CASE PRESENTATION

Students are required to present one case conceptualization/treatment plan this semester on a client they are counseling. The case conceptualization and treatment plan will be presented orally and a written paper is also required. A schedule for presentations will be developed in class. Clients should be discussed in a manner that protects their identity. The Case Conceptualization should conform to the following format. 1. Identifying Data: This section will include all relevant demographic information, 1) age 2) sex 3) race/ethnic background 4) partner status 5) living situation 6) manner of dress 7) physical appearance 8) general self-presentation

The purpose of this section is to target demographic and descriptive information about the client. By reading through it, both supervisor and trainee should be able to develop an impression of the client. As an example, a practicum student may describe a client as "a 20-year-old college student of medium build dressed in wrinkled and soiled clothes, who is extremely verbal and articulate in the interview." 2. Presenting Problem: This section should include a listing of the problem areas, from the client's perspective, noting particularly the client's view of their order of importance. Suggested items to focus upon: 1) Was there a precipitating set of circumstances? 2) How long has/have the problem(s) persisted? 3) Has/have this/these problem(s) occurred before? 4) What were the circumstances at the time?

The trainee must help the client to be specific about the presenting problem(s). It is not uncommon for counselor trainees to have had three or four interviews with a client and still be unsure about the presentingproblem. The trainee should help the client to identify the precipitatingcircumstances, consequences, how long the client has been cognizant of the problem, and whether or not it has occurred previously. 3. Relevant History: This section will vary in comprehensiveness according to depth and length of treatment, and will vary in focus according to theoretical orientation and specific nature of the problem is).

It is important that the reported history be relevant to the content and depth of the client's concerns. The trainee who collects ream after ream of data on the client and becomes lost in the process is encouraged to focus only on material pertinent to the problems. The history may then focus on academic content, sequel history, issues of social development, adjustment in school, and early family history. The data properly fitting into this section will be determined in part by the depth and length of treatment, by the particular focus of the problem, and by [the] theoretical orientation of the trainee and supervisor. Consequently, the psychodynamic trainee will probably submit quite a different section on relevant history that will the behaviorist. 4. Interpersonal Style: This section should include a description of the client's orientaticin toward others in his environment and should include two sections: a) Is there an overall posture he/she takes toward others? What is the nature of his/her typical relationships? Karen Horney's conceptual i zation may be useful here: 1) Moving toward (dependency, submission) 2) Moving against (aggressive, dominance) 3) Moving away (withdrawal) Is there a tendency toward one or the other polarity of dominance vs. submission, love vs. hate? b) How is the client's interpersonal stance manifested specifically within the therapeutic dyad? What is the client's interpersonal orientation toward the counselor? Here, the trainee is asked to describe the client's belief system and behavior toward others in the environment. It is suggested that this be answered in two parts: (a) the client's general attitudes toward others, including the nature of interpersonal relationships; and (b) the manner in which this orientation is manifested within the counseling dyad. Karen Horney's (1939) "submission, dominance, and withdrawal" conceptualization may be used by the trainee as it general way to describe the client's interpersonal style. It is important for the trainee to learn the way in which the client relates to people outside of counseling and to be able to recognize parallels when they occur in the sessions. Thererefore, the trainee is asked not only to attend to what the client is saying but also thee manner in which it is said. Clients' behavior in counseling often reflects to a degree, their behavior in other social situations (Cashdan, 1973). 5. Environmental Factors: This section should include: a) Elements in the environment which function as stressors to the client. Both those centrally related to the problem and more peripheral stressors. b) Elements in the environment which function as support for the client; friends, family, living accommodations, recreational activities, financial situation. The trainee is now asked to describe the elements in the client's environment that may be creating tension (stressors) and to be concrete about people, activities, and situations that are directly or peripherally related to the problem. The trainee may be surprised to

discover that certain people, places, and events may serve as both stressors an supporters at different times (or even concomitantly). Elements identified as either stressors or supporters often include friends, family, living accommodation, recreational activities, financial situation, and so forth. 6. Personality Dynamics A. Cognitive Factors: This section will include any data relevant to thinking and mental processes such as: a) intelligence b) mental alertness c) persistance of negative cognitions d) positive cognitions e) nature and content of fantasy life f) level of insight-client's "psychological mindedness" or ability to be aware and observant of changes in feeling state and behavior and client's ability to place his/her behavior in some interpretive scheme and to consider hypotheses about his/ her own and other's behavior g) capacity for judgment. Client's ability to make decisions and carry out the practical affairs of daily living

