Case Presentation Review

Overview

The case presentation will be in oral and written formats across the program. In some courses, you will only have to focus on certain aspects of the case presentation (e.g., assessment, diagnosis, treatment planning, case conceptualization, etc.). This assignment is derived from the Switzer and Rubin (2015), which is a required book across the curriculum. Your written paper should be 6-8 pages not including title or reference pages, double-spaced (except in the IPM and treatment plan charts), and follow APA professional guidelines format. You should have at least five (5) academic sources, specifically in the diagnosis, case conceptualization, treatment planning, integration, and personal counseling sections. Please be concise yet thorough in covering the information requested.

Instructions

Part 1 – Assessment and Diagnosis

COUC 699

Page 2 of 2

Date of Initial Assessment:

PSEUDO Name (DO NOT use actual client’s real name):

Age:

Gender:

Sexual Orientation:

Ethnicity:

Marital Status:

Employment Status:

Reason for Referral/Presenting Problem

In this section, offer the referral status (i.e., self-referred, school referral, court-ordered) and provide the initial reason for the referral. This may be a triggering event such as a divorce, death, pandemic, loss of employment, bullying, or client reported increase in signs, symptoms, impaired functioning, etc. Ideally, offering direct quotes on how the client describes the reason. This is one short paragraph in length. To protect the confidentiality of your client, please refer to them by a pseudo name in your case presentation. This section should include a statement indicating that you reviewed confidentiality and the limitations therein.

Source of Information: Provide the source and manner in which data was obtained in the preparation of this report. This includes both formal and informal assessments in the summary as well as throughout the case presentation as necessary to support your conclusions. A semi-structured interview is necessary in this section, but you should also include a battery of formal and other assessments (e.g., DSM-5 cross-cutting measures, GAD-7, PHQ-9, PCL-5, etc.).

Background, Family Information, and Relevant History

Offer clinically relevant background information on the client. Write this out in paragraph format – no bullet points. The section should include the following in this order:

· Demographic Information: age, gender, sexual orientation, ethnicity, marital status, etc.

· Family and Home Background: Identifying information about the client, parents, and siblings (i.e., ages, occupations, etc.). Client’s perception of the home environment and relationships within the family. Critical family incidents may be included.

· Educational History: Description of pertinent information in relation to educational background including academic achievement, school instances that were significant for understanding the individual and the client’s attitude toward education. Any assessment information would be helpful.

· Occupational History: A description of the client’s vocational history. Emphasis should be placed on current occupational functioning, history of work problems and reason for change. Quality of work and satisfaction and interests.

· Client’s Physical Health: A statement of the client’s significant health history, current conditions/treatment, and medications. Also, include data related to sleep, diet, and exercise.

· Substance Use History: Description of client’s alcohol/drug use, patterns of use, and last use; as well as how often client uses and how much.

· Sexual Adjustment: Current status, significant problems or disturbances in functioning, alternate lifestyles.

· Spiritual Assessment: Does client believe in God? Attend church? What role does religious affiliation play in the client’s life? Are spiritual resources or issues important to client? How does client describe God? What is the state of the client’s spiritual awareness? Additionally, an assessment of the religious background of the family is included.

Problem and Counseling History

Offer historical as well as present signs, symptoms, onset, duration, frequency, severity, areas of dysfunction, and other relevant data that will be needed for diagnosis and case conceptualization. Write this out in paragraph format – no bullet points. Do not include a diagnosis here. This section should include the following in this order:

· Mental Health: historical and as well as present signs, symptoms, onset, duration, frequency, severity, areas of dysfunction, and other relevant data that will be needed for diagnosis and case conceptualization. This should include mental health assessment results.

· Mental Status Examination (MSE): when first meeting the client, what are your observations that would include: speech, mood, affect, orientation (person, place, time, situation), thought process, delusions, hallucinations, concentration, risk (e.g., suicidality, homicidality, non-suicidal self-injury, violence), etc.

· Cultural Factors: Does the client have any factors such as acculturation, discrimination, etc. that impact the client and may be source of signs, symptoms? How would the client explain the problem from their cultural lens?

