Case Conceptualization

Adapted from: Stoltenberg, C.D., McNeill, B., & Delworth, U. (1998). IDM supervision: An

Integrated developmental model for supervising counselors and therapists. (pp. 187-1819). San Francisco: Jossey-Bass.

This format is designed to help therapists collect and integrate relevant information for case conceptualization, diagnosis, and treatment, to organize client information, and facilitate discussion leading to an understanding and ultimately decision making regarding client care.

Please document most of this data in past tense, as you have already met with the client.

1. Clinic Data

a. Therapist name

b. Status (first practicum site, intern, staff)

c. Agency/Clinic site

d. Number of sessions with client

e. Type of sessions (individual, group, marital, family)

2. Client Demographic Data

This section could include the client’s name (initials or altered name for confidentiality), age, sex, marital status, children (in and out of home, ages, sex), and living situation (house or apartment, people living in the home and relationship with client).

3. SES Data

This section could include the client’s occupation status, family members, average family income, transportation status (drives own car, public transportation), other economic resources (own house, savings, family support), and economic stressors (debts, child support, etc).

4. Cultural Influences and Impact on Career

This section could include the importance of culture and its impact on career, importance of family and its impact on career, importance of individual characteristics and its impact on career, and the interrelationships of culture, family, and individual characteristics on career.

5. Presenting Problem(s)

This section could include a description of the problem areas, listed separately, from the client’s perspective, particularly noting client’s view of their order of importance. Suggested items of focus could be precipitating factors, duration of problems, history of problem occurrences, circumstances for previous problem occurrences, possible connections between problems, and potential influences on career issues.

6. Relevant History

This section covers the client’s psychosocial, medical, and psychiatric history and will vary in comprehension and focus according to the depth of treatment, length of treatment, theoretical orientation utilized, and the specific nature of the problems. Suggested topics for discussion:

· Family and relationship history (family of origin/developmental issues, past marriages/significant relationships -duration, sexual functioning, dissolution factors, sexual orientation, etc., children -from current or prior relationships and current status, current family status and structure)

· Cultural history and identity (issues of ethnicity and race, identification/acculturation)

· Educational history (childhood/developmental, adulthood/current status)

· Vocational history (types, stability, satisfaction)

· Medical history (acute/chronic illness, hospitalizations, surgeries, major patterns of illness in family, accidents, injuries, with whom/where/how often receive medical care, etc.)

· Health practices (sleeping, eating patterns, use of tobacco, consumption of caffeine etc)

· Mental health history (prior problems, symptoms, diagnoses, evaluations, therapy experiences, past prescribed medications, current and family of origin mental health histories)

· Current medications (dosages, purposes, physician, compliance, effects, side effects, etc)

· Legal history (arrests, DUI, jail/prison, lawsuits, any pending legal actions)

· Use/abuse of alcohol or drugs (prescription or illegal)

· Family (current and origin) alcohol/drug history

7. Interpersonal Factors

This section contains a description of client’s orientation toward others in environment, such as manner of dress, physical appearance, general self-presentation, nature of typical relationship (e.g., dependent, submissive, aggressive, dominant, withdrawing, etc), and behavior toward therapist (e.g., therapeutic alliance).

8. Environmental Factors

This section could include a description of elements in the environment, not already mentioned, that function as stressors and/or supports (e.g., friends, family, recreational activities, etc.) to the client – those centrally related to the presenting problems and more peripheral.

9. Personality Dynamics

Cognitive factors (data related to thinking and mental processes), such as intelligence, mental alertness, persistence of negative cognitions, positive cognitions, nature and content of fantasy life, level of insight (awareness of changes in feelings, behavior, reactions of others, understanding of the interplay, etc), or capacity for judgment (ability to make decisions and carry out practical affairs of daily living).

Emotional factors, such as typical or most common emotional stress, predominant mood during interviews, appropriateness of affect, range of emotions client can display, or cyclical aspects of client’s emotional life.

Behavior factors, such as psychosomatic symptoms, existence of problematic habits, or mannerisms.

10. Psychological Testing

Discussion of the methods or instruments utilized (both past and present), the evaluator(s), location, dates, reasons for testing, and results.

11. Life Transition/Adaptation Skills

Discussion of the client’s coping skills (concrete efforts to deal with distressing situations; anticipation, preparation, response), social resources (supportive social networks), and psychological resources (adaptive personality characteristics; self-efficacy, hardiness, optimism).

12. Theoretical Conceptualization of the Case

First, identify the specific theory or theories used and provide a brief overview of the general theory’s main points. Next, describe how the conceptualization was then applied to understand the existence of this particular client’s problems. Finally, describe how the conceptualization affected the therapist’s approach to treatment, which may also include discussion related to multicultural variables.

13. Recommendations

Each of the following are required to be included in your recommendations:

· Prognosis.

· Should services continue to be offered, or would a referral for counseling services elsewhere be more appropriate?

· Potential referral(s) to other professions (e.g., medical, psychiatric, etc.).

· Recommendation for a specific therapeutic orientation to be used with this client.

· Nature of treatment (e.g., specific therapist, priority of treatment issues, interaction with client characteristics such as defensiveness, motivation for treatment, problem complexity, etc.).

· Format recommendations concerning working with the client (e.g., individual, group therapy, etc.).

14. Treatment Plan

Based on the above information, describe the treatment plan you will follow to address the presenting and emerging problems. Make it consistent with your theoretical orientation and available empirical evidence. Estimate the number and types of sessions needed to address the issues.

15. Mock Session and Interpretation Critique:

Treatment Goals for the Session:

In preparation for the session, what were the goals that were hoped to have been accomplished?

· These may or may not have been discussed with the client.

· Examples of session goals could have been generated in supervision just prior to the session.

· These may or may not be listed on the formal treatment plan.

· Examples of session goals that wouldn’t necessarily be listed on the treatment plan would be:

· Review the coping skills that were discussed during the previous session,” or “Strengthen rapport after the mandated breach of confidentiality due to risk of self harm.”

Interpretation Critique:

· In this section you need to identify which assessment you chose for your client.

· What was the rationale for the specific assessment with this client?

· What score did your client receive on this assessment?

· You will want to provide a reflection of the interpretation of the assessment:

· What areas do you feel were handled well?

· Are there any components that the client happened to comment on as being helpful?

· If you had the session to do over again, would you add or remove any of the session goals, say anything differently, use a different assessment, or use a different theoretical approach?