case conceptualization

Treatment Plan/Conceptualization  

In this assignment, you will practice developing a treatment plan (interventions and techniques based upon a theoretical approach) to address the needs of a child client. Vignette will be provided in class.

Directions: Develop a treatment plan relying upon your preferred theoretical orientation from the theories covered in this course: Psychoanalytic, Person Centered, Gestalt, Behavioral Counseling, Rational Emotive Behavioral Therapy (REBT), Cognitive Behavioral Therapy (CBT) or Play Therapy.  Your treatment plan should include a description of the problem (include specific symptoms or indicators of the problem), treatment goals (based on the client’s presenting concerns), and treatment objectives (what you will do with the client to meet the treatment goals, frequency and duration of treatment, and identify how you will measure treatment effectiveness).  A minimum of three goals should be presented along with corresponding objectives and interventions written in a way that allows them to be measured.

Submission Format: Your final paper will be a Word document, approximately 8-10 pages in length (not counting a title page or citations), utilizing a minimum of four scholarly references.  Your paper should be written in a clear, concise, and organized manner; demonstrate ethical scholarship in accurate representation and attribution of sources; and display accurate spelling, grammar, and punctuation.

Grading Criteria

Clinical Vignette Review Template

Introduction to the Theoretical Model

In this section summarize the previous ONE Individual and Family Theory model that you selected from the list that was indicated above. Describe the main points of these theories, using the language of these theories alone (don’t borrow concepts from other theories, stay focused on the one Individual Theory and one Family Theory you select and be the expert). This section should be a minimum of a one page.

Client ID:_______________________ Education:______________________

Age: _____ Gender: _____________ Session Date: ___________________

Culture/Ethnicity:________________ Therapist Name: ________________

Reason for Referral

A brief description of the client/patient, explanation as to the reason(s) the client has been referred to you and why they are entering treatment now.

History of the Present Illness

A detailed chronological description of problems and concerns experienced by the client, including onset, frequency, intensity, and duration of symptoms.

Identify the BASIC ID model for this patient: See chapter 3 of Counseling Children book

DSM 5 Diagnosis(including use of V-Codes)(list the diagnosis and rationale / should match symptom presentation listed above). Take this information straight from the DSM V and list criteria related to the diagnosis you selected.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Social and Family History

Describe family constellation and family relationships for current family and family of origin. Discuss any outstanding events or abnormal situations in family, relationships with peers, authority figures and community supports.

Birth Order:

Family Atmosphere: (describe if it was warm and nurturing or cold and distant)

Developmental stage of this child: list the developmental age of the child and review information from chapter 2 on Piaget / what stage of cognitive thinking might influence this child’s therapy. (Explain in a minimum of ½ of a page). What are cognitive errors that might occur at this stage that can influence therapy?

Developmental Problems: birth defects etc. (if there are no developmental problems then indicate that patient denied these problems)

Education (grades, problems in school?):

History of Brain Injury: document any history of brain injury. If there is no history indicate that the patient denied history.

Legal History and/or Financial Issues

Include any serious encounters with the law and/or any current financial stressors. Indicate how this information about the client might impact your work together in treatment?

Religious/Spiritual Practices (Current and Historical)

Indicate religious/spiritual belief system(s) if any. Reveal if different from family of origin and why. Indicate how this information about the client might impact your work together in treatment?

History of Employment and Education

Discuss employment and education history. How might having this information about the client impact your work together in treatment?

Psychological/Counseling / Psychiatric History

Include reasons for past treatment, type, outcomes, suicide attempts, hospitalizations and diagnoses. How might this information impact creating and achieving treatment goals?

Medical History/ Medications/ Psychological History

Discuss date of last physical, present state of health and any medical conditions. Indicate current medications, reason for usage and reported client side effects. Include sexual history, special diets, eating or sleeping problems. How might this information impact creating and achieving treatment goals?

History of Addictive Behavior

Discuss the nature of addiction(s) and impact on emotional, physical, relational health. How might this information impact creating and achieving treatment goals?

Mental Status & Behavioral Observations-

Provide behavioral observations and mental status of client. How might this information impact creating and achieving treatment goals?

Appearance:

Motor Activity:

Attitude/ eye contact:

Speech:

Thought Content:

Perception:

Mood:

Affect:

Judgment:

Suicidal:  Is the patient suicidal or homicidal? If not, state denied SI/HI

Ethical Considerations

Address 2-3 specific ethical and/or legal considerations for this case. Choose one of these issues addressed to review in depth using a specific ethical decision making model. Indicate the model used. How might this information impact creating and achieving treatment goals?

Cultural Factors/Multicultural Competence

Discuss the multicultural considerations (e.g., gender, age, ability, sexual orientation, ethnicity, socioeconomic status, religion, class, and/or culture) that are evident for this case. Describe and apply the tenets of a relevant multicultural theory or model as it pertains to this case. Discuss what counselor factors comprise multicultural competence. How might this information impact diagnosis, treatment and creation of treatment goals?

Assessment

What assessment measures would you decide to conduct to enhance your understanding of the client(s) in order to direct your diagnostic formulation?

Theoretical Formulation: Name the Theory/Therapy Model you selected (Case conceptualization)

a. Name a specific individual theory you would use to treat this case and why you would choose this theory.

b. Describe the specific, fundamental tenets of the individual theory.

c. Apply the individual theory to your case, specifying hypotheses based on your theory.

Diagnostic Impressions

1. Differential Diagnosis:

Develop a differential diagnosis. Indicate why you are considering these possible diagnoses by providing specific evidence from your case.

Treatment Plan

Using the template below, create a treatment plan for the theory you discussed in your theory theoretical formulation section (make sure the language you use in this section is consistent with the theory you chose. Read the book and power points prior to completing this section).

Give a brief summary of the approach discussed in your theoretical formulation for family therapy, then reveal the following:

Beginning

Pertinent interventions that will be use at this stage. Include:

A. Goals: Provide a minimum of 3 specific to chosen theory.

B. Objectives: Indicate how goals will be accomplished, specific to chosen theory.

Interventions: Strategies to accomplish goals/objectives based on chosen theory, from a multi-culturally competent perspective.

Middle

Pertinent interventions that will be use at this stage. Include:

A. Goals: Provide a minimum of 3 specific to chosen theory.

B. Objectives: Indicate how goals will be accomplished, specific to chosen theory.

C. Interventions: Strategies to accomplish goals/objectives based on chosen theory, from a multi-culturally competent perspective.

End

Pertinent interventions that will be use at this stage. Include:

A. Goals: Provide a minimum of 3 specific to chosen theory.

B. Objectives: Indicate how goals will be accomplished, specific to chosen theory.

C. Interventions: Strategies to accomplish goals/objectives based on chosen theory, from a multi-culturally competent perspective.

Pertinent Resources/Referrals

What referrals might benefit the client’s treatment (list specific referrals in the community with addresses and phone numbers and explain the referrals offered? Why are these good resources for this client?

a. Psychopharmacology

b. Group

c. Medical

**Please Note: Your Clinical Case Review will take into account Organization and Writing

Correct use of APA format and all proper writing mechanics is expected. Plagiarism is forbidden. Scholarly writing includes: APA format, thoughtful and clear responses, and critical thinking befitting a graduate level student.