Wk04_08 Case Conceptualization and Reflection Form

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CLINICAL MENTAL HEALTH COUNSELING

MARRIAGE, COUPLES, FAMILY COUNSELING

CASE CONCEPTUALIZATION FORM

This Case Conceptualization & Reflection Form will be used in conjunction with your recording assignment to analyze your skills demonstration. For these assignments, you will complete the case conceptualization on the client you have chosen for your skills demonstration. Ideally, this will be the same client for both Week 4 and Week 8.

FOR THE WEEK 4 CASE CONCEPTUALIZATION

PART I

FOR THE WEEK 8 CASE CONCEPTUALIZATION

PART II

PART I (Due Day 7 of Week 4)

Counselor name:	Client age:
Client initials:	Client race or ethnicity:
Number of sessions with client:	Self-identified gender:

Presenting Problem

To understand the presenting problem, describe the client’s past and present. Be sure to address each of the following elements:

· Demographic information

· Employment history

· Relevant legal problems

· History of counseling

· Reason for seeking counseling, according to the client

· Onset and duration of concern

· Frequency and intensity of symptoms

· What the client wants to improve

     

Family Structure

Clients and their concerns are shaped by their family structure and stage of development. Be sure to address each of the following elements and their impact:

· Family of origin and role within

· Family of choice if different and role within

· Significant relationships/relationship patterns

· Children, marriages, divorces

· Current living arrangements

· Major losses, family traumas

· Family mental health history

· Family substance abuse history

· Family violence or abuse history

· Stage of development impacts

· Developmental challenges

     

Multicultural Considerations

Clients and their concerns are shaped by a multitude of multicultural considerations and their intersectionality. Be sure to address each of the following elements and their impact:

· Race or ethnicity

· Religion

· Ability/disability

· Sexuality

· Socioeconomic status

· Military

· Criminal justice system

· Geographic influences

· Environmental factors

· Experiences of oppression or marginalization

Narrative Summary

Take a step back and, through the lens of your education to this point, work to conceptualize the big picture. Consider the influence of all the information in Part I. Consider how it has all culminated and impacted who your client is and their world view. Within that context, consider the problem they presented with for counseling and address each of the following elements:

· Describe your understanding of the problem.

· Describe your observations of the client.

· Describe your impressions of the client.

· Describe any factors contributing to or reinforcing the problem.

· Describe the purpose of the client’s behaviors.

· Describe themes and patterns that emerge or connect.

· Describe barriers to growth and coping.

· Describe strengths, assets, protective factors, signs of resilience.

     

DSM–5 Diagnosis

It is of utmost importance to diagnose ethically and responsibly. You must consider all elements covered thus far not only in your understanding of the problem but in rendering a diagnosis. With this in mind, address each of the following elements:

· DSM–5 diagnosis

· Rationale for how diagnosis was determined

· Two other diagnoses considered, but not given

· Explanation for ruling out diagnoses not given

· Mental health assessments or scales used

· Other assessments or scales that could be used

     

PART II (Due Day 7 of Week 8)

Counselor name:	Client age:
Client initials:	Client race or ethnicity:
Number of sessions with client:	Self-identified gender:

Theoretical Orientation and Application

Your theoretical orientation influences your counseling approach. While you are likely still in the very early stages of considering and trying on different theoretical orientations, you have likely noticed that some seem to resonate with you more than others. While you have been trained in Person-Centered Theory, consider another orientation that most closely aligns with your understanding of human behavior and your approach to it. In doing so, respond to the following:

· State your preferred theoretical orientation and the original theorist.

· Describe what elements of this preferred theoretical orientation resonate with you.

· Explain how this preferred theoretical orientation approaches client problems.

· Explain how this preferred theoretical orientation approaches positive change.

· Describe how this preferred theoretical orientation would make sense of your client’s presenting problem.

· Now select another counseling theory and contrast how it would make sense of your client’s presenting problem differently.

     

Treatment Planning

The nature of the treatment plan and evidence-based interventions should coincide with the needs of the client and the theoretical orientation utilized. Additionally, treatment goals should be SMART (specific, measurable, attainable, realistic, and timely). Using your theoretical foundation of Person-Centered Theory coupled with your preferred theoretical orientation described in Part II, respond to the following elements:

· Short-term SMART goal for treatment

· Interventions, approaches, and techniques to work toward this goal

· Mid-range SMART goal for treatment

· Interventions, approaches, and techniques to work toward this goal

· Long-term SMART goal for treatment

· Interventions, approaches, and techniques to work toward this goal

     

Ethical and Legal Considerations

Nearly all clients and every situation present the possibility for ethical concerns and dilemmas. It is important to be proactive and intentional in our consideration of what those might be. Ethical challenges can arise in a number of ways, including transference/countertransference, court-ordered counseling, informed consent, boundary violations, poor self-care, limits of confidentiality, and mandated reporting. Using the ACA Code of Ethics, reflect on your work with the client and respond to the following:

· Describe ethical dilemmas present or potentially present.

