BENCHMARK CASE PRESENTTION PAPER
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Case Presentation Paper
Samantha Deenihan
School of Clinical Mental Health Counseling, Liberty University
Case Presentation Paper
Part I: Intake Information
Identifying information
Date of Initial Assessment: 2/20/2025 Sexual Orientation: Cisgender/ Heterosexual
Pseudo Name: Ann Fay Race & Ethnicity: White
Age:14 Marital/Relationship Status: Single
Gender: Female Employment Status/Grade Level: 7th grade
Reason for Referral/ Presenting Problem
Ann Fay, a 14-year-old female in the 7th grade was referred for treatment due to ongoing
struggles with severe depression and anxiety. She is reporting feeling sad and empty most of the
time, often saying “I just feel like everything is wrong and nothing ever gets better. I don’t often
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want to get out of bed anymore. It’s like I’m stuck in this fog.” Ann is also reporting struggling
with sadness hopelessness, worthlessness, anhedonia, lack of motivation, low mood, isolation,
SI. “I have been feeling so sad and hopeless most of the day and it seems like forever, all I have
been thinking about lately is being alone and wanting to hurt myself sometimes but I do not
follow through. Ann is having difficulty concentrating in school and her grades have been
slipping because she feels too overwhelmed to focus on assignments or even participate in
class. “I know I should be doing schoolwork, but it feels pointless, and I just don’t care anymore”
she explains. Her social life has also been affected. Ann used to like spending time with her
friends, but now she is isolating herself and finding it difficult to connect anyone. “I used to
laugh with my friends but now I don’t even feel like hanging out with them. I don’t know how to
act around them. I feel like I’m dragging them down”. She was also reporting feeling an increase
of disconnect from her peers and has withdrawn from most of all her activates.
Ann is reporting having trouble falling asleep and often laying awake for hours feeling
restless. “I keep thinking about stuff, and then I can’t sleep. Sometimes I stay up all night and
then sleep all day. It feels like I’m never really rested,” she shares. Along with her disturbed
sleep, Ann’s appetite has changed. She either eats too much or has no interest in food at all. “I
don’t even feel hungry sometimes. Other times, I just eat to try and feel better, but it doesn’t
work.” Her sense of hopelessness if profound. She does not have any interest in her future. “I
don’t think things will ever get better. I don’t know what I want to do with my life, and it feels
like nothing really matters,” she states. This overwhelming sadness, coupled with an inability to
find joy or purpose in things she used to enjoy, has left her feeling emotionally drained and
unsure of how to move forward.
Part II: Client’s Biopsychosocial Spiritual Assessment
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Biological Assessment
Ann Fay is a 14- year- old female of white ethnicity and is currently in the 7th grade. She is
single and has no children. Ann identifies at heterosexual and lives with her parents. She has no
history of medical conditions but has been experiencing ongoing depression that has led to her
having trouble with daily functioning. Ann is reporting sleep disturbances. She is struggling with
falling asleep at night because her mind is racing with concerns. “I just keep thinking about
everything and can’t shut it off,” she says. As a result, Ann’s sleep is erratic, and she frequently
sleeps during the day to make up for the lack of rest at night, leaving her feeling tired and
groggy. Ann’s diet has fluctuated with her mood. She explains that when she feels down, she
often loses interest in food, skipping meals, or not feeling hungry at all. However, on some
occasions, she turns to food for comfort, eating excessively in an attempt to alleviate her
sadness.
“I eat when I feel bad, but I still feel empty afterward,” she notes. This pattern has led to
irregular eating habits and an overall lack of consistent nutrition. Exercise is not a regular part of
Ann’s routine. Due to her depressive symptoms, she has lost interest in physical activities she
once enjoyed, such as walking or playing outside with friends. “I used to ride my bike, but now I
just stay inside. I don’t have the energy or motivation,” she shares. This lack of physical activity
further contributes to her sense of lethargy and disengagement from daily life. Ann has no
significant medical history outside of her current struggles with depression. She has not been
prescribed any medication for her condition yet but is being evaluated for potential treatment
options. However, her parents have expressed concerns about her mood changes and the
impact on her ability to function at school and in social settings. As she is still in the early stages
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of receiving care, treatment options are being discussed to help alleviate her depressive
symptoms.