B. Emotional Factors a) typical or most common emotional states b) mood during interview c) appropriateness of affect C. Behavioral Factors a) psychosomatic symptoms b) other physical related symptoms c) existence of persistent habits or mannerisms d) sexual functioning e) eating patterns f) sleeping patterns d) range of emotions the client has the capacity to display e) cyclical aspects of the client's emotional life

1. Cognitive Factors that deal with the thinking and mental processes of the client. Here, the trainee will report on the general intelligence or alertness of the client arrived at either by referring to test results or interview impressions. Such a discussion should include the client's ability to make sound judgments and decisions and to function adequately in the tasks of daily living, noting any persistent negative cognitions and then giving some indication of the client's level of insight. In addition the client's fantasy life may be recorded in terms of the content and frequency of fantasies and the circumstances under which they tend to occur.

2. Emotional Factors that should be addressed by the trainee include: the client's mood during interviews, appropriateness of affects, range of emotions displayed, and any cyclical aspects of the client's emotional life. Here, the trainee is forced away from an intellectual approach to the client and guided to attend to what is going on emotionally in the sessions. Information concerning the client's outside emotional life should also be described and discussed in this section. 3. Behavioral Factors should attend to all areas of the person's behavior. This section can help the trainee determine major patterns of symptoms, and often provides the concrete focus for the initial phases of the treatment plan. 7. Counselor's Conceptualization of the Problem: This section will include a summary of the counselor's view of the problem. Include only the most central and core dynamics of the client's personality and note in particular the inter-relationships between the major dynamics. What are the common themes? What ties it all together? This is a synthesis of all the above data and the essence of the conceptualization.
Loganbill, C. & Stoltenberg, C. (1983). The case conceptualization format: A training device for practicum. Counselor Education and Supervision, 22, 235-241.
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Treatment Plan
DSM IV Diagnostic Impression: Axis I: Axis II: Axis III: Axis IV: Axis V (current): Axis V (highest): 1. Client Strengths: (Examples: ability to express feelings, motivated for treatment, ability to stand up for his/her rights, ability to make decisions, ability to show concern for others, enjoyment of music, active participation in church/social organization, interested in sports, enjoyment of music, creative, mechanical ability, etc.).

2. Client Needs/Concerns: (Presenting problem, other needs expressed by client or significant others, and needs/problems observed by clinician). 3. Treatment Goals: Goals should be: A. Appropriate: Related to eliminating or lessening specific concerns of the client. B. Achievable: The goals should be client rather than environment centered and realistic. (Example: The client has control only of her or his responses to a spouse, child, job, etc. Inappropriate: My spouse will treat me better. Appropriate: Client will use assertive statements three times per week with her spouse.) C. Important to the client as well as the therapist. D. Measurable:

What changes in behavior, thinking, or feeling will result from treatment. Written in specific (not vague) language that everyone (including the client) can understand. (Vague: client will become less depressed. Specific: client will walk 30-minutes three times per week.). Have an expected date of achievement. Stated positively rather than negatively when possible (e.g., Client will use assertive statements when interacting with spouse rather than client will stop angry outbursts).

4. Assessments Needed: Should include the following: A. Goal Evaluation and Monitoring Strategy for each goal listed under #3 above. B. Further appraisal by a physician, psychiatrist, personality inventory, vocational inventory, IQ inventory, depression inventory, anxiety inventory in order to understand the needs of the client. Example: a clinician may refer the client to a physician if some type of physical problem is related to the client's current situation. "B" may be omitted in the treatment plan if further appraisal is not needed. 5. Clinician/Staff: (In most cases this will be yourself but may include other treatment team members. For example, if your client was involved in group counseling list these clinician names as well. Be sure to include your highest relevant academic degree and title. Example: Jane Smith, BS, clinician.) 6. Location of Treatment: (Example: Southern Illinois University Clinical Center). 7. Interventions to be used: This will depend on your theoretical orientation and be related to the client's goals. Specifically, how do you plan to:

A. Establish and maintain a therapeutic relationship. B. Provide support. C. Provide information and education. D. Reduce painful feelings, especially anxiety and depression. E. Decrease specific maladaptive behaviors. F. Modify specific misperceptions. G. Help clients put their concerns in context and make sense of them. H. Expand emotional awareness. I. Enhance interpersonal effectiveness. 8. Emphasis of Treatment: Should include the level of directiveness; level of exploration; and emphasis on thoughts, feelings, actions, or combinations of all three. These categories should be considered as a continuum and not in either/or terms. For example, a client may need moderate direction as well as some freedom to develop his/her therapeutic goals. Some guidelines to consider are as follows: A. Level of directiveness 1. Directive: a. Therapist directed b. Structured c. Goals:

changing maladaptive behavior reducing symptoms developing new skills solving problems

d. Recommended for clients who are: willing to take direction from others or unable to establish own direction motivated to achieve only limited goals severely disturbed, dysfunctional, fragile in crisis having difficulty setting limits and boundaries, especially in therapy

