Running head: ASSIGNMENT 4.

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Assignment 4.1: Case Study and Treatment Planning

Ana M. Herrera

Wake Forest University

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Introduction

Crystal Smith has come to counseling with feelings of despair and a feeling of distrust

toward her family, namely her husband’s family. She has a history of trauma following her

parent’s divorce when she was a child. There is evidence that the irritability and fights with

others at school reported by teachers during that time was her reaction to her home environment

and feelings of loss after her parent’s divorce. She reports no alcohol or substance use but was

prescribed an antidepressant of which she no longer takes. She has come at the urging of her

husband. He is reporting that Crystal loses her temper and gets quite irritable leading to

arguments. Currently, Crystal has five of the nine DSM 5 criteria for major depression with

melancholic features (APA, 2013).

Rationale for Crystal Smith’s Diagnosis

My diagnosis of Major Depression Disorder (MDD) with melancholic features is based

on Crystal’s presenting symptoms which include sadness, poor sleep, weight loss, anhedonia,

and thoughts of death (APA, 2013). Administering the PHQ-9 to assess severity of MDD along

with the Beck Depression Inventory along with a suicide assessment will help determine the

level of care Crystal will need. She has struggled with these symptoms for approximately eight to

ten months.

The severity of this episode may be moderate to severe. Medication may be necessary

while working with Crystal in counseling and on her cognitive distortions that exacerbate her

feelings of sadness and despair. Her symptoms, according to the biopsychosocial evaluation,

may warrant for her treatment to be ongoing and multiple times a week. She may need three to
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five sessions in an intensive outpatient program along with individual and family therapy until

her depressive symptoms diminish and no longer cause problems life. It could be possible she

may need intensive and/or weekly sessions, depending on the severity in Beck Depression

Inventory and Suicide Assessment. If severity is moderate to high, intensive outpatient therapy

3-5 sessions a week, four hours a day. Weekly sessions will should be prescribed with family one

to two hours a week.

Crystal is described as an outgoing, sociable when she was younger. She may have had a

depressive episode when she was ten or eleven that may have gone undetected because she

showed anger rather than sadness at school after her parents’ divorce. At the moment, she has

been married for thirteen years and was a regular church-goer. The effects of depression has

lessened her religious faith or desire to socialize, and her irritability has built anger between her

and her family. There is marked deterioration in her level of satisfaction and functioning in all

areas of her life due to major depression. Another possibility is that Crystal has been dealing

with depressive symptoms from the time she was in middle school (between age ten and eleven).

Crystal struggled in school and in her studies. She married at age twenty and had a brief trial

with an antidepressant. By stopping her medication, and functioning well enough in her daily

life, she may have been grappling with a milder form of depression called dysthymia (APA,

2013) which may have been missed. Now due to conflict with her husband or something similar

to that, her depression has become more severe and is diagnosable as MDD since it is interfering

in all areas of her life. My assumptions about dysthymia are hypothetical but reading her case got

me thinking about her mental health and her history of brief treatment with an antidepressant that
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she stopped without medical advice. I would have to do a more thorough psychological history

for proof of dysthymia which can manifest in children as irritability (Mayo Clinic, 2017).

The Therapeutic Relationship and Interventions

Crystal needs a counselor who can support her and build a connection with her by

establishing genuineness, acceptance, warmth, gentleness, and openness. Since Crystal is prone

to mistrust others including her last psychiatrist and counselor, it is of utmost importance that her

counselor acknowledge her feelings of sadness, despair, and distrust. Crystal’s counselor needs

to be patient with her, check Crystal’s level of engagement, allow Crystal to discuss if she is

feeling insecure openly, establish a contract that will help Crystal vocalize if she feels the

counselor is saying or behaving in a way that Crystal does not understand, and check with

Crystal how she is feeling periodically using scaling questions. As her counselor, being a

minority and a woman may be helpful in Crystal’s recovery. I noted this because it was

mentioned that she had seemed quieter with the Caucasian, middle-aged counselor. Finding a

counselor or psychiatrist that matched her demographic profile may be beneficial in achieving

connection and treatment compliance. Again, this assumption is purely hypothetical and I do not

have any certainty that a minority woman would work better for Crystal but it could be a good

predictor of her remaining in counseling if she feels connected culturally to the counselor. Also,