Psychological Assessment
Ann Fay has not previously attended counselling or received any psychiatric
hospitalizations. This is her first time seeking mental health treatment. However, her parents
have expressed concern over her recent emotional changes and behaviors, prompting them to
refer her to support. She has not been previously diagnosed with any mental health conditions,
though her symptoms have become more pronounced in the past several months, leading to
her current and diagnosis of major depressive disorder, reoccurring episode, severe. Ann has no
known trauma history and has not reported experiencing any significant life events or views that
could be contributing to her current depressive state. However, she does mention feeling
increasingly overwhelmed by her struggles with social interactions and school performance,
which may have exacerbated her emotional difficulties. Regarding substance abuse and has no
history of alcohol or drug use. She reports that she's never consumed alcohol smoked or used
recreational drugs. She did mention that some of the friends that she's hung out with has
partake in these activities, but she declined. Ann appears to be in a low-risk category in terms of
substance abuse, but her depression and emotional distress may make her more vulnerable for
potential future risks if left unaddressed. The risk assessment for Ann was conducted through an
initial evaluation, during which she was asked about any thoughts of self-harm (SH), suicidal
ideation (SI), or behaviors. She reported feeling hopeless and overwhelmed but in denied any
current suicidal thoughts or intent, but she also reported that she has SH before and has had SI
before. She expressed fear that her emotional state might worsen over time, but she has not
engaged in much self-destructive behaviors. Despite her distress, Ann does not present an
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immediate risk of harm to herself but remains at an elevated risk due to the severity of her
depressive symptoms. Ann's family mental health history is notable for her mother having
experience bouts of depression during her teenage years period Anna's mother was treated
with therapy and medication, and she has since managed her condition well. Ann's father does
not report any significant mental health challenges, though there is a family history of anxiety
on her paternal side. This may be an important factor in understanding the potential genetic
influences of Ann's mental health
Social Assessment
Ann does not report significant cultural factors, such as acculturation or discrimination
that may contribute to her depression. She has grown up in a predominantly homogenous
community, and her family has not experienced significant cultural or ethnic challenges.
However, Ann has indicated feeling different from her peers at school. She has struggled with
making close friends and often feels isolated, though she has not specifically attributed these
feelings to cultural factors. Ann would likely explain her struggles from the lens of feeling
emotionally disconnected from those around her, stating that it is difficult to relate to others
and share her emotions.
Ann's family consists of her mother, father, and two younger siblings. Her mother, age
40, works as a nurse, while her father, age 42, works as a software engineer. Ann's younger
brother, age 9, and younger sister, age 6, are still in elementary school. Ann describes her
relationship with her parents as somewhat strained due to her emotional struggles, saying, “I
think they’re worried about me, but I don’t really know how to talk to them. I feel like they
don’t understand how hard this is for me.” Despite her parents’ concern, Ann feels that there is
a lack of open communication at home, which has contributed to her sense of isolation. While
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there are no major incidents that have caused family conflict, Ann's emotional difficulties have
created tension in the household, as her parents are unsure of how best to support her. She
often feels that her siblings receive more attention, leaving her feeling overlooked. Ann does not
currently have a romantic partner, and she has no interest in dating. She reports that her focus
has been on her emotional well-being and schoolwork, and she has not had a significant
relationship with a peer in recent months. Ann’s lack of engagement in social activities,
including dating, is largely due to her depression and lack of motivation to connect with others.
In terms of academic history, Ann has always been a bright student, though her
academic performance has declined recently. She used to be an enthusiastic learner, excelling in
subjects like English and History. Over the past several months, her grades have slipped, and she
finds it difficult to stay focused in class. “I used to get straight A’s, but now it’s hard to keep up. I
just don’t care about school anymore”. Her teachers have reported that she is often distracted
and disengaged during lessons. Ann has not sought out extra help or attended tutoring sessions,
indicating that her feelings of hopelessness extend into her academic life. Her emotional state
has significantly impacted her ability to perform at her usual high level, and she expresses
frustration about her inability to improve.
