Case laboratory · fictional case
Aaliya: a first-year student who has stopped attending class
A 19-year-old student living away from home for the first time presents with low mood, poor sleep and falling attendance. Depression, adjustment, physical and contextual explanations all need consideration — and a safety question must be handled well.
Stage 1 of 7
1 Observe
Presenting concerns
Aaliya says she has felt 'heavy and empty' for about six weeks. She sleeps late, wakes exhausted, has missed many lectures and feels guilty about wasting her parents' money.
Behavioural observations
- Arrives on time, neatly dressed, makes limited eye contact.
- Speaks softly with long pauses; becomes tearful when discussing family.
- Answers questions fully once rapport develops.
Your turn: What do you notice, and what are your first questions? Avoid labelling at this stage.
Teaching discussion for this stage
Good first observations are descriptive: duration (six weeks), mood ('heavy and empty'), sleep disturbance, guilt and functional decline. Her punctuality and neatness suggest she is still managing some routines. Tearfulness about family is a cue to explore relationships and possible stressors.
Early questions might explore onset, a typical day, sleep and appetite, what has changed since moving, supports, substance use, physical health — and, gently and directly, whether she has had thoughts that life is not worth living.
2 Gather information
Relevant history
Her mother had a period of depression when Aaliya was 12. Aaliya was a high achiever at school. This semester her grandfather, with whom she is close, was hospitalised; she could not travel home during exams.
Context and culture
She describes strong family expectations to become a doctor; she chose science but is unsure. She says mental health 'is not talked about' at home and fears being seen as weak. Prayer and calls with a cousin help her.
Available assessment information
- A depression screening questionnaire completed at intake scored in a range the service's protocol flags for further assessment.
- She reports one or two days a week of not eating lunch, and occasional headaches.
- When asked directly, she says she sometimes thinks 'it would be easier not to wake up', with no plan or intent, and that her faith and family stop her from acting.
Your turn: What does this information add? What is still missing?
Teaching discussion for this stage
The history suggests possible vulnerability (family history, perfectionism) meeting several stressors (relocation, academic pressure, grandfather's illness, uncertainty about career). The screening result supports further assessment but is not a diagnosis.
Her passive thoughts of death require immediate, careful follow-up within the service's safety procedures — a collaborative safety plan, involvement of a supervisor, and agreement about whom to contact if things worsen. Her stated protective factors (faith, family, cousin) are important but do not replace ongoing assessment.
Missing information
- Physical health: thyroid, anaemia or other medical causes of fatigue — has she seen a doctor?
- Sleep pattern detail and phone use at night.
- Substance use, including caffeine.
- Previous episodes of low mood.
- Her own explanation of what is happening.
- Academic standing and any deadlines at risk.
3 Generate hypotheses
Your turn: List at least three explanations for Aaliya's difficulties and what evidence would support or weaken each.
Teaching discussion for this stage
Hold several hypotheses at once rather than committing early. Each predicts different findings, which guides the next questions.
Possible explanatory hypotheses
- A depressive episode, given duration, pervasive low mood, sleep change, guilt and functional decline.
- An adjustment reaction to multiple stressors, which might resolve as circumstances change.
- Grief and anticipatory grief related to her grandfather's illness.
- A physical contributor such as anaemia or thyroid dysfunction producing fatigue and low mood.
- Career and identity conflict contributing to avoidance of lectures.
Differential considerations
- Bipolar disorder — ask about past periods of elevated mood or reduced need for sleep.
- Anxiety disorders — avoidance may be anxiety-driven.
- Substance use.
- Cultural expressions of distress — somatic complaints such as headaches may carry emotional meaning.
4 Formulate
Your turn: Draft a biopsychosocial formulation using the 4P grid. Explain how factors interact.
Teaching discussion for this stage
A coherent formulation links the factors: a family history and self-critical style create vulnerability; relocation, exam pressure and her grandfather's illness precipitated the episode; withdrawal, late-night sleep disruption, skipped meals and a belief that seeking help is 'weak' perpetuate it; her faith, her cousin and her own wish to get better are protective.
| Factor | Biological | Psychological | Social / cultural |
|---|---|---|---|
| Predisposing | Family history of depression | Perfectionism; high achievement standards | Strong family expectations about career |
| Precipitating | Disrupted sleep after moving | Perceived failure in early exams | Relocation; grandfather's hospitalisation; unable to travel home |
| Perpetuating | Irregular sleep and skipped meals | Self-critical thoughts; avoidance of lectures | Stigma about mental health; isolation in hostel |
| Protective | No reported substance use (to confirm) | Insight; motivation; faith | Close cousin; supportive warden; access to counselling service |
5 Plan assessment
Your turn: What further assessment would you plan, and why?
Teaching discussion for this stage
Assessment should be proportionate and purposeful: confirm or rule out explanations and monitor risk.
Possible next assessment steps
- A structured or semi-structured diagnostic interview conducted by a qualified clinician.
- Medical review to rule out physical causes (with her consent).
- Sleep diary for two weeks.
- Ongoing, collaborative review of thoughts of death at each contact, following the service's safety procedure.
- Questions about past elevated mood.
- Repeat brief symptom measures to track change.
6 Consider interventions
Your turn: What evidence-informed options might be offered, and how would you involve Aaliya in choosing?
Teaching discussion for this stage
Options should be discussed collaboratively, considering evidence, her preferences, culture and practicalities such as exam timetables.
Evidence-informed options to discuss
- Structured psychological therapy such as cognitive-behavioural therapy or behavioural activation, which have research support for depression.
- Practical problem solving about attendance and academic deadlines, with consent to liaise with the college.
- Sleep regularity and meal routine as part of behavioural activation.
- Referral to a psychiatrist for medication assessment if symptoms are severe, persistent or not improving — a medical decision.
- Psychoeducation that reduces stigma, framed in ways consistent with her values.
- If she wishes, involving family in a supportive way.
7 Review outcomes
Fictional follow-up
After eight sessions, Aaliya attends most lectures, sleeps more regularly and her repeated symptom scores have fallen. Her thoughts of death have stopped. She has spoken to her mother, who was more understanding than she expected. She still worries about her career choice.
Your turn: How would you judge whether progress is meaningful, and what would you plan next?
Teaching discussion for this stage
Judge change against agreed goals and reliable change on measures, not just a lower number. Plan relapse prevention around predictable stressors such as exams, and consider whether the career question warrants career counselling. Planned termination with an option to return is appropriate.
Remember: this outcome is invented for teaching. Real courses of treatment vary, and some clients need different or longer care.
Ethical questions and references
Ethical questions to discuss
- How should confidentiality and its limits be explained to an adult student whose parents fund her education?
- What are the risks of a counsellor relying on a screening score alone?
- How might stigma in her community affect her willingness to seek help, and how should the service respond?
- When should a college counselling service refer on, and to whom?
References and resources
- Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613.
- Plante, T. G. (2005). Contemporary clinical psychology (2nd ed.). John Wiley & Sons.
- Government of India. (2017). The Mental Healthcare Act, 2017 (Act No. 10 of 2017).