Crystal absolutely needs a Rogerian, person-centered approach along with a cognitive-behavioral

therapy to develop a caring relationship and to also begin to gently challenge her depressive

thought process.​ ​Motivational interviewing and interpersonal therapy to make genuine

therapeutic connection and establish trust (Gladding & Newsome, 2017). Being fully present
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may be too difficult for Crystal at first but the goal is to introduce mindfulness and deep

breathing as she begins to feel better.

The counselor for Crystal needs to be medication may help jumpstart her feelings of

betterment and allow her to start becoming more present and introduce and practice

mindfulness-based exercises with an emphasis of positive affirmations. It will be beneficial to

include her husband in the therapy to reinforce their connectedness and show his support for

Crystal. The better Mr. Smith is able to understand Crystal’s depression and symptoms the more

empathetic and supportive he will become. Their tension with each other will lessen if they can

both be supported by mental health professionals and if they are open to developing better

coping skills they can use to prevent misunderstandings with each other. Since

Crystal has felt depressed for so long, it may help to differentiate her struggle with

depression from her ‘real self.’ Including her husband/family in this process will allow the

counselor to get to know at her previous level of functioning. Goal-setting could also be helpful

by using motivational interviewing to instill hope that Crystal can and will reach wellness if she

is engaged her treatment. Sense of time and sense of self may have been lost with the set of

symptoms she presents and the length of her illness. Rebuilding hope for wellness and self-care

are the ultimate priorities along with the other therapeutic interventions shown in her client map.

Major Depressive Disorder: Crystal’s Prognosis

Crystal Smith’s prognosis is very good. She has had a previous episode of depression of

which she seemed to recover from enough to be high functioning. Her status and her ability to

function as a wife and mother have been good. There is no indication that she cannot reach that

same level of functioning if she is treated adequately. Her husband is proactive by bringing to a
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counselor knowing she is not feeling well. His support is another positive on Crystal’s side. Her

treatment with medication and intensive counseling will help her, if she is compliant. The one

drawback could be her deciding she does not want treatment and terminate it prematurely.

Assessing her suicidality is also paramount. Her not admitting that she would kill herself may be

true but other signs of subtle hints such as “maybe it would be better if I was gone” may show a

deeper feeling of despair that she may not be comfortable sharing with anyone.

Other Thoughts and Conclusion

Lastly, along with these evaluations, Crystal needs a thorough physical to rule out any

medical problems that may contribute to or exacerbate the depressive episode (APA, 2013).

There is no indication of a medical explanation of her symptoms but thyroid, hormonal

deficiencies, and other physical explanations to her mood state must be explored. It is important

to inform Crystal and her husband about every test and reasons for the tests to help Crystal

understand how different physical, mental, and emotional factors play into her overall health and

functioning. Helping her see her treatment as something necessary for good health and wellness

may enable her to see each goal she sets in therapy as a step closer to feeling better and attain

optimal functioning. A strong relationship with her psychiatrist and counselor should be

developed as a partnership to help Crystal gain trust in her doctor, counselor, and

medical-therapeutic process of getting better and staying well. The client map I did is an outline

of which I delineated throughout this paper. Psychoeducation along with the therapeutic

interventions described above could reduce and/or eliminate symptoms of major depressive

disorder in Crystal Smith’s case.

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References

American Psychiatric Association (2013). ​Diagnostic and Statistical Manual of Mental 

 
Disorders ​(5th edition). American Psychiatric Publishing, Arlington, VA.

Gladding, S. T. & Newsome, D. W. (2017). ​Clinical mental health counseling in community and
agency settings​ (5th ed.). Upper Saddle River, NJ: Merrill/Pearson Education.

Mayo Clinic (2017). Persistent depressive disorder (dysthymia). Retrieved from

http://www.mayoclinic.org/diseases-conditions/persistent-depressive-disorder/symptoms-
causes/dxc-20166596