Apply the course content to a counseling situation. In this Case Study Assignment you will have the opportunity to think through a clinical case, identify and prioritize key issues involved, consider and clarify relevant diagnostic issues, provide one assessment to clarify the case, and formulate treatment recommendations that are most likely to be helpful to the client. This Case Study Assignment will directly apply to your work in COUC 667 and with clients when you begin practicum.
read the case study then generate a report that uses the following outline. Each section should be separated by the appropriate APA headings (Level 1, Level 2…)
Client Concerns
Symptoms Behaviors Stressors
(Examples) Sadness Trouble sleeping Parents’ divorce
Fatigue
No appetite
Hopelessness
Client Concerns: Using a table as in the example above, identify and list the client’s symptoms and any other key issues/concerns noted. (Modify the chart size as needed.) For example, these may include biological, psychological, social, and/or spiritual problems. If symptoms/behaviors overlap, you only need to list them once.
Assessment
Provide one assessment that will be used to clarify the diagnosis — a valid assessment that a counselor can use. Give a short (3-5 sentences) overview of the assessment, what it would help you learn about the client, and why you chose it over other assessments (for example: Beck Depression Inventory: identifies clinical depression, strong research base, short, easy to administer and score). Provide one peer-reviewed journal article reference to support the use of this assessment.
Diagnostic Impression
Provide the primary diagnostic impression based upon the DSM-5-TR. Include the ICD-10 code and full name of each diagnosis. Be sure to consider secondary disorders in addition to the primary disorder. Is there more than one diagnosis? Provide the following for all diagnoses.
Signs and Symptoms
List the signs (client’s report) and link them directly to the symptoms (criteria you find in the DSM-5-TR) in table form (example below) to make sure you have linked every client sign to every DSM-5-TR symptom you will use to support the diagnosis. Be sure to adjust the size of the table accordingly. If there are client reported signs that do not fall into the DSM-5-TR diagnosis, make note that you considered them, but they did not align with the DSM-5-TR.
DSM-5-TR Diagnostic Criteria: disorder name and code number Client’s Signs/Reported Symptoms:
Criterion A:
Criterion B:
Criterion C:
Criterion D:
Criterion E:
Criterion F:
Other DSM-5-TR Conditions Considered
List other DSM-5-TR conditions you considered and the process you went through to decide they were not the correct diagnosis. For example: “The client reported three symptoms of Major Depressive Disorder, but five symptoms are needed for this diagnosis, so the disorder was ruled out.”
Developmental Theories and/or Systemic Factors
Discuss theories of normal and abnormal development and/or systemic and environmental factors that affect human development, functioning, and behavior. For example, consider questions such as “What Erikson stage is the client in?” or “What is occurring within the client’s family system that may be influencing the client’s current functioning or behavior?”
Multicultural and/or Social Justice Considerations
Discuss multicultural or social justice considerations that went into your diagnostic thought process. For example, what would the client say about their symptoms/situation from their cultural point of view? Is/Could the client be experiencing concerns related to discrimination, marginalization, oppression, etc.?
Treatment Recommendations
Key Issues for Treatment
• In bullet point form, identify the top 2-3 symptoms/issues you believe are involved in the case study, in order of importance.
• The goal here is to clearly delineate what you believe will be of the most help to your client.
Recommendations for Individual Counseling
Identify two treatment recommendations for individual counseling based on the 2-3 key issues you identified. You will need to cite these recommendations using peer-reviewed journal articles, focusing on the treatments a counselor would provide. Medication or referral to another type of therapy may be a recommendation, but since these are case management, they do not count towards the two required recommendations and should not be the primary recommendations listed. Consider recommendations that will be motivating to your client and reflect a collaborative approach. Be mindful of multicultural, ethical, and social justice considerations. Approach this part of the assignment as your exploration of what you would do with this type of client in individual counseling.
Specific Considerations
For each case study you will have one specific consideration. You will need to provide one paragraph responding to the questions that correspond with each case study. In your response to these questions, address how these considerations affected your diagnostic impression and your treatment recommendations.
Anna – Case Study 1: How important of a role does cultural background play in this case? What additional information would you need about her culture? What kinds of values conflicts might you experience due to the client’s culture? How would you manage your personal values while working with this client?
Sam – Case Study 2: How does a client being in crisis change the focus of your assessment and treatment planning? How might a client being in crisis affect a diagnosis?
Jeff – Case Study 3: How do multiple diagnoses affect the decision-making process for diagnostic impressions and treatment planning? How do you decide what disorder you might address first, or do you address both simultaneously? How does a substance use disorder affect the process of diagnostic impressions and the order you make treatment recommendations?
Jane – Case Study 4: How does a triggering event affect how you prioritize treatment interventions? How important is it to collaborate with the client when treatment planning? What are some barriers you might encounter treatment planning with this client and how might you address those barriers?
Phil – Case Study 5: How might the client’s age affect diagnosis and treatment recommendations? What kind of consideration must be made for the family system?
Each Case Study Assignment is to be 3 – 5 pages in length. This excludes the title page and reference page. Use current APA format. The Case Study Assignment does not require an abstract. The Case Study Assignment requires a minimum of 3 resources from peer-reviewed journals. This can include the maximum of one textbook reference. All resources need to be less than 10 years old.
