Treatment Plan Goals

MHC610ComprehensiveCaseConceptualizationTemplate.docx

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MHC 610 Comprehensive Case Conceptualization Template

Instructions: Complete this template by replacing the bracketed text with the relevant information. Do not delete any boxes from this form, and be sure to remove the Guidance sections from your treatment plan before submitting the final version of your project.

Student Name: [Insert text]

Final Project Part One

Theoretical Orientation and Integrated Personal Approach

[Describe your integrated personal approach or single theoretical orientation. If you use a model such as nondirective vs. directive play therapy, the adaptive information processing model, or another method for structuring your sessions and counseling goals, please specify this.]

Guidance

In this section, describe (1) how you use your theory to help you conceptualize the client’s problems, and (2) how you use your theory to guide you in developing a treatment plan and providing counseling to the client.

Background Information

[Include demographics, age, disability, religion, social class, sexual orientation, indigenous background, national origin, gender identity, family unit, highest level of education, employment, military background, current and past legal issues, relationship status/social history, and substance abuse and treatment history if applicable.]

Guidance

Provide an overview of the client’s history, including demographics, family dynamics and history, work and education history, cultural considerations, key moments in the client’s life (both positive and negative), early childhood memories, medical history, career, and any other relevant information that will help you better understand the unique person who is your client. For example, some clients may have a military background, current or past legal issues, and/or other unique experiences.

Comprehensive Overview of Presenting Concerns

Presenting Concerns: [Describe the problem, explain the symptoms, note the intensity and frequency of the symptoms, identify potential harmful behavior, and note if there is family history.]

Current Triggers: [Describe triggers that activate the pattern, resulting in the presenting problem.]

Guidance

Based on the client’s history from the Background Information section and the history of the client’s problems, describe the triggers (e.g., events, behaviors, sights, sounds, smells, etc.) that activate or intensify the client’s problems.

Promoters: (Triggers (e.g., events, behaviors, sights, sounds, smells, etc.) that activate one’s patterns of behavior, resulting in the presentation)

Maladaptive Patterns: [Describe inflexible, ineffective manner of perceiving, thinking, acting.]

Guidance

Based on the Background Information and Current Triggers sections, describe the client’s current and past responses (thinking, feeling, and behaving) to the problem that have been ineffective.

Developmental Influences: [Describe factors fostering adaptive or maladaptive functioning; be sure to reference the human development theory you used to guide your information gathering.]

Guidance

Include the past history of the issues that brought the client to counseling, and use a timeline or your human development theory stages to organize the background: theories of individual and family development across the lifespan.

Protective Factors: [Describe biopsychosocial/spiritual factors that mitigate risk and support adaptive management of stress.]

Guidance

Based on the Background Information and Current Triggers sections, describe the client’s current and past responses (thinking, feeling, behaving) to the problem that have been effective. Describe any other client strengths that could be developed into protective factors for current and future problems.

Co-occurring Disorders: [Describe issues with addictions and mental health issues, if applicable. Assessment of the issues that includes neuro-bio factors organized with the stages of change is required.]

Mental Status Exam: [Note whether the client was on time; their behavior, attitude, and orientation to person, place, time, and situation; their mood, affect, tone of voice, rate of speech, judgment, and memory; their suicidal or homicidal ideation; and any observable symptoms/behaviors.]

Guidance

Summarize the results of the mental status evaluation of the client, including the following: Note whether the client was on time; their behavior, attitude, and orientation to person, place, time, and situation; their mood, affect, tone of voice, rate of speech, judgment, and memory; their suicidal or homicidal ideation; and any observable symptoms/behaviors.

Cultural Considerations

Cultural Identity: [Describe sense of belonging to a particular group (i.e., race, ethnicity, gender, sexual orientation, etc.).]

Cultural Stressors: [Describe level of adaptation to the dominant culture, and stress-rooted acculturation including psychosocial difficulties. Focus on minority stress, marginalization…What does this mean to you?]

Guidance

What are present stressors affecting your client’s cultural identity? Consider the impact of multiple minority statuses, marginalization, stress-rooted acculturation, psychosocial difficulties, institutional and social barriers, biases, power, and privilege.

Cultural Influencers: [Describe beliefs regarding cause of distress, condition, or impairment.]

Guidance

Using a cultural lens, what are your client’s beliefs regarding the cause of their distress, condition, or impairment?

Personality Patterns: [Describe operative mix of cultural and personality dynamics.]

Summary

Theory-Driven Case Summary: [Outline the history of the client’s problems, referring to the overview of the client’s history, including the client’s strengths and barriers (from the Background Information section) and your theoretical orientation (from the Theoretical Orientation and Integrated Personal Approach section), including both counseling and human development theories.]

