Case Presentation Topic for Instructor Approval
COUC 546 BENCHMARK CASE PRESENTATION PAPER ASSIGNMENT INSTRUCTIONS OVERVIEW This Benchmark Case Presentation Paper Assignment is designed to help you make application of course content to a counseling situation. In this Benchmark Case Presentation Paper Assignment, you will have the opportunity to create a clinical case, identify and prioritize key issues involved, consider and clarify relevant diagnostic issues and formulate treatment recommendations that are most likely to be helpful to the client. This Benchmark Case Presentation Paper Assignment will directly apply to your work in COUC 667 and with clients when you begin practicum. INSTRUCTIONS For this Benchmark Case Presentation Paper Assignment, you will create a case presentation to review, diagnose and provide treatment recommendations for. Part 1 Step 1: Choosing the Diagnosis At the end of Module 3: Week 3 in the Quiz: Case Presentation Topic for Instructor Approval you will submit your request for the diagnosis on which you will base your case presentation. You must receive written approval from your professor to proceed with the case presentation. You will need to provide the full name and ICD 10 code for the diagnosis you are requesting, including any specifiers. Once you receive approval, you can begin to construct your case. Step 2: Writing the Benchmark Case Presentation Paper Assignment For this case presentation the following sections are to be organized using Level 1 and Level 2 APA headings: Basic Case Summary Identifying Information (approximately ½ page) This section needs to include the following information exactly as listed here: Date of initial assessment: Age: Client’s Name: Gender: Employment Status: Race/ Ethnicity: School Status: Marital Status: Reason for Referral/Presenting Concern (approximately ½ page) Provide a brief reason the client has entered counseling. This may be a triggering event such as a divorce, death, pandemic, loss of employment, bullying, or client reported an increase in signs, symptoms, impaired functioning, etc. For example, you may provide a brief description of the client’s situation, signs of the symptoms of the disorder they are experiencing, how the signs of the symptoms are affecting major areas of life (functioning in relationships, employment, school, etc.). This section should be told in third-person narrative style, including Page 1 of 5 COUC 546 some direct quotes from the client. In this section you will connect some of the symptoms in the DSM of the disorder by presenting corresponding signs (client report) of the symptoms. This section should be clearly worded and sound like something you would expect a client to report. It should not be a listing of symptoms from the DSM; rather, how a client would represent their experience of the symptoms. Example of language not to include in this section: DSM: Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). Example of language to include in this section: “I feel so sad all the time. Sad, empty and I cry at the drop of a hat. I have been at lunch with two different people since this started and I started crying uncontrollably, which was pretty embarrassing. I have never cried in public like that. And it just happened! This has been going on every day for about eight weeks… but it feels like it has been going on for years and I am starting to worry I will never feel happy or hopeful again.” Not all signs of symptoms to support the diagnosis must be in this section, but there must be a strong foundation for the diagnosis. You will provide additional information to support the diagnosis in the “Mental Health” heading under “History.” History (approximately 2 pages) Below are points to include in your Benchmark Case Presentation Paper Assignment. Please use Level 2 APA headings to organize this section. The required information is as follows: Family and Home/Religious Background Identifying information about the client, parents, and siblings (names, 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. Mental Health Historical and current signs and symptoms, as well as mental health test results (formal and informal) as applicable, such as DSM-5 cross-cutting symptom measure, Beck’s Depression Inventory, etc. Client’s Physical Health A statement of the client’s significant health history, current treatment, and medications. Occupational History Page 2 of 5 COUC 546 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. Sexual Adjustment Current status, significant problems or disturbances in functioning, alternate lifestyles 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. 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? Cultural/ Social Justice 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/ cultural/ social justice/ motivational factors that would influence the success of treatment? Other Pertinent Data (if relevant) 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. Mental Status Exam (approximately 1 page) This section should be a very brief overview of initial observations, perceptions, and impressions of the case presentation. Very briefly remark on anything that would support the diagnosis you are presenting (for depression you might comment on sadness, flat affect, or tearfulness…). The following are required to be in the mental status exam: o Presenting Appearance o Basic Grooming and Hygiene o Interpersonal Characteristics and Approach to Evaluation o Speech o Eye Contact o Expressive Language o Receptive Language o Orientation o Alertness o Coherence Page 3 of 5 COUC 546 o o o o o o o o o Concentration/ Attention Thought Processes Hallucinations and Delusions Judgement/ Insight Intellectual Ability Mood Affect Suicidal and Homicidal Ideation Risk of Violence At the end of the instructions is a list with more detail about the terms you must use. You can add from the list below if appropriate. Answer Key (1/2 to 1 page) As part of this Benchmark Case Presentation Paper Assignment, you will provide an answer key, to confirm that you have intentionally provided adequate information to support your diagnosis. This Answer Key will include the chart indicating your client meets all the criteria for the chosen DSM-5-TR disorder. Be sure to include the full name and ICD 10 code for the diagnosis. DSM-5 Diagnostic Criteria: disorder name and code number Criterion A: Client’s Reported Symptoms: Criterion B: Criterion C: Criterion D: Criterion E: Criterion F: Treatment Recommendations (approximately 1 page) Two treatment recommendations: Choose what you think is the most important issue to address in the case and provide two treatment recommendations. You will need two peerreviewed journal articles that are not more than 10 years old to support your recommendations and the rationale for why each treatment approach was chosen for this particular client/symptom. Please make sure you provide recommendations that are counseling focused, e.g., what would you as a counselor do with this client in your office? Any case management (medication evaluation, etc.) can be noted but does not suffice as the treatment recommendation. Medication considerations: Discuss whether you would refer the client for a medication evaluation and discuss why or why not. If you would refer, provide a brief discussion of the Page 4 of 5 COUC 546 research regarding the use of medication for this diagnosis. For example: which symptoms would be the most likely to benefit from the use of medication? What broad classification of medications might be prescribed (e.g., anti-anxiety, anti-psychotic, mood stabilizers, etc.)? Be sure to provide at least one scholarly reference to support your discussion. The Treatment Recommendations will be the final section of the Benchmark Case Presentation Paper Assignment. This Benchmark Case Presentation Paper Assignment should be 6-8 pages long, excluding the title page and reference page. Use current APA format. No abstract is required. This Benchmark Case Presentation Paper Assignment requires a minimum of 4 resources (the DSM-5-TR included as one of the four) from peer-reviewed journals that are less than 10 years old. You may use textbooks, but they will not count towards the required resources. You may not use web site or other non-professional literature. Be sure to view the Benchmark Case Presentation Paper Grading Rubric before beginning this Benchmark Case Presentation Paper Assignment. Note: Your assignment will be checked for originality via the Turnitin plagiarism tool. Page 5 of 5
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