2. Experiential a. Client directed b. Amount of structure varies, depending on client c. Goals:

developing self-awareness reducing identity confusion increasing sense of direction promoting independence building self-confidence

d. Recommended for clients who are: capable of establishing own direction guided by broad, far-reaching goals functioning acceptably but not up to potential not in crisis able to establish appropriate interpersonal boundaries, in and out of therapy

B. Levels of Exploration in Therapy 1. Probing a. Seeks to eliminate barriers to growth b. Focuses on past as well as present, seeking patterns c. Provides challenge and stimulus for change, in an accepting context d. Helps client find interpretations, information e. Goals

To promote growth and development To increase understanding of intrapsychic conflict To develop new resources

f. Recommended for clients who are:

Highly motivated, well organized, reasonably healthy, in contact with reality Insightful, psychologically minded, verbal Internally controlled, like to see change as a result of own efforts

2. Supportive a. Builds on existing defenses and strengths b. Focuses on the present c. Provides acceptance, protection, reassurance, empathy d. Provides explanation, information e. Goals

To promote symptom reduction and improved functioning To increase self-acceptance To strengthen existing resources

f. Recommended for clients who are:

Resistant, fragile, highly dysfunctional, in poor contact with reality Action oriented Externally controlled, other-directed

C. Thinking, feeling, acting: What thinking patterns, feelings, or behaviors need to be changed or modified? 9. Nature of Treatment: Individual, couple, family, group, or a combination of treatment modalities. Guidelines include: A. Individual therapy recommended for: 1. Highly anxious, withdrawn, isolated, or introverted clients 2. Clients who have difficulty with ambiguity 3. Clients seeking help with intrapsychic concerns 4. Suspicious, guarded, hostile, antisocial, or destructive clients who have difficulty with trust 5. Clients seeking independence and individualization 6. Very intimate or idiosyncratic concerns 7. Concerns of very long duration 8. Crises B. Group therapy recommended for:

1. Anxious clients with authority concerns 2. Dependent clients (after or in combination with some individual therapy) 3. Interpersonal concerns 4. Clients who may feel stigmatized or scapegoated as a result of individual therapy (for instance, the identified patient in a family) 5. Clients who are likely to give the therapist excessive power 6. Clients who need reality testing and group feedback 7. Specific behavioral concerns, shared with other group members 8. Clients with limited financial resources C. Family therapy recommended for: 1. Problems in the family structure 2. Intergenerational or other family conflicts 3. Family communication problems 4. Families needing consolidation 5. Acting-out adolescents 6. Families with limited resources when more than one family member needs help 7. Families with no severe pathology 10. Timing, pacing, duration of treatment: How frequently will appointments be scheduled and how long will the session be? How long will the client need to be in therapy? Example: 1 hour once per week. 11. Medications needed: Many studies suggest that, for most of the severe mental disorders, a combination of medication and treatment is better than either alone. If you suspect medication is needed a referral to a physician or psychiatrist is warranted. If medication is not needed simply write, "none recommended at this time." Guidelines to consider are: A. Antipsychotic medication--primarily for treatment of acute schizophrenia and other disorders involving delusions and hallucinations. B. Antidepressants--including tricyclic antidepressants and monoamine oxidase (MAO) inhibitors. Tricyclic antidepressants seem to facilitate the treatment of moderate to severe major depression with melancholia; panic attacks; bipolar depression; and eating, sleeping, and obsessive compulsive disorders. MAO inhibitors tend to be effective with atypical depressions associated with prominent phobias, anxiety, and reverse vegetative signs (for example, increased eating and early-morning awakening); panic attacks; and related disorders that have not responded to tricyclics. C. Lithium--for treatment of bipolar disorders and some types of cyclothymia. D. Antianxiety agents--for reduction of anxiety. 12. Adjunct services: These services include social and educational programs (e.g., legal aid, parent training, exercise programs, nutrition planning, home budgeting planning) and peer support groups (e.g., AA).

13. Prognosis: Information provided here will include how much change or improvement can be expected from people experiencing the disorder, how rapidly progress is likely to occur, and what is the overall prognosis.
Seligman, L. (1990). Selecting effective treatments: A comprehensive guide to treating adult mental disorders. San Francisco: Jossey-Bass.