Case Presentation Review
Supporting documents attached.
3 years ago 65
CasePresentationTemplate2ndClient.docx
CasePresentation2ndClient1.pptx
CasePresentationTemplate2ndClient.docx
Case Presentation Template
Student Name
School of Behavioral Sciences, XXXXX University
Author Note
Student Name https://orcid.org/#####
I have no conflicts of interests to disclose.
Correspondence concerning this paper should be addressed to Student Name, 1971 University Blvd., City, State zip. Email: student@xxxxxxxx.edu
1
CASE PRESENTATION TEMPLATE 1
Case Presentation Template
Part 1 – Assessment and Diagnosis Identifying Information
Identifying Data
Date of Initial Assessment:
PSEUDO Name:
Age:
Gender:
Sexual Orientation:
Race/Ethnicity:
Marital Status:
Employment Status:
Reason for Referral/Presenting Problem
Text here
Source of Information: Text here
Background, Family Information, and Relevant History
Text here
Problem and Counseling History
Text here
Diagnostic Impression
Principal diagnosis:
Diagnosis 2 or z-code:
Diagnosis 3 or z-code:
Differential Diagnosis:
Discussion of Diagnostic Impression
Text here
Part 2 – Case Conceptualization: Inverted Pyramid Model (IPM)
STEP 1: IDENTIFY AND LIST CLIENT CONCERNS AND ANY OTHER PROBLEM AREAS
Text here
Text here
STEP 2: ORGANIZE CONCERNS INTO LOGICAL THEMATIC GROUPINGS
Theme Used
Text here
STEP 3: THEORETICAL INFERENCES:
ATTACH THEMATIC GROUPINGS TO INFERRED AREAS OF DIFFICULTY
Text here
STEP 4: NARROWED INFERENCES AND DEEPER DIFFICULTIES
Text here
Narrative of the Case Conceptualization
Text here
Part 3 – Treatment Planning/Integration/Counseling Theory
Treatment Plan
|
Problems |
|
|
|
Goals for Change |
|
|
|
Objectives & Therapeutic Interventions |
|
|
|
Outcome Measures of Change |
|
|
Integration
Text here
Personal Model of Counseling
Text here
References
Provide all references here (at least five)
image1.gif
CasePresentation2ndClient1.pptx
Malcolm X
Hard Knocks University
Case Presentation 2nd Client
29yo male
African American
Heterosexual
Married
No children
Masters in education
School teacher
Christian
Struggling with anxiety, depressed mood, and familial discord
No mental health history
Occasionally drinks alcohol
No legal history
Demographic Information/ Bio-Psycho-Social-Spiritual (10th visit)
Depressed mood
Sexual trauma
Feelings of anxiousness
Lacks focus
Sleep disturbances
Disinterested in previously enjoyed activities
Isolation
Low self-esteem
Low motivation
Fear
Presenting Concerns/Problems
DSM-5-TR diagnosis (provisional)
F43.10 Posttraumatic stress disorder PTSD)
F41.1 Generalized anxiety disorder (GAD)
Z61.3 Events resulting in loss of self-esteem in childhood
Z62.4 Emotional neglect of child
Differential Diagnosis
Major depressive disorder (MDD) as client meets the symptoms of at least 5 of the criterion but lacks frequency
Diagnostic Impression
Depressed mood
Feelings of anxiousness
Worry/fear
Relational discord (family)
Tearful spells
Relational discord (friends)
Irritability
Low motivation
Low self-esteem
Feelings of worthlessness
Grief
Sexual trauma
Sleep disturbances
Lack of focus
Self-isolation
Fatigue
Case Conceptualization/Inverted Pyramid Step 1 (wide net)
Sexual trauma (college)
Depressed mood
Anxiety
Fear
Clinically significant impairment in social (familial/friend) functioning
Supports the assigned diagnoses (PTSD, GAD, Z61.3 [low self-esteem], Z62.4 [childhood emotional neglect]).
