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Student Name: Celisa Jones

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.]

My integrated personal approach is Cognitive Behavioral Therapy, (CBT), was developed by Dr. Aaron T. Beck in the 1960s. CBT is a form of Psychological treatments that have been shown to be effective for an assortment of problems involving depression, anxiety disorders, also alcohol and drug use problems, marital problems, eating disorders, and severe mental disorders. I will use Cognitive Behavioral Theory to help the client overcome his feeling of being lost, depressed, withdrawn, and his worrying. I will use CBT to help to identify what the problems are with the client. Acknowledge the clients thoughts, emotions, behaviors, and beliefs. Help to change the negative thinking. This will help me to create a treatment plan that will be beneficial for the client.

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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the client. 1 I will use Cognitive Behavioral Theory to help the client overcome his feeling of being lost, depressed, withdrawn, and his worrying. 2 I will use CBT to help to identify what the problems are with the client. Acknowledge the clients thoughts, emotions, behaviors, and beliefs. Help to change the negative thinking. This will help me to create a treatment plan that will be beneficial for 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.]

Charles is 21-year-old, single, straight, African American and Lakota male. Charles is self supporting, undergraduate college student. Charles works the mid-night shift full-time at a ware house. Charles was an only child and was raised by his mother, along with an extended family. The extended family is Baptist and as a child, Charles attended church with his extended family, but Charles identifies as spiritual rather than religious. Growing up, Charles was a good student and was popular in high school. At age 14, Charles had drinking episodes, and at age 15, he had his first experience with marijuana. After high school, Charles’s mother moved out and eventually got married, and his father left when Charles’s mother was still pregnant. As a child, Charles had a good relationship with his mother, but it deteriorated as an adult.

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.]

Charles’s presenting concerns are that he feels lost, withdrawn from friends, and worried about money. He has been increasingly feeling depressed.

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

Charles’s current triggers are worrying about money, the end of his 3 year relationship, and being unable to find his ideal employment. Charles’s does not feel close to and supported by his parents. Another trigger for Charles is not being able to get past the phone call or interviews for jobs.

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)

Charles’s triggers are the loss of his 3 year relationship, being able to find his ideal job, trying to make ends meet, being bi-racial, his mother, his father, and his family.

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

Charles gets depressed when he thinks about the end of his 3 year relationship, when he cannot find his ideal employment, he is worried about his financial situation, he feels withdrawn from friends, he feels lost, he has trouble slowing down after work, and he has trouble sleeping. Charles is discouraged about being single and money.

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.]

Charles’s developmental influences started when his mother told him about his father leaving before he was born. Charles did not grow up with his father, so he was missing that father influence. Also, smoking marijuana and drinking at a young age had some developmental influences. Charles witnessed his mother being the only head of the family and the money maker of the family, so Charles is following in his mother footsteps about keeping a job and making money.

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.]

Charles has good insight and judgment. He is punctual, cooperative, pleasant, attentive, and he is self supported financially. He works a full time job, and he is in college studying computer science and he is in good shape. Charles wants to go to counseling to get help for his situation, even though his family doesn’t agree.

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.]

Charles has been drinking since he was 14 and smoking marijuana since he was 15. Charles has depression, and anxiety.

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.]

Charles was on time for his counseling appointment. He was dressed nice, quiet cooperative, pleasant, attentive, and well groomed. He speaks coherently. He has a dry sense of humor and smiled several times. He denied being suicidal, homicidal, and psychosis. Charles is cognitively intact, and his insight and judgment was good.

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.).]

Charles is African American and Lakota. He is a straight male. Charles identifies as being spiritual. Char e has been drawn to exploring the spiritual beliefs and practices of the Lakota Nation.

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?]

Charles states that as a young biracial man, he is generally expected to be strong and independent, and norms of masculinity have made him hesitant to attend counseling. His family views counseling as something that is only for “crazy people.

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.]

Charles’s family believes that counseling is for crazy people. The cultural influence is that as a bi-racial man, he should be strong and that he does not need counseling and that there are people in his family that is struggling with addiction and mental health problems but won’t go to counseling because they were taught that biracial men should do not need counseling.

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.]

Charles is a hard worker, quiet; his sense of humor is dry. He is punctual, cooperative, pleasant, and attentive. Charles likes to work and feel that he is independent.

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.]

Charles came to counseling because he feels lost, withdrawn from friends, and he is worried about money. Charles is 21-year-old, single, straight, African American and Lakota male. Charles is self supporting, undergraduate college student. Charles works the mid-night shift full-time at a ware house. Charles was an only child and was raised by his mother, along with an extended family. The extended family is Baptist and as a child, Charles attended church with his extended family, but Charles identifies as spiritual rather than religious. Growing up, Charles was a good student and was popular in high school. At age 14, Charles had drinking episodes, and at age 15, he had his first experience with marijuana. After high school, Charles’s mother moved out and eventually got married, and his father left when Charles’s mother was still pregnant. As a child, Charles had a good relationship with his mother, but it deteriorated as an adult. Charles is a hard worker, quiet; his sense of humor is dry. He is punctual, cooperative, pleasant, and attentive. Charles likes to work and feel that he is independent. CBT is a form of Psychological treatments that have been shown to be effective for an assortment of problems involving depression, anxiety disorders, also alcohol and drug use problems, marital problems, eating disorders, and severe mental disorders. I will use Cognitive Behavioral Theory to help the client overcome his feeling of being lost, depressed, withdrawn, and his worrying. I will use CBT to help to identify what the problems are with the client. Acknowledge the clients thoughts, emotions, behaviors, and beliefs. Help to change the negative thinking. This will help me to create a treatment plan that will be beneficial for the client.

