CASE PRESENTATION OF PENNY 1
Case Presentation of Penny
John Doe
School of Behavioral Sciences, Liberty University
CASE PRESENTATION OF PENNY 2
Case Presentation of Penny
Basic Case Summary
Identifying Information
Date of initial assessment – 8/19/2021
Client’s name – Penny For Your Thoughts
Employment status – Unemployed
School status – Public High School
Age – 16
Gender – Female
Presenting Concern
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.
Background, Family Information, and Relevant History
Penny is a Black female, age 16, who attends a local public high school in her junior year.
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 and it 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 experiences any physical abuse but did report witnessing potential verbal abuse between her
parents. Penny has a 5-year old sister, Margaret, who attends kindergarten.
CASE PRESENTATION OF PENNY 3
Academically, Penny 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.
Penny stated she was “spiritual” and attended her local church somewhat regularly with
her parents before the divorce but not currently. Penny is not currently sexually active and
heterosexual. She does not report any physical health concerns.
Problem and Counseling History
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. 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.” The Beck Depression Inventory-II (BDI-II)
corroborated her depressive state with a score of 23. 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.”
Penny stated she sleeps up to 12 hours a day and finds it difficult to awake in the morning.
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.” She did not report any cultural aspects associated with
her “best” friend in the hospital. She remarked she had few close friends other than her friend in
the hospital. She stated that the continued parental conflict makes “life difficult” and she feels
CASE PRESENTATION OF PENNY 4
“helpless” toward herself 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.
The client did not report any physical, substance use/abuse, harm to self, or others.
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.
Diagnostic Impression
F32.1 Major depressive disorder, single episode, moderate (principal)
Z63.5 Disruption of family by separation or divorce
Z60.5 Target of (perceived) adverse discrimination and persecution (provisional)
Discussion of Diagnostic Impression
Penny is experiencing her first major depressive episode. She has met DSM-5 criteria for
major depressive disorder, single episode, and moderate for around 1 month (American
Psychiatric Association, 2013). 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). 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
CASE PRESENTATION OF PENNY 5
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 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 parent 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.
Case Conceptualization
Step 1: Identify and List Client Concerns and Any Other Problem Areas
Feeling sad
Fatigue
Avolition
Hypersomnia
Parental divorce
Joint custody
Elevated PROMIS
Emotional Distress-
Depression Score
Low self-worth
Low grade performance
Drop in attendance
Worry about sister
Fear of visiting a friend
High parental conflict
Elevated BDI-II score
Parental conflict
Worry about parents
Feels lonely
Withdrawal from friends
Potential discrimination
A friend in car accident
Infidelity
Feels “helpless”
Step 2: Organize Concerns Into Logical Thematic
Groupings
Descriptive-Diagnostic Theme Used
F32.1 Major depressive disorder – feeling sad, fatigue,
avolition, hypersomnia, low self-worth, avoidance, helpless,
CASE PRESENTATION OF PENNY 6
false guilt
Z63.5 Disruption of family by separation or divorce – parental
divorce 2 months ago, high conflict, affair, joint custody
Z60.5 Target of (perceived) adverse discrimination and
persecution (provisional) – “Black kids can’t get a break”
Step 3: Theoretical Inferences: Attach
thematic groupings to Inferred Areas of
Difficulty
Maladaptive thoughts (CBT)
Maladaptive thinking in the following areas:
the false guilt of parent’s divorce – “I caused
my parent’s divorce,” perceived fear of visiting
a hospitalized friend, and poor view of self
“helpless”
Maladaptive behavior (CBT)
Maladaptive behaviors in the following areas:
Withdrawing from relationships (isolation),
avoiding locations (hospital, school), sleeping
more, and not engaging in enjoyable activities.
Step 4: Narrowed Inferences
and Deeper Difficulties
Deepest Negative Distortion
(CBT): I am “helpless”
Case Conceptualization Narrative
Using a CBT lens (Beck Institute, n.d.; Murdock, 2017), Penny’s core maladaptive belief
is helplessness which is driving her maladaptive thoughts and behaviors resulting in some of her
CASE PRESENTATION OF PENNY 7
current problems. Penny has expressed sadness, which can be healthy, but sadness, crying,
avoidance as well as other maladaptive activities are driven by cognitive errors, 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.
