1. Case Study of MH
BY BRENDA WIMBERLY
NOVEMBER 2011
ASSESSMENT
COUN 621

2. Client Description
 Caucasian male
 University of Mississippi student
 Academic problems
 Diagnosed with ADHD
 Repeat EDHE student
 Previous issues with depression

3. Purpose of Assessments
 BASIS-A
 Determine purpose of behavior
 Identify ways of perceiving self and others
 Help client with problem solving
 Beck Depression Inventory (BDI-II)
 Previous counselor reported depression
 Determine if depression still exists
 Client presents with sense of failure and lack of self-satisfaction

4. Assessment Procedures and Protocol
 Discuss testing protocol with site supervisor
 Identify ethically appropriate instruments
 BASIS-A
 3rd meeting
 Self scored instrument
 65 questions
 Two dimensions:
 Life Style Themes (BASIS-A)
 General Approach to Life (HELPS)
 Beck Depression Inventory (BDI-II)
 6th meeting
 21 questions

5. Medical/Developmental/Psychiatric History
 Diagnosed with ADHD in high school – Sees local Family Practice
physician for medication
 Does not like having to take Adderall – only takes it when he feels it
is necessary
 Father also has ADHD
 Previously identified as depressed by EDHE counselor
 No other medical history reported

6. Familial Psychiatric History
 No reported history of psychiatric issues in family

7. School/Academic History
 Client reports having focus issues since high school
 Prescribed Adderall to help with focus problems – took it daily for
years, but only takes it now when he needs to study for a test or has
a big project
 Average to low grades in college. Passed EDHE 202 in the spring of
2011
 Had to re-enroll in EDHE 202 because of grade point average
 Failed a MIS class because of a “problem with group project”

8. Home Behavior/Social
 Oldest child – has one sister
 Very close to his sister – she gives him moral support
 Has very few friends at Ole Miss because most of them have already
graduated
 Socializes with his room mates – watching sports on television
 Does not like to party – finds it difficult to make new friends
 Does not report being in a romantic relationship

9. Assessments & Appropriate Interpretations
 BASIS-A
 Used to help clients recognize the interaction of personality
dynamics developed as a child and current problem solving
strategies
 Measures five personality styles
 Internal consistency est. (Coefficients ranging from .82 to .87)
 Validity of the structure of the scales (supported when correlated
with other instruments)
 Beck Depression Inventory (BDI-II)
 Reliability (Coefficient Alpha = .92)
 21 items that assess the force of depression in clinical and normal
patients
 Increased content validity
 Factorial validity

10. Summary of Findings
 BDI-II
 Total score = 8 (minimal range) – no longer depressed
 BASIS-A
 Belonging (BSI)– Sees himself as supportive and cooperative, but
may be assertive
 Going Along (GA)– Tends to be an independent thinker but may
be viewed as aggressive when stressed
 Taking Charge (TC)– May be viewed as assertive
 Wanting Recognition (WR)– May not be concerned about
approval of others (Incongruity: HELP Scale of Entitlement
indicates he may enjoy special attention from others
 Being Cautious (BC)– May avoid conflict

11. DSM Diagnosis
 Axis I
 314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type
 Axis II
 V71.09 (No Diagnosis)
 Axis III
 None
 Axis IV
 Father recently underwent heart surgery
 Graduation from college delayed
 Academic Problems
 Previous issues with depression
 Axis V
 GAF = 71 (current)

12. Treatment plan and Recommendations
 Monitor ADHD medication
 Follow up with Family Practitioner
 Possibly adjust level of medication
 Monitor depression
 Determine triggers of past depression
 Help client learn approaches to deal with depression
 Help client recognize incongruities
 Use unconditional positive regard and empathy to continue to
build therapeutic relationship with the client
 Use reflection to assist the client’s growth
 Review the results of BASIS-A assessment

13. References
 Beck, A. T., Steer, R. A. & Brown, G. K. (1996). Beck Depression
Inventory-II. San Antonio, TX: Harcourt Brace.
 Kern, R. (1998). BASIS-A interpretive key and guide for clinicians.
Highlands, NC: TRT Associates, Inc.
 Kern, R., Rasmussen, P., Byrd, S., & Wittschen, L. (1999). Lifestyle,
personality, and attention deficit hyperactivity disorder in young
adults. The Journal of Individual Psychology, 55(2), 186-199.