Ann has no occupational history, as she is still a student and not old enough to work
just yet. She has expressed an interest in working with animals, particularly as a veterinarian, in
the future.
Spiritual Assessment
Ann Fay does not have a significant religious or spiritual background. She has not
been raised in a religious household, and her family does not regularly attend church or practice
any form of organized religion. Ann's parents have not emphasized religious beliefs in their
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family life, and Ann herself has not been exposed to a particular faith tradition. Currently, Ann’s
spiritual beliefs are not a prominent part of her daily experience. She has expressed uncertainty
about her beliefs, saying, "I don't really think about God or religion much. I don’t know what I
believe right now." While Ann does not attend church or engage in religious activities, she is
open to exploring her spirituality. Regarding the integration of spiritual beliefs into the
counseling process, Ann has not expressed a strong desire to incorporate religious or spiritual
practices. She has not specifically requested prayer, Scripture readings, or spiritual discussion
during therapy. However, she is open to discussing spiritual matters if they become relevant to
her mental health.
Part III: Mental Status Exam
Anns mood appeared consistently low throughout the session, with a noticeable lack
of energy and motivation. Ann’s affect was flat, and she often seemed distant, making minimal
eye contact and speaking in a soft, monotone voice. There were no signs of tearfulness, but her
body language suggested sadness and emotional fatigue. Her responses were brief, and she did
not seem fully engaged in the process.
Presenting Appearance
Ann appeared to be dressed causal wearing oversized clothing. She was disheveled,
would indicate lack of personal grooming. She had her hair pulled into a bun and seemed to be
unwashed and brushed.
Basic Grooming and Hygiene
Grooming was minimal, her hygiene appeared to be neglected with unkept hair,
and
stain on her oversized clothing.
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Interpersonal Characteristics and Approach to Evaluation
Ann was cold and passive during the evaluation. She seemed hesitant to engage
fully in the discussion, providing short and guarded responses.
Speech
Her speech was soft, slow and at times, monotone. There was no evidence of being
pressured to speak during the assessment, but her responses were brief and lacked elaboration.
Eye Contact
Limited eye contact. She was mainly looking down or away during the discussion.
Expressive Language
Language was clear, though she spoke in a minimal and detached manner. She did
not appear to engage emotionally in the conversation.
Receptive Language
She demonstrated appropriate comprehension of the questions asked in response
appropriately.
Orientation
She was fully oriented to person, place, and time period she did not show any signs
of confusion or being disoriented.
Alertness
Ann was alert and appeared fully aware of her surroundings throughout the
evaluation.
Coherence
Her thoughts were coherent and organized, though she seemed to struggle with
elaborating on her experiences.
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Concentration/ Attention
She had difficulty focusing on the evaluation. She did seem distracted and was
unable to maintain consistent attention.
Thought Processes
Her thought process was logical and goal oriented, though at times she did appear
to
struggle with initiating or sustaining the flow of conversation.
Hallucinations and Delusions
No evidence of hallucinations or delusions during evaluation or reported.
Judgement/ Insight
Ann demonstrated partial insight into her depression, meaning she was able to
acknowledge that she felt disconnected and overwhelmed but was unsure how to move
forward.
Intellectual Ability
Her intellectual ability appeared average with appropriate response to questions
there were no indication of cognitive impairment.
Mood
Ann described her mood as sad and empty, consistent with her report of depression.
Her affect matched her described mood, appearing flat and consistent with her emotional state.
Affect
Ann’s affect was constricted, and she demonstrated little emotional expression
throughout the evaluation.
Suicidal and Homicidal Ideation
Ann denied and current SI and HI but did report that has had some SI in the past but
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not in the past year.
Risk of Violence
There was no indication that Ann posed any immediate risk of harm to others. She
did not demonstrate any signs of aggression or violent tendencies during the evaluation.
Part IV: Answer Key
DSM-5 Diagnostic Criteria: disorder name and
code number
Client’s Reported Symptoms:
Criterion A: Five (or more) of the following
symptoms have been present during the same
2-week period and represent a change from
previous functioning; at least one of the
symptoms is either (1) depressed mood or (2)
loss of interest or pleasure.
