CASE PRESENTATION 1 1
Case Presentation 1
School of Behavioral Health, Liberty University
Author Note
I have no known conflict of interest to disclose.
Correspondence concerning this article should be addressed to
CASE PRESENTATION 1 2
Case Presentation 1
Part 1 – Assessment and Diagnosis
Identifying Data
Date of initial assessment: June 10, 2022 Pseudo name: Matthew R.
Reason for Referral/Presenting Problem
Matthew is self-referred. Matthew revealed that he is having a hard time coping with
increasing stress,s and it is making him feel isolated and lonely. The client stated that the things
that stress him out are his job, Covid-19, the increase in violent news around the world, and fear
of his own mortality. Matthew reported that one of his triggers is his dad because his dad has
created conspiracies surrounding current events. The client also stated that he has struggled with
symptoms of depression since childhood stating that he has cycles of depression that last 3-5
days a few times a year. Matthew revealed that due to Covid-19, he feels isolated from both
relationships with his family and friends. The client also stated that he has become more
frustrated as customers have been more combative since the pandemic began. The client also
stated that he is still grieving the loss of his mother, which negatively impacts his depressive
symptoms. Something that the client attempts to do to get his mind distracted is watching TV,
playing video games, or listening to music.
Source of Information. The information provided was collected during the psychotherapy
intake with the client. Other information may be from the PHQ, GAD-7, or from previous
sessions.
Summary
Matthew is a Caucasian male that is 37 years old. He is heterosexual and has been
married for three years. The client stated that he was raised Catholic and even attended a
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Catholic school, but by the time he was around 13 years old, he stopped practicing Catholicism
and relates more to Agnostic. Matthew said he does not consider himself part of any cultural
communities. The client currently lives with his wife, and they do not have any children. They
dated for nine years before they got married. He states having a great relationship with his wife
as she is supportive and dependable. They both enjoy time alone, so when they do have a date
night, it makes it even more special. Matthew reported that his mother recently passed away and
that he has two sisters and one brother. Matthew stated that he knows his sisters are also in
Therapy for anxiety and depression but doesn't know if his brother is. The client stated that his
parents separated when he was three and divorced when he was six. As a result, Matthew and his
siblings primarily lived with their mother and stayed with their father every other weekend.
Matthew referred to his family as "fractured" and that he does not have a strong relationship with
his father or most of his extended family.
The client revealed that he completed one year of college in computer science. He is
currently a store manager at a local gaming shop, an online book reviewer, and a video game
streamer. The client stated that he feels overworked and exhausted but feels that the situation is
inevitable due to his lack of a degree. Matthew reported considering going back to school
because he would enjoy learning but wouldn't go to enhance his professional career. He has
considered quitting book reviewing, but his growing frustration with his job in retail makes him
hesitant to do so.
Matthew stated that when he was in High School, he considered suicide. He stated that he
never had a plan but no longer wanted to live. He stated that if he killed himself that maybe
people would understand how much pain he was in. While he continues to struggle with
depressive symptoms, he is no longer in a hopeless state and actually has a fear of his mortality.
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The client stated that more often than not, he notices his thoughts go to a negative place,
especially when he is alone. The client reported having anxious symptoms surrounding Covid-19
as he has a plethora of respiratory issues and no health insurance. The therapist administered the
GAD-7 and PHQ9. These assessments revealed that the client had moderate depression and
anxiety. Matthew reported never considered having anxiety, but that it makes sense.
The client appeared oriented to person, place, and time during the first meeting. His
appearance and dress were both appropriate. The client's motor activity was unremarkable, as
well as his thought process and perception. The client's mood was euthymic, and his affect was
congruent. The client had both good insight and judgment/impulse control. Matthew's memory
and functional status were both intact, and his attention/concentration was good. The client is a
telehealth client who is always on time and communicates well.
Matthew reports having respiratory issues ranging from asthma to allergies and
everything in between. He also reports having irregularities with his thyroid, potentially causing
him to be overweight. He is currently only using an inhaler as needed. He does not see a doctor
regularly as he doesn't have insurance which is a source of frustration for him due to the fact that
it is difficult and expensive to acquire insurance. Matthew stated that his parents had cancer and
his mother succumbed to it. The client stated that when he was 18, he used tobacco and
marijuana sparingly and currently doesn't do either. He also stated that he has fewer than 6-8
alcoholic drinks a year.
The client is always open to trying different therapeutic interventions. When assigned
homework Matthew always completes it and thoroughly describes whether or not it was
effective. I believe he can successfully lower his depression and anxiety symptoms via telehealth,
but I would eventually like to see him in person. The only barrier I see is how negatively he is
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impacted by the world around him. He tends to become defensive when he is encouraged to
shrink his focus to what he can control. It is apparent the client is disenchanted with the state of
the world.
DSM-5 Diagnosis
309.28 (F43.23) Adjustment Disorder with Mixed anxiety and depressed mood
Z56.9 Other problem related to employment
Z59.7 Insufficient social insurance or welfare support
Matthew stated shortly after returning to his retail job, his symptoms became more
evident. Although he has dealt with depression throughout his life, he stated that it was more
urgent and debilitating this time. He stated, "I have explored the possibility of help multiple
times in the past but have never sought help until now." Whenever Matthew is at work, he stated
constantly feeling worried, mostly about contracting Covid-19. This spills over into his personal
life as an added safety precaution as he no longer sees friends in person and doesn't take his wife
on dates unless they grab take-out. This is a significant impairment in social function. He stated
that he was feeling down and stressed more often than not. The client complains of feeling
worried and on edge at the possibility of being exposed to Covid-19.