Treatment Plan
Problems
1. Major depressive disorder– feeling sad, fatigue, avolition, hypersomnia, low self-worth,
avoidance, helpless, and false guilt
2. Disruption of family by separation or divorce – parental divorce 2 months ago, high
conflict, affair, joint custody
3. Target of (perceived) adverse discrimination and persecution (provisional) – “Black kids
can’t get a break.”
Goals for Change
1. Major Depressive Disorder (CBT)
Understand the relationship between cognitive errors, maladaptive core beliefs, and
depression.
Decrease and potentially eliminate negative automatic thoughts of self and others.
Increase engagement in non-depressed activities to reduce avoidance behaviors.
Increase realistic relational schemas within the family system to reduce conflict and
depression symptoms.
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)
CASE PRESENTATION OF PENNY 8
Understand how discrimination may influence negative thoughts of self, others, and the
world.
Eliminate faculty core beliefs associated with adverse discrimination and persecution.
Increase resiliency to cope with perceived discrimination.
Therapeutic Interventions
1. Major depressive disorder
The counselor will provide psychoeducation about the relationship between negative
self-talk, avoidance behaviors, and mood.
The counselor will provide psychoeducation on good sleep hygiene.
The client will identify and engage in good sleep hygiene activtiies.
The client will write down “therapy notes” of each session and read them daily
between sessions.
The client will identify her maladaptive assumptions, poor coping strategies, and
maladaptive core beliefs in session with the counselor using the cognitive
conceptualization diagram.
The client will identify adaptive behaviors by using the pleasure/mastery scale in the
session.
The client will challenge negative automatic thoughts connected with core beliefs by
completing a weekly thought record and using coping cards.
The client will use behavioral experiments for cognitive restructuring of maladaptive
thoughts and core beliefs.
The client will engage in activity scheduling such as self-care, exercise, and social
events every week.
The client will call the counselor weekly to report on success on identified actions for
that week.
The client will identify and engage in actions to prevent relapse.
The counselor will provide boosters sessions as needed to prevent and recover from
relapse.
2. Disruption of family by separation or divorce
The counselor will provide psychoeducation on divorce.
The counselor will offer Bibliotherapy, The divorce helpbook for teens.
The client will engage in cognitive restructuring of “guilt” via thought log.
The client will process grief/loss of family system through Socratic questioning.
The counselor will refer client to family therapy to conjointly process the divorce.
The counselor will refer client to grief “teen” group counseling.
The target of (perceived) adverse discrimination and persecution (provisional)
The counselor will provide psychoeducation of the CBT triad (feelings, thoughts,
behaviors) to perceived discrimination.
The counselor will conduct a cognitive conceptualization of perceived discriminatory
events to assist the client in understanding the antecedents, behaviors, and
CASE PRESENTATION OF PENNY 9
consequences.
The counselor will assist the client in identifying “normative” discriminatory
perceptions leading to problem-solving actions through Socratic questions.
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 thought log.
The client will use behavioral experiments for cognitive restructuring of maladaptive
thoughts and core beliefs.
The counselor will provide psychoeducation of distress tolerance and mindfulness,
progressive muscle relaxation, and mastery/pleasure activities.
The client will identify and engage in distress tolerance tools.
Outcome Measures of Change
Improved self-worth, improved mood, increased engagement in pleasurable activities and
increased support seeking.
Client report of reduced maladaptive thoughts and behaviors along with increased
pleasure and mastery activities.
Pre-post measures on the Beck Depression II Inventory.
Counselor observation of improved mood via signs, symptoms reduction, and change
talk around automatic thoughts, assumptions, and core beliefs.
Client report of reduced family disruption.
Client report of increased distress tolerance of perceived adverse discrimination.
CASE PRESENTATION OF PENNY 10
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Beck, J. (n.d.). Essentials of CBT: The Beck approach. Course Manual. Beck Institute.
Murdock, H. L. (2017). Theories of counseling and psychotherapy: A case approach (4 ed.).
th
Pearson.
Rubin, A. M., & Switzer, L. C. (2015). Diagnosis & treatment planning skills: A popular culture
casebook approach . (2nd edition) Sage.