1. Depressed mood most of the day,
nearly every day
2. Markedly diminished interest or
pleasure in all, or almost all, activities
most of the day
3. Significant weight loss when not
dieting, weight gain, or decrease or
increase in appetite
4. Insomnia or excessive sleeping
5. Psychomotor agitation or retardation
(restlessness or slow movement)
Ann is reporting feeling sad and empty most
of the time period she describes the
persistent sense of hopelessness. She is also
lost interest in activity she once enjoyed. She
is also reporting fluctuating appetite,
sometimes not feeling hungry at all and
sometimes over needing to cope with her
emotions. She is having difficulty falling
asleep at night and sometimes it's sleeping
excessively during the day. She also reported
feeling physically and emotionally drained.
She has expressed a sense of worthlessness.
She is also finding it difficult to concentrate
and staying focused during school. And denies
a specific plan to harm herself but has had SI
in the past it also expresses significant
hopelessness and worry about her future and
has stated that she doesn't see how things
could get better and
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive
guilt
8. Diminished ability to think or
concentrate, or indecisiveness
9. Thoughts of death or suicidal ideation
without a specific plan or suicide
attempt
sometimes there's like nothing matters.
Criterion B: The symptoms cause clinically All of her symptoms are having it hard for her
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significant distress or impairment in social,
occupational, or other important areas of
functioning.
to function in her daily life whether it's home
life or school life.
Criterion C: The episode is not attributable to
the physiological effects of a substance or
another medical condition.
She's not taking any substance and does not
have another medical condition
Criterion D: The occurrence of the major
depressive episode is not better explained by
a psychotic disorder or a substance-induced
mood disorder.
Does not have a psychotic disorder or a
substance-induced mood disorder.
Criterion E: There has never been a manic
episode or hypomanic episode.
No manic episodes or hypomanic episode
Criterion F: The occurrence of the major
depressive episode is not better explained by
bereavement.
Has not had bereavement to explain
Part V: Treatment Considerations
Two Counseling Approaches
Cognitive behavioral therapy (CBT) has been widely studied and shown to be an effective
treatment in treating major depressive disorder especially in adolescents (Cuijpers et al.,
2020). CBT focuses on identifying and challenging negative thought patterns, which is
particularly beneficial for a client like Ann who's experiencing pervasive feelings of
hopelessness, self-worthlessness, and depression. By helping and recognize and reframe these
cognitive distortions, CBT can help her develop healthier thinking patterns and coping
mechanisms to manage her depressive symptoms.
In CBT, the therapist would work with and to identify the automatic negative thoughts that fuel
her depression. For example, she believes that she is “failing everything” could be challenged
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through cognitive reconstructing. A key focus would also be on increasing her engagement and
pleasant activities and social interactions, counteracting that isolation. This approach would be
beneficial for her because she already reports losing interest in activities that once brought her
joy. So encouraging her to engage in these activities again are small steps that can reduce her
sense of isolation and increase her mood and energy levels that she's lacking.
CBT has been found to be effective in treating adolescent depression, especially when
integrated with behavioral strategies aimed at increasing engagement in positive activities and
improving emotional regulation (Weersing et al., 2017). This is consistent with Anne symptoms
because she is struggling with lack of motivation and social withdrawal.
A counselor would begin by conducting cognitive reconstruction during exercises,
focusing on helping and challenge her negative self-perceptions and those beliefs about her
ability to cope with her emotions. Behavioral activation techniques could also be used to help
her start reintroducing enjoyable activities into her routine and helping her experience more
positive emotions and reduce those feelings of hopelessness and sadness.
Interpersonal Therapy (IPT) is another evidence based approach to treating depression
comma particularly when depression is linked to difficulties in interpersonal relationships
(Markowitz & Weissman, 2019). Ann reports emotional withdrawal and struggles with her
family relationships in addition to her social isolation this will make her an excellent candidate
for IPT. This therapy focuses on improving interpersonal functioning and resolving those
interpersonal stressors which in Ann's case may be exacerbating her depressive symptoms that
she's talked about. She has expressed difficulties in her relationship with her parents and her
family's feeling that they don't understand her struggles. She has also become disconnected
from her peers. IPT would help and explore and improve her communication with her family
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and her peers. A focus on communication skills and could help her reestablish a sense of
connectedness with those around her and her family and her peers which could help reduce her
feelings of isolation and hopelessness.