· Barriers to Treatment/Success: Are there personality factors, stages of change influences, or contextual factors that would influence the success of treatment?

· Other pertinent data: Provide any other data points not captured from the sections above such as signs, symptoms, severity, onset, conditions, context that provide a clearer picture for the development and discernment of the diagnosis as well as client insight and motivation to treatment.

Diagnostic Impression

Principal diagnosis

Diagnosis 2 or z-code

Diagnosis 3 or z-code

Differential Diagnosis: for each mental health diagnosis

Offer all your diagnoses and z-codes in order of priority. Include the ICD-10 code, severity, specifiers, etc. for each disorder. The first diagnosis is called the principal diagnosis. If the client does not meet all the criteria for a disorder and it is likely that they will if you had more information, offer that it is provisional – ex: Generalized anxiety disorder (provisional).

Discussion of Diagnostic Impression

When writing up this section, make sure to offer each disorder criteria with case data to support the diagnosis. For example, for MDD, the client reported a lack of desire or interest during the clinical interview and confirmed in the PROMIS instrument, “I wanted to be by myself” and “It is hard for me to have fun” (Criteria A.2).

The first paragraph is only for the principal diagnosis, the next paragraph is on the second disorder, and then additional paragraphs are for the other disorders. Each paragraph is to focus on only one disorder. It is like building a court defense. If your records are subpoenaed or you transfer a client to another counselor, they are not questioning your diagnosis as being incorrect, inconclusive based on the diagnostic discussion. For the final paragraph, discuss your differential diagnosis.

This section should include a concise rationale for each diagnosis, differential diagnoses, and Z codes provided above.

STEP 1: IDENTIFY AND LIST CLIENT CONCERNS AND ANY OTHER PROBLEM AREAS

Offer a “grocery” list of the main concerns, problems based on the clinical data you collected. Be as comprehensive as possible. This can include behaviors, thoughts, affect, physiology, life role adjustment, institutional adjustment, family roles, relationships conflicts, work problems, school problems, clinical problems such as self-harm, medical problems, meds, developmental problems, cultural social influences, psychological assessment results, MSE concerns, and maintaining factors (anxiety but working from home as a safety behavior).

STEP 2: ORGANIZE CONCERNS INTO LOGICAL THEMATIC GROUPINGS

Use and identify one of the four thematic groupings offered by Switzer and Rubin (Descriptive-Diagnostic, Clinical Targets, Areas of Function and Dysfunction; Intrapsychic Areas). These themes are important in that they will be used in the treatment plan as primary problems to craft the treatment plan. This section is atheoretical. Identify which one of the four themes used for clarity to the reader.

STEP 3: THEORETICAL INFERENCES:

ATTACH THEMATIC GROUPINGS TO INFERRED AREAS OF DIFFICULTY

Identify which counseling theory you are using. Group based on theoretical constructs.

STEP 4: NARROWED INFERENCES AND DEEPER DIFFICULTIES

Offer the deeper core issue using your counseling theory that is driving Step 3 groupings and client concerns, problems identified.

Use the key terms and constructs of your chosen counseling theory to explain (not describe as the DSM-5 does) the clinical problems and maintaining factors. This section needs to be rich in theory and should reference and apply sources for application of theory such as counseling theories books, journal articles, etc. Start by offering the “deeper issues” in Step 4, then connect the deeper issues to Step 3 groupings by using the problems identified in Steps 1 and 2 along with additional case study data.

Treatment Plan

Integration

In this section, write a one-page (minimum), double-spaced reflection about (1) how you assessed this client’s spiritual background, and (2) how you integrate faith into this client’s counseling, explicitly and/or implicitly. You must incorporate which integration approach you would use with this client as described by Johnson’s Psychology and Christianity: Five Views or Entwistle’s Integrative Approaches to Psychology and Christianity.

Personal Model of Counseling

In this section, write a ½ -page reflection about your use of a specific theoretical orientation in your counseling with this client. Think about how well you are using theory-based interventions and ways you can improve in applying your theoretical orientation as you go forward (strengths and areas for improvement).

References

(on separate page per APA 7)

Note: Your assignment will be checked for originality via the Turnitin plagiarism tool.