Summary of Conceptualization Presented to the Client: [Write the script of what you will say to the client to offer a brief explanation of the conceptualization, and present the conceptualization to the client in language free from jargon so that they can correct and confirm the summary. Also add your theoretical orientation and integrated personal approach and focus on the object of change. For this section, you need to write up an explanation about the counseling process. You are informing the client about the steps you will take to assist them in addressing their objects of change.]

Final Project Part Two

Diagnosis

Primary Diagnosis and Justification: [List both the ICD and DSM-5 codes. What is the overall descriptor of the diagnosis? What criteria are met, and what behaviors are used to meet diagnostic criteria? What are the cultural considerations?]

After assessing Mr. Jones’ information, it is evident that he has acute adjustment disorder with depression. According to the DSM-V, Jones’ issues is acute adjustment disorder with depression since his symptoms connect to the criteria. The condition occurs for people exposed to stressful events in their lives recently or even in their past (Sissons, 2020). The process of generating the diagnosis involves assessment of situations in Mr. Jones’ life to determine what triggered the recent feelings of being lost, withdrawn socially, and having financial issues. The main issues that Mr. Jones identified were ending his three-year romantic relationship and lacking the appropriate employment.

Assessments: [List all of the assessments you used to justify this diagnosis.]

It is possible to assess the situation of Mr. Jones by apply a dimensional approach which offers accurate assessment of his behavior and impact between his personal life and finding an effective method of collaborating with external conditions. Mr. Jones was exposed to a lot of issues in his childhood that resulted in him adjusting to social situations where he had to form maladaptive behavior. The dimensional diagnosis approach focuses on placing abnormal behaviors in a patient’s life and connecting them to the frequency in occurrence and level of severity when attempting to find effective solutions. There is a connection between the abnormal behaviors in a person’s life and their ability to form an agreeable personality based on their social problems.

Secondary Diagnosis and Justification: [List both the ICD and DSM-5 codes. What is the overall descriptor of the diagnosis? What criteria are met, and what behaviors are used to meet diagnostic criteria? What are the cultural considerations?]

The study of Mr. Jones’ condition requires analysis of his behavior to determine an effective method of managing his personal factors and ability to connected with proper social development. The diagnostic criteria for depression are required to determine the types of behaviors Mr. Jones displays and they can lead to future solutions. A person with depression would have moody behavior, little interest in pleasurable situations, weight loss, restlessness, fatigue, feeling of being worthless, and reduced concentration (Truschel, 2020).

Assessments: [List all of the assessments you used to justify this diagnosis.]

The appropriate assessments for Mr. Jones are substance abuse assessment, psychological testing, and individualized treatment. The process of performing substance abuse assessment is imperative to connect to Mr. Jones since he reported that he had been using alcohol and marijuana in his childhood. This issue is detrimental in the case of Mr. Jones since it is difficult for him to function properly yet he has not recently engaged in alcohol abuse. Mr. Jones’ problem would have to get solved early to ensure he does not resort to alcohol and substance abuse to manage his feelings of low self-worth. Mr. Jones need to access health improvement measures that target his mental balance.

Tertiary Diagnosis and Justification: [List both the ICD and DSM-5 codes. What is the overall descriptor of the diagnosis? What criteria are met, and what behaviors are used to meet diagnostic criteria? What are the cultural considerations?]

Assessments: [List all of the assessments you used to justify this diagnosis.]

Additional Diagnosis and Justification: [What is the overall descriptor of the diagnosis? What criteria are met, and what behaviors are used to meet diagnostic criteria? What are the cultural considerations? This is where you will list all applicable V codes that are related to the complete diagnosis.]

Assessments: [List all of the assessments you used to justify this diagnosis.]

Final Project Part Three

Client-Centered Goals

Goal 1: [List long-term goal targeting an element of the presenting problem and/or part of the diagnosis that is agreed upon between the client and counselor using the SMART format.]

Objective 1 of Goal 1: [List a short-term goal that is a smaller element of the stated long-term goal that is agreed upon between the client and counselor.]

Intervention 1: [Describe what specific intervention the counselor will use and what is expected of the client to promote growth toward the objective (e.g., “Will use early recollections from Adlerian theory; Lifestyle Assessment to assist the client in discovering the guiding fictions they decided at an early age”).]

Intervention 2: [Describe what specific intervention the counselor will use and what is expected of the client to promote growth toward the objective.]

Intervention 3: [Describe what specific intervention the counselor will use and what is expected of the client to promote growth toward the objective.]

Objective 2 of Goal 1: [Insert text]