event(s) that lead the individual to blame
himself/herself or others.
Client says she replays the events in her head
thinking of ways she could have changed the
outcome.
D4: Persistent negative emotional state
(e.g., fear, horror, anger, guilt, or shame).
D5: Markedly diminished interest or
participation in significant activities.
D6: Feelings of detachment or
estrangement from others.
Client says she avoids spending time with
family and friends because she worries that
they don’t understand why she is feeling this
way.
Client reports difficulty bonding with her
infant son.
D7: Persistent inability to experience
positive emotions (e.g., inability to experience
happiness, satisfaction, or loving feelings).
Client says there is not a connection with her
baby like the ones she had with her other
children.
Criterion E: Marked alterations in arousal
and reactivity associated with the traumatic
event(s), beginning or worsening after the
traumatic event(s) occurred, as evidenced by
two (or more) of the following:
E1: Irritable behavior and angry outbursts
(with little or no provocation) typically
expressed as verbal or physical aggression
toward people or objects.
Client reports being very irritable, specifically
with her young children, despite normally
being a gentle person and mother.
E2: Reckless or self-destructive behavior.
E3: Hypervigilance.
E4: Exaggerated startle response.
E5: Problems with concentration. Client reports feeling nervous to the point
where she is distracted and can’t think
straight.
10
CASE PRESENTATION
E6: Sleep disturbance (e.g., difficulty
falling or staying asleep or restless sleep).
Client reports difficulty sleeping due to
nightmares about the event.
Criterion F: Duration of the disturbance
(Criteria B, C, D, and E) is more than 1
month.
Client reports feeling this way since the birth
of her son 2 months ago.
Criterion G: The disturbance causes
clinically significant distress or impairment in
social, occupational, or other important areas
of functioning.
Client has difficulty bonding with her child
and is avoidant of social activities.
Criterion H: The disturbance is not
attributable to the physiological effects of a
substance (e.g., medication, alcohol) or
another medical condition.
No reported substance use or medical
conditions that may have attributed to the
disturbance.
Part V: Treatment Considerations
Two Counseling Approaches
The most important issues to address in Jessica’s case are helping her to focus on
bonding with her infant, finding positivity in her relationship with him, and helping reduce her
symptoms. I recommend Jessica begin Trauma-Focused Cognitive Behavioral Therapy (TF-
CBT). Studies have shown TF-CBT to be highly effective in reducing acute traumatic stress
symptoms, especially when started early (Taylor Miller et al., 2021). CBT is one of the preferred
methods of treatment for PTSD. It helps the client focus on how their thoughts and feelings can
impact other areas of their lives. By helping improve on these negative behaviors or emotions,
they can begin to change their thought patterns, replacing the negative feelings or behaviors with
positive ones (American Psychological Association, 2017). In Jessica’s case, helping her to
change her focus from the negative feelings she has regarding her birth experience and instead
11
CASE PRESENTATION
focusing on building a positive bond between herself and her infant son can help lead to a
healthier, more positive mindset.
Another promising treatment for birth-related PTSD I would recommend for Jessica is
Eye Movement Desensitization and Reprocessing (EMDR) Therapy. Multiple studies have
shown it to be an effective treatment for past-partum women with symptoms of PTSD
(Wetherell, 2022). This therapy assumes that PTSD results from the memory of the event being
inadequately processed within the brain. This results in the memories containing the emotions,
beliefs, and physical manifestations of the event that can be triggered and create the symptoms of
PTSD (American Psychological Association, 2017). This is done by using eye movements and
stimulations while the client focuses on memories of their trauma. Unlike CBT, EMDR doesn’t
involve exposing the client to the trauma event for long periods of time. Instead, it focuses on
changing how the memory is stored in the brain and reducing the symptoms (American
Psychological Association, 2017).
Medication Considerations
Because of Jessica’s history of anxiety and previous success with controlling these
symptoms with Zoloft (Sertraline), I recommend she be evaluated for restarting this regimen.
Sertraline is also a recommended medication for the treatment of PTSD (American
Psychological Association, 2017). Studies consistently show success with a combination of
SSRIs such as Sertraline and psychotherapy particularly in the areas of social functioning and
managing trauma-related emotions (Graham et al., 2020). Jessica mentioned concerns regarding
the safety of SSRI use while breastfeeding. Research shows that Sertraline is the preferred
option for lactating women as it has the lowest concentration transferred by breast milk of all
SSRIs (Ushkalova & Ushkalova, 2023).
12
CASE PRESENTATION
Spiritual Integration Considerations
Jessica mentioned that she wanted to incorporate her faith and spirituality into the
counseling process. Because she is angry with God at the moment, I would work on rebuilding
that trust through reflection, meditation, and prayer. I would also encourage her to reconnect
with her church and look into finding a small group when she feels ready to do so.
13
CASE PRESENTATION
References
American Psychiatric Association. (2022).MDianostic and statistical manual of mental
disordersM(5th ed., text rev.).Mhttps://doi.org/10.1176/appi.books.9780890425787
American Psychological Association. (2017). Clinical Practice Guideline for the Treatment of
PTSD.
Graham, B., Garcia, N. M., Bergman, H. E., Feeny, N. C., & Zoellner, L. A. (2020). Prolonged
exposure and sertraline treatments for posttraumatic stress disorder also improve multiple
indicators of social functioning.MJournal of traumatic stress,M33(4), 488-499.
Taylor Miller, P. G., Sinclair, M., Gillen, P., McCullough, J. E. M., Miller, P. W., Farrell, D. P.,
Slater, P.F., Shapiro, E., & Klaus, P. (2021). Early psychological interventions for
prevention and treatment of post-traumatic stress disorder (PTSD) and post-traumatic
stress symptoms in post-partum women: A systematic review and meta-analysis.MPLoS
One,M16(11), e0258170.
Ushkalova, E. A., & Ushkalova, A. V. (2023). Comparative analysis of the use of selective
serotonin reuptake inhibitors during pregnancy and the postpartum period. Safety of
sertraline.MNeurology, Neuropsychiatry, Psychosomatics,M15(5), 94-101.
Wetherell, S. (2022). Investigating the impact of eye movement desensitization and reprocessing
(EMDR) in reducing birth trauma symptoms. InMAPPM(Vol. 9, No. 2, pp. 67-75).
14