Inverted Pyramid Step 2 (thematic groupings)
Gestalt Therapy
Empty chair techniques
Here and now
Maladaptive thoughts
Negative thoughts surrounding sexuality
Feelings of worthlessness (don’t have anything good to offer)
Self-confidence issues (never been validated by father).
Maladaptive behaviors
Self-sabotage
Inverted Pyramid Step 3 (Gestalt Therapy/CBT)
Deepest negative distortions
Continued self-blame (MDD)
Unresolved familial discord (MDD)
Suicidality
Inverted Pyramid Step 4 (deeper issues)
Treatment Plan
F43.10 Posttraumatic stress disorder
Client will increase self-efficacy by the engagement in self-affirming exercises.
Client will reduce overall stress by engaging in exposure to stress-producing stimuli
Client will improve self-awareness by practicing grounding techniques.
Clinician will provide psychoeducation on EMDR therapy
F41.1 Generalized anxiety disorder
Client will reduce overall stress by engaging in exposure to stress-producing stimuli
Client will reduce feelings of anxiousness by engaging in square breathing.
Z61.3 Events resulting in loss of self-esteem in childhood
Client will reduce self-doubt by authoring a minimum of three self-affirming statements and meditating on them daily
Client will increase self-efficacy by participating in the empty chair exercise during session.
Z62.4 Emotional neglect of child
Client will reduce harmful thoughts through finding closure by way of the empty chair technique
Treatment Plan (continued)
ACA code A.4.b (personal values) governs the clinician on not imposing their values onto the client (ACA, 2014).
Victim advocacy
Strained relationship with father.
Christian values
ACA code C.2.b charges the clinician to operate within their scope of practice (ACA, 2014)
EMDR therapy
Ethical Considerations
Client disclosed that being a teacher makes him prone to solution-focused culture. His treatment goals may require a modality layered approached for the highest efficacy rate.
Sexuality
Religiosity
Multicultural Components
Links
American Counseling Association. (2014). 2014 ACA code of ethics. https://www.counseling.org/knowledge-center
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders: DSM-5 TR (5th ed. Text Revision). American Psychiatric Press, Inc. Retrieved from Psychiatry Online | DSM Library (liberty.edu).
References
image1.png
image2.jpeg
CasePresentationTemplate2ndClient.docx
Case Presentation Template
Student Name
School of Behavioral Sciences, XXXXX University
Author Note
Student Name https://orcid.org/#####
I have no conflicts of interests to disclose.
Correspondence concerning this paper should be addressed to Student Name, 1971 University Blvd., City, State zip. Email: student@xxxxxxxx.edu
1
CASE PRESENTATION TEMPLATE 1
Case Presentation Template
Part 1 – Assessment and Diagnosis Identifying Information
Identifying Data
Date of Initial Assessment:
PSEUDO Name:
Age:
Gender:
Sexual Orientation:
Race/Ethnicity:
Marital Status:
Employment Status:
Reason for Referral/Presenting Problem
Text here
Source of Information: Text here
Background, Family Information, and Relevant History
Text here
Problem and Counseling History
Text here
Diagnostic Impression
Principal diagnosis:
Diagnosis 2 or z-code:
Diagnosis 3 or z-code:
Differential Diagnosis:
Discussion of Diagnostic Impression
Text here
Part 2 – Case Conceptualization: Inverted Pyramid Model (IPM)
STEP 1: IDENTIFY AND LIST CLIENT CONCERNS AND ANY OTHER PROBLEM AREAS
Text here
Text here
STEP 2: ORGANIZE CONCERNS INTO LOGICAL THEMATIC GROUPINGS
Theme Used
Text here
STEP 3: THEORETICAL INFERENCES:
ATTACH THEMATIC GROUPINGS TO INFERRED AREAS OF DIFFICULTY
Text here
STEP 4: NARROWED INFERENCES AND DEEPER DIFFICULTIES
Text here
Narrative of the Case Conceptualization
Text here
Part 3 – Treatment Planning/Integration/Counseling Theory
Treatment Plan
|
Problems |
|
|
|
Goals for Change |
|
|
|
Objectives & Therapeutic Interventions |
|
|
|
Outcome Measures of Change |
|
|
Integration
