Clinical assessment paper

This paper provides the opportunity to apply the theories and interventions learned throughout the semester to an individual from your CURRENT field placement or to one of the cases provided for you. If you have never utilized interpersonal, psychodynamic, and/or cognitive behavioral approaches in your work, then act as if you did.  By this I mean: analyze the client through the lenses of interpersonal, psychodynamic, and cognitive theories and then apply the interventions stemming from these theories.

It is expected that the paper include references from this course (i.e., texts, required readings), and a minimum of FIVE empirical and theoretical scholarly articles that are not on the syllabus. At least FOUR of your outside sources should come from scholarly journals, not books or websites. The DSM does not count as one of your scholarly sources.

The paper should be 11 to 12 pages (not including title page or references) typed in 12-point font, double-spaced, and with one inch margins. APA style citations and references are required. NO EXCEPTIONS. It is essential that you protect the confidentiality of your client (i.e., use pseudonyms in place of actual names of persons and in place of highly sensitive information that could link individuals and agencies). DO NOT INCLUDE AN ABSTRACT. NO DIRECT QUOTES ALLOWED. PARAPHRASE ONLY.

                                         ORGANIZATION OF THE PAPER

Part I: Choose a client from your current field placement OR one of the cases provided for you. If you choose one provided for you, the instructor cannot provide any other information regarding the case.

Part II: Assessment (no more than 5 pages)

1. Briefly describe your professional setting (no more than two or three sentences).
2. Identify the client’s presenting problem. Include client information (age, gender, race/ethnicity, sexual orientation and/or gender identity, family composition, etc.). Also, discuss whether the client used social or mental health services in the past. This is a good place to cite literature that is not on the syllabus.
3. Discuss how membership in an oppressed group might contribute to or exacerbate the problem. For example, if your client is Latina, discuss some of the psychosocial issues encountered by Latina populations and whether or not these issues relate to your client. This is a good place to cite literature that is not on the syllabus.
4. What family issues and/or stressful/traumatic/developmental experiences have contributed to the client’s current problem? Describing these experiences is not enough. Advanced clinical practice requires you to carefully analyze these experiences and explain how they affect your client’s psychosocial functioning. This is a good place to cite literature that is not on the syllabus.
5. Include a psychiatric diagnosis according to DSM-5. See example below. Please phrase in the following way:

According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013) Ms. Smith meets criteria for:

            Obsessive Compulsive Disorder

            Schizotypal Personality Disorder

            Diabetes Mellitus

6.      Briefly describe the client’s strengths. Or briefly explain the way in which the client has manifested resilience throughout his or her life. Discuss the importance of client’s religion or spirituality, if applicable.

7.      Describe two of the client’s treatment goals. The client’s treatment goals should stem from the problems under discussion. Please see the chapter on goals in the course tools section. Goals should be one sentence each and should be measurable. Only describe two treatment goals.

Part III: Interpersonal Interaction (no more than three-quarters of a page)

How does the client interact with you during sessions or during your contacts with them? How does this help you to understand how s/he interacts with others, or the way in which others react to her/him?

Part IV: Engagement (no more than 1 page)

Describe the role of the holding environment in the engagement process. First, define the holding environment and briefly discuss the clinical/developmental theories underlying this intervention. Second, discuss why the holding environment is necessary for engaging and establishing a therapeutic alliance with your client. The discussion should be specific to your client—DO NOT discuss the material in a general way. This is a good place to cite literature that is not on the syllabus. 

Part V: Cognitive Behavioral Therapy (CBT) OR CBT-Related Interventions (no more than 4 pages)

Describe TWO cognitive behavioral interventions (e.g., uncovering automatic thoughts, identifying distortions, using thought stopping, or using deep breathing) that can be used to help the client achieve his/her goals. Your discussion MUST include the theory underlying the cognitive behavioral model.

PROVIDE SPECIFIC EXAMPLES. Do NOT discuss the interventions in a general way. Relate the interventions to the client’s problem.

OR

Describe TWO interventions stemming from (a) Dialectical Behavior Therapy (DBT), (b) Trauma-Focused CBT, or (c) Exposure and Response Prevention. Choosing one of these approaches means that you will have to describe the specific theory underlying the approach. For example, if you choose DBT, you will discuss Linehan’s biosocial theory and how it informs the skills training component of DBT.

PROVIDE SPECIFIC EXAMPLES. Do NOT discuss the interventions in a general way. Relate the interventions to the client’s problem.

Part VI: Professional Use of Self (no more than 1 page)

Describe some of the factors (e.g., countertransference, personal biases, judgments) that influenced—or could have influenced—the development and maintenance of the therapeutic relationship. Did you need to modify your practice in any way?