CASE PRESENTATION OF HANK 2
Case Presentation of Hank
Part I – Intake Information
Identifying Data
Date of initial assessment – 8/19/2021
Client’s name: Hank 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
Hank is self-referred with parental consent. Hank 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, Hank 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
CASE PRESENTATION OF HANK 3
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
Hank 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
Hank 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
Hank does not report any recreational activities as this time. Prior to her depressive
symptoms, she did engage in recreational basketball.
Medication
CASE PRESENTATION OF HANK 4
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
Hank 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. Hank does
not report any previous episodes of clinical depression.
Addiction Screening
Hank reports no history of addiction. The client does not consume alcohol or other drugs.
Risk Assessment
Hank 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
Hank 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.
CASE PRESENTATION OF HANK 5
Social Assessment
Cultural Factors
Hank 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), Hank 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. Hank now splits her time between her
parents’ household. Hank 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. Hank did not
report observing or experiencing any physical abuse but did report witnessing potential verbal
abuse between her parents. Hank 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
CASE PRESENTATION OF HANK 6
Academically, Hank, a junior, identified a dip in her academic grades and attendance
during the past five months. Historically, Hank 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. Hank may also be process in her identify
development as a Black women based on her CFI interview.
Spiritual Assessment
Spiritual/Religious History
Hank 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
Hank 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
CASE PRESENTATION OF HANK 7
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
Hank 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 Hank 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
CASE PRESENTATION OF HANK 8
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)
Z63.5 Disruption of family by separation or divorce
Z60.5 Target of (perceived) adverse discrimination and persecution (provisional)
Diagnostic Rationale
Hank is experiencing her first major depressive episode. She has met DSM-5TR criteria
for major depressive disorder, single episode, and moderate for around 1 month (American
Psychiatric Association, 2022). Hank 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 Hank (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 Hank’s current state.
CASE PRESENTATION OF HANK 9
Z63.5, disruption of family, was assigned because of the continued parental conflict and
the divorce of her parents. Hank reported, “I caused my parents’ divorce” which may be
associated with the disruptive family system. Finally, Hank 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.
