Wk04_08Case Conceptualization and Reflection Form CMHC MCFC (1)

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 socmasfieldexperience@waldenu.edu 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 Rev: June 2020 1

PART I (Due Day 7 of Week 4 ) Counselor name: Kasey Bazan Client age: 16 Client initials: I.K. Client race or ethnicity: Caucasian Number of sessions with client: 6 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  Employment history  Relevant legal problems  History of counseling  Reason for seeking counseling, according to the client  Onset and duration of concern  Frequency and intensity of symptoms  What the client wants to improve Isabella is a 16-year-old Caucasian, sexually fluid female who resides in an apartment with her maternal Grandmother. Isabella began coming to counseling on October 23 rd of this year. Isabella states she has wanted therapy for a while due to different things going on in her life. Isabella moved in with her maternal Grandmother again because of a fight with her stepfather while he was drinking and smoking marijuana. Isabella was living with her biological mother and stepfather in a single-family home with her stepsiblings coming over on weekends. Isabella states she is close with her stepbrothers but does not see them too often. Isabella is an employee at Mehlman’s Cafeteria and has worked there for four years. Mehlman’s is the second job that Isabella has had. Isabella works four days a week at her place of employment. Isabella is a full-time student in her junior year of high school. Isabella had previously visited a counselor, but she did not return since she did not feel a connection with them. Isabella grew up in Virginia with her biological mother and father until she was seven years old and then moved back to The Ohio Valley. Isabella is mourning the death of her father, who committed suicide a little more than three years ago in January. Isabella claimed that her father was a heroin addict, and that heroin was his drug of choice. Isabella had seen her mother and father engage in domestic violence on numerous occasions. Isabella had to assist her mother in mopping up the blood on the floor after her father cut his neck when she was five years old. Isabella has had no relevant legal problems. Isabella says that she is quite angry because of things that happened at home when her father was alive and because she is currently battling her stepfather. Isabella claims to be very upset and resentful. Isabella listed the frequency and severity of her symptoms, which include anxiety, disturbed appetite, irritated and melancholy moods, difficulty focusing, difficulty concentrating, feelings of worthlessness, and inappropriate guilt. By healing and overcoming her trauma, Isabella hopes to get healthier. Rev: June 2020 2

Isabella was five years old, her mother forced her to help clean up his blood, and Isabella stated that troubles her to this day. Since October of this year, Isabella has been living with her grandma once more. Since her mother hasn't expressed regret or acknowledged her feelings, Isabella has stated that she wants to break off contact with her for the time being. Isabella claimed that despite writing a lengthy letter to her stepfather, she has not received a response—not even an apology. Because she can talk to her grandmother about anything and they are very close, Isabella said she loves living at her grandmother's apartment. Isabella has experienced severe trauma and witnessed drug abuse and violence in her life. Following her altercation with Isabella's stepfather, Isabella's mother and stepfather reportedly stopped drinking. When Isabella visited the other day, she discovered a garbage bag full of empty cans. Isabella doesn't misuse alcohol or drugs. Isabella claims that she has previously drunk alcohol and liked the way it made her feel. Isabella claimed that because both of her parents were substance abusers, she was afraid of this emotion. The emotional experiences of Isabella's early life have impacted her growth; she has expressed that she feels strongly about everything that occurs, even though her grandmother doesn't comprehend it. Isabella also suffers from adjustment disorder and depression. Isabella claims to be upset and bitter toward her mother for the events that have happened to her. Multicultural Considerations Clients and their concerns are shaped by a multitude of multicultural considerations and their intersectionality. Be sure to address each of the following elements and their impact:  Race or ethnicity  Religion  Ability/disability  Sexuality  Socioeconomic status  Military  Criminal justice system  Geographic influences  Environmental factors  Experiences of oppression or marginalization Isabella, a 16-year-old Caucasian female, belongs to Generation Z and describes herself as a sexually fluid female. Isabella is not religious and does not attend church. Isabella is an able-bodied junior in high school who attends classes full-time. Isabella is an excellent student who consistently receives good grades. Isabella works three nights a week after school and on Sundays at Mehlman's Cafeteria. Isabella has started saving money for her high school graduation by opening a savings account. The socioeconomic standing of Isabella's family is middle class. Rev: June 2020 4

Isabella claimed that because her stepfather's whole income is allocated to child support, her mother looks after him. Isabella is sixteen years old and has never served in the military. Isabella does not intend to enlist in the military when she turns eighteen. Isabella stays out of problems at school and stays out of the criminal justice system. Isabella has no ties to any gangs or drugs. As a junior in high school, Isabella is unsure about her plans, including going to college. English is Isabella's preferred language, and she is an American citizen. Isabella resides in Belmont County, in the Appalachian region of Ohio. Isabella is independent of place and capable of locating resources as required. Isabella has gone through a lot of traumas in her early years, starting when she was just two years old. Her stepfather and mother both consume alcohol currently. According to Isabella, her father has always used drugs. Her father's drug of choice was heroin. As a child, Isabella saw a lot of domestic abuse between her mother and father. Knives would be pushed through the door of the locked room where Isabella used to hide. Because Isabella was born a woman, she is subject to oppression. Women have fought for generations against oppression and in favor of equality. While certain victories have been achieved, which include having the ability to vote along with equal chances for education, women continue to be disproportionately impacted by discrimination alongside all types of violence. 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 world view. Within that context, consider the problem they presented with for counseling and address each of the following elements:  Describe your understanding of the problem.  Describe your observations of the client.  Describe your impressions of the client.  Describe any factors contributing to or reinforcing the problem.  Describe the purpose of the client’s behaviors.  Describe themes and patterns that emerge or connect.  Describe barriers to growth and coping.  Describe strengths, assets, protective factors, signs of resilience. Since she was two years old and started to remember things, Isabella has seen oppression, observed domestic abuse, and experienced her parents' consumption of drugs and alcohol. 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: Rev: June 2020 5

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: Rev: June 2020 7

 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 8