Research supports the effectiveness of IPT in treating adolescent depression by
enhancing social functioning, resolving relationship issues, and improving mood regulation
(Mufson et al., 2021). IPT Can provide Anne with tools to navigate her emotional difficulties and
help her strengthen her support system.
The therapist and or counselor would help and explore her interpersonal relationships
and help her identify patterns of social withdrawal or conflict period role-playing techniques
may be very helpful and can be used to practice communication skills that could help and
express her needs and feelings more effectively. This would play good particularly with her
parents. IPT Could help provide Ann with tools to address social isolation and help her re-
establish connections with peers and reduce the emotional distance she is feeling and reporting
from others.
Medication Considerations
Research indicates that the combination of therapy and medication is often more
effective than therapy alone in treating severe depression, especially when symptoms are
significant and persistent (Fournier et al., 2010). Anne's symptoms are severe, with significant
impairment in her daily functioning. What occasion can help alleviate her mood symptoms
which could complement therapy by allowing her to engage more effectively in the therapeutic
interventions. Her symptoms such as fatigue, low mood, lack of interest in activities could be
eased by antidepressant medications which would enable and to benefit more from CBT and
IPT.
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Selective serotonin reuptake inhibitors (SSRIs) are often the first line treatment for
depression in adolescents (Cheung et al., 2018). SSRIs such as Prozac or Zoloft may help alleviate
Ann’s mood symptoms and improve her overall emotional regulation, providing her with the
foundation to engage in more in therapy. SSRIs Have been shown to be effective in treating
adolescent depression, particularly in improving mood and decreasing the risk of suicidal
ideation (Hetrick et al., 2016). Medication would be beneficial in interesting the biological and
neurological components of Anns depression, by potentially improving her overall mood and
enabling her to engage with therapeutic process more effectively
Spiritual Integration Considerations
Based on Ann's spiritual slash religious history, which reveals a lack of strong religious
affiliation the practice, integrating spiritual aspects into her treatment may not be immediately
necessary. She has not expressed any part particular need for spiritual guidance or support in
her current emotional distress, and she has a lot of uncertainty about her beliefs so this could
suggest that this area may not be a priority in her treatment. But as time goes on she could start
to begin to express some interest in exploring during therapy, and if so council could incorporate
open and non-directive discussions about her beliefs and values. This could be exploring her
sense of meaning or purpose in life, as it relates to her feelings of hopelessness.
References
Cheung, A. H., Zuckerbrot, R. A., & Jensen, P. S. (2018). Treatment of adolescent depression: The
role of medications. Journal of the American Academy of Child and Adolescent
Psychiatry, 57(5), 1–9.
Cuijpers, P., Karyotaki, E., Weitz, E., Andersson, G., & van Straten, A. (2020). The effects of
psychotherapies for major depressive disorder in children and adolescents: A
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metaanalysis. Journal of the American Academy of Child & Adolescent Psychiatry, 59(11),
1–
9.
Fournier, J. C., DeRubeis, R. J., Hollon, S. D., & Shelton, R. C. (2010). Antidepressant medications
versus cognitive therapy in people with depression and anxiety. The
American Journal of Psychiatry, 167(4), 387–391.
Hetrick, S. E., Simmons, M., & Townsend, M. L. (2016). Antidepressants for major depressive
disorder in children and adolescents: A systematic review and meta-analysis.
Psychological Medicine, 46(10), 2189–2198.
Markowitz, J. C., & Weissman, M. M. (2019). Interpersonal therapy for depression: A
metaanalysis. The American Journal of Psychiatry, 176(7), 1–10.
Mufson, L., Dorta, K., & Moreau, D. (2021). A randomized controlled trial of interpersonal
psychotherapy for adolescent depression. The Journal of Clinical Psychiatry, 82(6), 1–9.
Weersing, V. R., Weisz, J. R., & Cartwright, J. (2017). Cognitive-behavioral therapy for adolescent
depression: A meta-analysis. Journal of the American Academy of Child &
Adolescent Psychiatry, 56(10), 813-821.
