624B Informal Case Presentation #3

Identifying information
 Name: KR
 7th grade, 13 years old Hispanic
 From Anaheim, CA
 Student lives with mom, dad, and an older brother, and younger sister. She’s the
middle child
Presenting problem
 She was initially referred by her English teacher because she was having a
difficult time in class.
o The student disclosed that she has a difficult time expressing her
concerns to her parents.
 Her relationship with her mother has gotten better but she still has some difficulty
opening up to her father
o She still challenges herself to talk to her dad, but often times scared of
how he will react to it

Diagnosis/ Eligibility
o Mild depression: scored a 9 on the PHQ-9 screener

History
 Has a history of suicidal ideation, but no history of self-harm
o Done a risk assessment in the past when she was in 6th grade and on Feb
28  score came out to be low risk

Evidence-based treatment
 Motivational interviewing: Applied MI strategies to see how she is making
progress after the risk assessment
 Role-playing: enhances skill acquisition by practicing and acquiring how to
effectively communicate by utilizing I statements to express feelings and needs

Theoretical Conceptualization
 Motivational interviewing: Utilized the OARS technique to progress in addressing
her current problem (difficulty communicating with dad)

Individual/ Cultural Considerations

 Bilingual (English and Spanish)
  The parents initially had a hard time understanding the importance of mental
health; however, after conducting a risk assessment and discussing its
importance, the mom is appreciative that she is being seen
 Mom requested more consistent check-ins, realizing the value of ongoing support
in addressing her daughter’s mental health needs
o Mom is also taking the time to take a 5-minute check-in with her daughter
before she sleeps.
o On the weekend, they made a routine to go on a night drive date where
they can openly communicate their highs and lows  both bonded over
this activity

Methods of intervention
 Individual counseling session (1x every other week or at times weekly, ~30-40
min)
 Psychoeducation on “I-statements”
 Role-playing

Transference/ Countertransference
 None identified

Response to treatment
 Student has made remarkable progress utilizing coping skills and positive
affirmations

Termination
 The student will be ready to terminate when she feels like she can healthily cope
with her problems

Recommendations
 Student should continue to have check-in