· Identify your own barriers or challenges that may complicate the ethical dilemma.

· Explain the steps you should take to be intentional and proactive in your ethical approach.

     

Social Change Implications

The end of your work with a client should not be the end of your work. Each client impacts us as we impact them. Reflect on your client and their circumstances. Consider their efforts in relation to their successes and failures. Keeping in mind all of the information you have considered for this case and all of the insight you have gained, respond to the following elements:

· Address the systems and barriers the client experiences that impacted the current situation and outcomes.

· If changed or removed, identify what systems and barriers could impact positively upon this individual in the future.

· Discuss how your work with this client has informed your understanding of a larger social challenge or barrier.

· Identify steps you could take to effect positive social change in relation to this social challenge or barrier.

     

Rev: June 2020

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************Please complete the case conceptualization based upon the below synopsis. In order to answer all the questions on the template, if you need to provided additional insight/substance, that is fine. Please communicate with me any barriers. This is due to me 3/24 by 6:00 PM E/T.*************

History: Christian is an African-American 10-year-old boy. This evaluation was requested because the therapist at the school shared with mom that the client shared he wanted to kill/farm himself while at school. One of his friends informed the counselor that the client shared he wanted to kill himself. The client shared that the conversation with his peers was in relation to him wanting to be an animal. He used the phrase "kill himself" because he thought that if he killed himself, he would go to Heaven and be able to ask God about being reincarnated into another animal. He did not plan to hurt himself. Mom thinks he heard the term reincarnated on t.v. The client shared that before he said he wanted to kill himself, he shared that people were being mean to him, which prompted him to anger.

History:

Christian today denies any psychiatric symptoms. Hallucinations, delusions, and other symptoms of psychotic process are denied. Mood is described as euthymic and stable. No unusual anxiety is reported. Behavior has been stable and uneventful. He at times does experience some social isolation with peers and experience days of saddness.

Current Stressors:

Information Received From:

*Christian

*Family (mom)

Serious problems in school are described. Christian is reportedly being bullied. A number of symptoms stem from these interactions. At times he experiences bullying from other peers but it is mainly with the two little girls. Significant academic difficulties are present in relation to paying attention, and writing. Reports cards are good.

Significant social problems are present.

Symptom Review:

Information Received From:

*Family

Lack of energy stops the client from being happy, per mom.

He describes a depressed mood at present. Christian reports that he becomes easily fatigued. He reports having feelings of sadness. He reports that he no longer enjoys previously enjoyed activities, mainly going outside and playing with toys.

The client shared that at times he hears voices, he believes it is the ghost of his grandmother on Dec. 2, 2022. The voices are good voices, that he hears in his mind.

Past Psychiatric History:

Entirely negative. Christian has never been treated, counseled or hospitalized for a psychiatric condition. There is no history of emotional dyscontrol, unusual anxiety, or behavioral disturbance.

Social/Developmental History:

School History:

Christian is currently in fourth grade.

Current School Behavior:

*Has a peer group, likes specials

*Takes responsibility for behavior

School Satisfaction:

*Good , he likes PE and music and science

Intellectual Functioning:

* Intellectual performance is average.

ADHD Problems:

*Attentional problems, without hyperactivity, are reported present in the classroom.

Abuse/Neglect:

There is no known history of physical, sexual or emotional abuse.

There is no known history of physical, emotional, sexual, or monetary exploitation.

There is no known history of physical, medical, or emotional neglect.

Activities of Daily Living: Sometimes will complete his chores. He is responsible in completing chores, he takes care of himself well and can make sandwiches,

Childhood History:

Christian was born in Washington, D.C. He was raised by his mother, as a single parent. His father was absent and non supportive. He is the youngest child

Quality of childhood was:

*Not associated with physical or emotional abuse. Stable home with family. He likes his life "sometimes," because sometimes he gets into trouble if he does not complete his tasks.

Currently lives with:

*Mother

*Brother

Indicators of emotional problems include the following;

Family History of Separation/Divorce: irregular visitation since Dec 2021

Gestational & Developmental Histories:

Christian’s gestational and developmental histories were normal.

Family History:

Christian's family psychiatric history is negative. There is no history of psychiatric disorders, psychiatric treatment or hospitalization, suicidal behaviors or substance abuse in closely related family members.

Medical History:

Client has asthma, he uses a pump when needed.

Adjustment disorder, unspecified, F43.20 (ICD-10) (Active)

Encopresis not due to a substance or known physiological condition, F98.1 (ICD-10) (Active)

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