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To demonstrate ability to consolidate and apply information learned in the cours
To demonstrate ability to consolidate and apply information learned in the course, using a provided vignette, students will write-up a conceptual understanding of the client, offer a diagnosis and a brief treatment plan, as well as discussing crisis intervention and risk assessment. Students will additionally explore the integration of faith into treatment. Students will utilize the Complete Adult Psychotherapy Planner (Jongsma, 2021) and are also expected to utilize academic research beyond class-assigned readings. The paper should be scholarly in tone, following APA (7th edition, professional style) formatting guidelines. Paper should consist of the 10 sections below, and should be at least 6 pages long. Citations are necessary wherever factual information is presented. The domains to discuss in your paper and the assignment sections are:
1. Identifying Information: About the client and the setting in which the client presents. 2. Presenting Complaint: Onset and course, including client’s perceptions, precipitating event(s), and previous treatment. Why did the character seek treatment? Who referred them and why?
3. History: Results of the ″clinical interview″ (information from creative work) and mental status exam (based on your observations of their functioning in the creative work), including developmental, family, social, medical and educational history. This should NOT be a plot summary or a synopsis of the creative work.
4. Assessment & Diagnosis: Based upon the case overview, a recognizable theoretical model of assessment and diagnosis. Do not just give a diagnosis. You must include a clinical formulation of diagnostically relevant symptoms resulting in a DSM 5-TR diagnosis. Meaning, based on the diagnosis you have given your case, what criteria was met with regards to the DSM. Include specifiers when necessary.
5. Differential Diagnosis: Discuss alternative possibilities that have been considered and your rationale for discarding them. A final diagnosis may not be possible, but the elements considered and the possible alternative diagnoses should be presented.
6. Legal and Ethical Issues: Include discussion where relevant, of legal and ethical issues such as: risk of harm to self or others, duty to warn, confidentiality, informed consent, therapist concerns such as dual relationships or scope of practice, drugs, alcohol, adolescent pregnancy, abuse, incest, severe depression/suicide, organicity, psychosis, elderly, medical emergency, etc. If not already a part of your treatment plan, include specific recommendations such as referrals to other agencies, services, professionals, etc. such as; a physician for medical evaluation, medication evaluation, medication compliance, other medical or psychiatric necessities.
7. Risk assessment and crisis intervention : What are crisis issues that are emergent in this case? Discuss how risk assessment will be conducted and what interventions will be used to address them. 8. Case Formulation: The formulation may be considered from several theoretical perspectives-family systems, psychodynamic, cognitive behavioral, etc. The formulation should be grounded in basic observational and historical data. How do you see all of the information fitting together for this client? This should be a summary of how the history, environmental/biological/social factors contribute to the presenting problem. Why is the client they way they are?
9. Treatment Plan: Provide at least 2 Long-term goals; 2 short-term objectives for each goal, and at least 2 interventions for each objective.
Vignette:
Juan is a 45-year-old Mexican-American male who sought treatment at the insistence of his family. He reports experiencing symptoms of persistent sadness and loss of interest in most activities he used to enjoy, including his woodworking hobby and participating in his running club. Juan states that he is more irritable than usual and mostly wants to be left alone. He also reports that he doesn′t have much of an appetite these days and has lost about 15 pounds over the last 2 months. He tells you that he has trouble sleeping and often either can′t fall asleep or is wakeful throughout the night. He is ″tired all the time″ and feels like he′s just ″no good to anyone anymore.″ He admits to having recurrent thoughts of death, but denies a plan to end his life by suicide. These symptoms have been present for approximately 6 months, occuring ″more or less daily″ and having gradually worsened over time.
Juan works as a manager at a large bank branch and describes feeling overwhelmed by the stress and demands of his job. He reports strained relationships with his colleagues and friends, and especially with his wife and two teenage daughters, who have expressed concern about his emotional withdrawal and irritability. Juan reports a history of similar episodes dating back to his early adulthood, for which he received counseling and medication management intermittently. He is the first in his family to have been born in the United States, his parents having moved to Chicago about 12 years prior to his birth. He describes growing up in a Mexican-American household and holds strong cultural values and traditions. Juan identifies as a practicing Catholic, although he admits that his faith has wavered in recent years. Juan expresses a desire to reconnect with his spirituality and seeks guidance on how to integrate his faith into his recovery process while balancing cultural influences.
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