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AngelAccredited by the Higher Learning Commission of the North Central Association of Colleges and Schools 100 Washington Avenue South, Suite 900,

Angel

Accredited by the Higher Learning Commission of the North Central Association of Colleges and Schools

100 Washington Avenue South, Suite 900, Minneapolis, MN 55401

www.waldenu.edu

College of Social and Behavioral Sciences

School of Counseling

Counseling Masters’ Programs

[email protected]

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: Angel Brown

Client age: 30

Client initials: GG

Client race or ethnicity: White

Number of sessions with the client: 2

Self-identified gender: Female

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 GG is a 30-year-old female married but separated with one child. GG’s child lives with his father until treatment is established. GG was married in 2021. GG has a brother, her parents divorced when she was 18.

· Employment history currently unemployed

· Relevant legal problems GG currently has an assault charge pending.

· History of counseling this is GG’s first time in counseling.

· Reason for seeking counseling, according to the client Alcoholism and marijuana use.

· Onset and duration of concern GG has ADHD which is untreated due to her abusing the medication. GG reported being given beer at the age of 11 by her father and started experimenting with marijuana at the age of 18.

· Frequency and intensity of symptoms of severe alcoholism and mild use of marijuana.

· What the client wants to improve GG reports wanting to stabilize her sobriety.

     

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 the family GG mentions mother, father, brother, son, and husband.

· Family of choice is different and role parents were married until GG was 8 years old and divorced.

· Significant relationships/relationship patterns raised in a single-family home after parents divorced.

· Children, marriages, divorces GG has a son, and she is married but separated.

· Gabby is married with a child that lives in the home.

· Current living arrangements GG lives alone due to separation from her husband and their son resides with him.

· Major losses, and family traumas

· Family mental health history there is no known family history. GG reports having ADHD but no one else in the family.

· Family substance abuse history both of GG’s parents abuse alcohol.

· Family violence or abuse history. GG assaulted her mother, GG reported being verbally abused by her mother.

· Stage of development impacts Currently GG is in the stage of contemplation.

· Developmental challenges

     

Multicultural Considerations

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

· Race or ethnicity GG identifies as being white.

· Religion GG speaks of her high power but does not identify with a religious preference,

· Ability/disability

· Sexuality GG identifies as a heterosexual.

· Socioeconomic status middle class

· Military GG has no military background

· Criminal justice system GG reports this is her first arrest.

· Geographic influences GG reports parties and the people she associates with

· Environmental factors friends and her father.

· Experiences of oppression or marginalization GG reports not experiencing any 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 worldview. Within that context, consider the problem they presented with for counseling and address each of the following elements:

· Describe your understanding of the problem. At an early age, GG has introduced the alcohol and began abusing the prescribed medication for ADHD. GG’s negligence has caused her to assault her mother.

Describe your observations of the client.GG is in the contemplation stage she is aware of her problem but has failed to communicate with her mother because of the mother’s alcohol use. GG appears to love her family and it appears GG is a loving, nurturing, and caring mother to her son.

Describe your impressions of the client GG is most likely would not return to alcohol and marijuana use because she is eager to complete the program, and she has obtained herself a sponsor. GG attends AA and she is completing all assignments and IOP meetings and meets with her student counselor weekly. Also, GG desires to reunite with her husband and son.

· Describe any factors contributing to or reinforcing the problem. Currently, GG’s alcoholism is a contributing factor to her family and her personal life.

· Describe the purpose of the client’s behaviors. GG feels since she is in a treatment program for her issues GG feels she does not want anything negative to get in her way such as family and friends.

· Describe themes and patterns that emerge or connect. GG shared that her mother and father are both alcoholics and GG reports she experiences some of the same symptoms as her mother.

· Describe barriers to growth and coping. GG feels her Alcohol has caused barriers between her mother and brother due to her behavior since she was arrested.

· Describe strengths, assets, protective factors, and signs of resilience GG is 45 days drug-free, respectful, independent, and a good communicator.

     

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 F90.9 Attention-Deficit

The rationale for how the diagnosis was determined When speaking with GG about her diagnosis and listening to her explain her family history. I began to read my research I viewed the hypotheticodeductive style which involves proposing a differential diagnosis since GG self-reported having ADHD but after viewing her assessment she exactly was diagnosed with mild intellectual disability therefore when reading hypotheticodeductive style it simply stated asking a question, using the answer to refine the differential diagnosis, asking another question, again refining the differential, and so on until a final working diagnosis is obtained. However, this could have been used to determine GG diagnosis. In addition, Clinical assessment by collecting information and drawing conclusions using observation with psychological testing.

Two other diagnoses were considered, but not given. I will have to say sever Alcoholism and borderline personal disorder.

Explanation for ruling out diagnoses not given According to the text, Doctors rule out a diagnosis to determine the correct diagnosis.

· Mental health assessments or scales used I feel KL was tested with the detailed assessment

· Other assessments or scales that could be used Neurological testing-

     


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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