Due to Matthew having increased anxiety while at work, he was also assigned other
problem related to employment. Since Matthew is considering quitting his retail job, this may be
significant as well. Also, since the client does not have health insurance, he was assigned
insufficient social insurance or welfare support, which is a significant cause of his consternation.
Major depressive disorder was also considered. However, he still takes pleasure in
streaming and playing video games. Matthew also did not complain about problems surrounding
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his sleep. He stated that his weight gain is partly due to thyroid issues and a sedentary lifestyle.
Lastly, he can have coherent thoughts and can make decisions when necessary.
Part 2- Case Conceptualization
STEP 1: IDENTIFY AND LIST CLIENT CONCERNS AND ANY OTHER PROBLEM
AREAS
-Isolation
-Stress
-Hopelessness
-Fear of Death
-Lack of insurance
-Sad
- Frustrated
-Panic
-Intrusive thoughts
-Lack of coping skills
-Grief
STEP 2: ORGANIZE CONCERNS INTO LOGICAL THEMATIC GROUPINGS
1. History of depressive symptoms, such as hopelessness, loss of interest, and feeling
worthless.
2. History of health issues that are mainly respiratory-related and lack of medical insurance
causing increased anxiety.
STEP 3: THEORETICAL INFERENCES: ATTACH THEMATIC GROUPINGS
TO INFERRED AREAS OF DIFFICULTY
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Cognitive behavioral theory (CBT)
The client has increased cognitive distortions that prevent him from processing
how the pandemic affected him, hindering his quality of life.
STEP 4: NARROWED INFERENCES AND DEEPER DIFFICULTIES
The client has the faulty belief that he is not safe and not worthy due to his
upbringing and interactions with customers.
Narrative of the Case Conceptualization
Matthew's biggest obstacle is his lack of medical insurance. This has created
maladaptive thoughts surrounding his worthiness. He has expressed feeling sad but also
tends to ignore his emotions. Another concern is interactions with his customers, that
treat him less than human. Viewing this through a CBT lens, it is apparent that Matthew
has a few maladaptive thoughts. This surrounds a core belief of "I am not worthy." He
feels that it isn't worthy of having insurance, to be treated with respect, and to heal.
Matthew avoids his feelings of sadness; however, doing so exemplifies his thoughts of
worry.
Part 3- Treatment Planning/Integration/Counseling Theory
Problems
1. Adjustment Disorder, with mixed anxiety and depressed mood- Cognitive distortions
surrounding self and others- Isolation and fear of death- difficulty adjusting to the world
post-pandemic. Avoidance of difficult emotions.
Goals for Change
1. Adjustment disorder, with mixed anxiety and depressed mood (CBT)
The client will learn how to cope with changes in the world and learn to be okay
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with current events that are triggering.
The client will learn to process and cope with past experiences that are
contributing to his feelings of stress and depression.
The client will reduce the overall frequency, intensity, and duration of the anxiety
related to health concerns so that daily functioning is not impaired.
Therapeutic Interventions
The client will engage in 4-6 months of weekly individual sessions of CBT
1. Adjustment Disorder, with mixed anxiety and depressed mood
The counselor will provide psychoeducation on coping mechanisms
The counselor will provide coping mechanisms such as thought stopping
The counselor will provide psychoeducation on decatastrophising
The client will identify/learn/process, and practice three healthy coping
skills to manage depressed mood
The client will process/discuss how unresolved grief has led to depressed
states.
The client will reduce anxious symptoms by implementing three healthy
coping skills to manage symptoms
Outcome Measure of Change
Improved socialization, improved self-worth, decreased maladaptive
coping skills, and continued support seeking.
The client will report socialization at least two times a month over a
period of three months
The client will report having a reduction in maladaptive coping
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mechanisms 80% of the time over a period of eight weeks.
The client will report an increase in a positive sense of self for at least five
days a week over a period of six weeks.
The client will score lower on GAD-7 and PHQ9
Integration of Faith
Matthew has stated that, at this time, he is agnostic. He revealed that he has no interest in
discussing faith or spirituality as he is highly logical and views life from this standpoint.
Therefore, out of respect for my client, I do not integrate any faith into his counseling. Due to
him being very clear on the matter, I believe it would be unethical to integrate faith into his
sessions without his informed consent. As ACA code of ethics A.4.b Personal values state,
"Counselors are aware of -and avoid imposing- their own values, attitudes, beliefs, and
behaviors. [ CITATION Ame22 \l 1033 ]." To be very honest and transparent, I am also in a place
of questioning my beliefs regarding Christianity. I approach my sessions from the viewpoint of
non-judgmental love and provide a place of healing and safety. If I get a client that wants to
integrate prayer and scripture into the session, I am open to providing a space to do so as long as
it is therapeutic. However, I will not integrate Christianity into sessions without my client's
informed consent.
Personal Model of Counseling
I incorporate multiple models of counseling into my sessions. However, I realize that I
tend to gravitate to CBT interventions, especially when a client has symptoms of anxiety and
depression. I also tend to lean into client-centered Therapy. I start out with client-centered
Therapy and follow my client's lead. When it comes time to incorporate interventions, that is
when CBT comes in. I feel that the more well-rounded in terms of modalities, the better I can
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pivot and be flexible for my clients. Essentially, it is their session, and they put in the work. What
works for one client may cause harm to another. Thought-stopping is an intervention I use the
most, followed by mindfulness and breathwork. I look forward to becoming more proficient in
these therapies and adding EFT and IFS into the rotation as well.
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References
American Counseling Association. (2022). 2014 ACA Code of Ethics. Retrieved from
Counseling.org: https://www.counseling.org/resources/aca-code-of-ethics.pdf
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