Text here
Personal Model of Counseling
Text here
References
Provide all references here (at least five)
image1.gif
CasePresentation2ndClient1.pptx
Malcolm X
Hard Knocks University
Case Presentation 2nd Client
29yo male
African American
Heterosexual
Married
No children
Masters in education
School teacher
Christian
Struggling with anxiety, depressed mood, and familial discord
No mental health history
Occasionally drinks alcohol
No legal history
Demographic Information/ Bio-Psycho-Social-Spiritual (10th visit)
Depressed mood
Sexual trauma
Feelings of anxiousness
Lacks focus
Sleep disturbances
Disinterested in previously enjoyed activities
Isolation
Low self-esteem
Low motivation
Fear
Presenting Concerns/Problems
DSM-5-TR diagnosis (provisional)
F43.10 Posttraumatic stress disorder PTSD)
F41.1 Generalized anxiety disorder (GAD)
Z61.3 Events resulting in loss of self-esteem in childhood
Z62.4 Emotional neglect of child
Differential Diagnosis
Major depressive disorder (MDD) as client meets the symptoms of at least 5 of the criterion but lacks frequency
Diagnostic Impression
Depressed mood
Feelings of anxiousness
Worry/fear
Relational discord (family)
Tearful spells
Relational discord (friends)
Irritability
Low motivation
Low self-esteem
Feelings of worthlessness
Grief
Sexual trauma
Sleep disturbances
Lack of focus
Self-isolation
Fatigue
Case Conceptualization/Inverted Pyramid Step 1 (wide net)
Sexual trauma (college)
Depressed mood
Anxiety
Fear
Clinically significant impairment in social (familial/friend) functioning
Supports the assigned diagnoses (PTSD, GAD, Z61.3 [low self-esteem], Z62.4 [childhood emotional neglect]).
Inverted Pyramid Step 2 (thematic groupings)
Gestalt Therapy
Empty chair techniques
Here and now
Maladaptive thoughts
Negative thoughts surrounding sexuality
Feelings of worthlessness (don’t have anything good to offer)
Self-confidence issues (never been validated by father).
Maladaptive behaviors
Self-sabotage
Inverted Pyramid Step 3 (Gestalt Therapy/CBT)
Deepest negative distortions
Continued self-blame (MDD)
Unresolved familial discord (MDD)
Suicidality
Inverted Pyramid Step 4 (deeper issues)
Treatment Plan
F43.10 Posttraumatic stress disorder
Client will increase self-efficacy by the engagement in self-affirming exercises.
Client will reduce overall stress by engaging in exposure to stress-producing stimuli
Client will improve self-awareness by practicing grounding techniques.
Clinician will provide psychoeducation on EMDR therapy
F41.1 Generalized anxiety disorder
Client will reduce overall stress by engaging in exposure to stress-producing stimuli
Client will reduce feelings of anxiousness by engaging in square breathing.
Z61.3 Events resulting in loss of self-esteem in childhood
Client will reduce self-doubt by authoring a minimum of three self-affirming statements and meditating on them daily
Client will increase self-efficacy by participating in the empty chair exercise during session.
Z62.4 Emotional neglect of child
Client will reduce harmful thoughts through finding closure by way of the empty chair technique
Treatment Plan (continued)
ACA code A.4.b (personal values) governs the clinician on not imposing their values onto the client (ACA, 2014).
Victim advocacy
Strained relationship with father.
Christian values
ACA code C.2.b charges the clinician to operate within their scope of practice (ACA, 2014)
EMDR therapy
Ethical Considerations
Client disclosed that being a teacher makes him prone to solution-focused culture. His treatment goals may require a modality layered approached for the highest efficacy rate.
Sexuality
Religiosity
Multicultural Components
Links
American Counseling Association. (2014). 2014 ACA code of ethics. https://www.counseling.org/knowledge-center
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders: DSM-5 TR (5th ed. Text Revision). American Psychiatric Press, Inc. Retrieved from Psychiatry Online | DSM Library (liberty.edu).
References