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.]

You came to counseling with your presenting concerns. I will use the Cognitive Behavioral Therapy to help you with those concerns. CBT will help you to learn new behaviors, thinking, and beliefs. Cognitive Behavioral Theory will help you to overcome your feeling of being lost, depressed, withdrawn, and worrying. In our first session, we will get to know each other and create a plan and a goal for your treatment success. In our second session, we will talk about interventions that will help you be successful with your treatment. In the future sessions, we will work on skills that will help you full your goals.

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?] 296.32 (F33-1), F32.0

Depression. Feeling lost, withdrawn from friends, and worried about money. The cultural considerations are that Charles is biracial and was raised by his mother. Father wasn’t in his life.

Assessments: [List all of the assessments you used to justify this diagnosis.] The Beck Depression Inventory (BDI), Patient Health Questionnaire (PHQ-9).

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?]F41.9, 300.02 (F41.1)

Worrying about finances, worrying about finding a job that he likes. The cultural considerations are that his mother was a single mother who worked and took care of Charles, so Charles was raised to have a job to take care of himself.

Assessments: [List all of the assessments you used to justify this diagnosis.] The Kessler-10 (K-10) and the Generalized Anxiety Disorder-7 item scale (GAD-7)

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?] F33.1, 296.20-296.36

Therapy for depression and Anxiety. Feeling lost, financially stressed. The culture considerations are his bi-racial status, father not there, and family not supportive

Assessments: [List all of the assessments you used to justify this diagnosis.] The Beck Depression Inventory (BDI), Patient Health Questionnaire (PHQ-9).

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.] V15.49 (Z91.49) Mental Health diagnosis. Seeking therapy for his depression and anxiety. Depressed about his break up with girlfriend, and financially stressed. Cultural considerations, raised by mother, father not there, family thinks that therapy is for the crazy people.

Assessments: [List all of the assessments you used to justify this diagnosis.] Interview with your Dr., Physical examination, Medical tests.

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.]A long term goal for CJ is to reduce his anxiety and improve his coping skills.

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.]A short term goal for CJ is to learn how to manage his anxiety by going to therapy.

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”).]I will use Play the Script until the End from the Cognitive Behavioral Theory; helping CJ to recognize that fear and anxiety can be managed.

Intervention 2: [Describe what specific intervention the counselor will use and what is expected of the client to promote growth toward the objective.]I will use Cognitive Restructuring from the Cognitive Behavioral Theory. This intervention will benefit CJ because it will help him to figure out what is causing his negative thinking that leads to his anxiety, and it will help him to revamp those negative thoughts and replace them with positive thinking so that he can manage his anxiety and depression.

Intervention 3: [Describe what specific intervention the counselor will use and what is expected of the client to promote growth toward the objective.]I will use Relaxed Breathing from the Cognitive Behavioral Theory will help CJ to breath regular and breath calmly will allow CJ to approach his problems from a place of balance, easy, more effective, and sensible decisions.

Objective 2 of Goal 1: [Insert text]Effectively decrease anxiety levels

Intervention 1: [Insert text] Play the script to the end

Intervention 2: [Insert text] Cognitive Restructuring

Intervention 3: [Insert text] Relaxed Breathing

Objective 3 of Goal 1: [Insert text] CJ will write down when feeling anxious or fear

Intervention 1: [Insert text] Journaling

Intervention 2: [Insert text] Relaxed Breathing

Intervention 3: [Insert text] Interoceptive Exposure

Goal 2: [Insert text] Improve overall mood

Objective 1 of Goal 2: [Insert text] Graduate from college on time

Intervention 1: [Insert text]Relaxed Breathing

Intervention 2: [Insert text]Journaling

Intervention 3: [Insert text]Unraveling Cognitive Distortion

Objective 2 of Goal 2: [Insert text]Find an ideal job

Intervention 1: [Insert text] Learn to accept disappointment as a normal part of life.

Intervention 2: [Insert text] Finish each day by visualizing its best parts

Intervention 3: [Insert text] Learn to accept disappointment as a normal part of life

Objective 3 of Goal 2: [Insert text] ]Increase communication with his peers at least once a week

Intervention 1: [Insert text]Exposure

Intervention 2: [Insert text]Homework

Intervention 3: [Insert text]Functional Assessment

Prognosis

Guidance

[In this section, summarize the likely course, duration, and outcome of the mental health condition with and without treatment.]

Reevaluation of Treatment Plan

Guidance

[In this section, identify the importance of assessing the goals you developed for your client. Also, describe how you will reevaluate your treatment plan and how often this reevaluation process will happen.]

SOAP Note

Guidance

[In this section, you will have to use your imagination on the likely progression of a session and objective behavioral presentation of your client. SOAP notes describe subjective observations, objective observations, assessment, and plan.]