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Case conceptualization, Intervention and Evaluation
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Can you discuss a theoretical approach working with a specific client (hypothetical), and how you used this perspective as you collected information about the client and developed counseling goals?
(1) Can you address the following topics in 4-part forma?
Part 1: Client Information
Select a client (hypothetical), pretend you have worked with this client in individual counseling sessions over several weeks by presenting information about the client.
Isabella is a 27-year old Mexican woman, who presents with anxiety. She has been referred by her primary care physician to see a local mental health practitioner. Her physician acknowledges the side effects from her diabetes medication, but tells her it should not be causing the anxiety she is experiencing. She admits the recent separation from her husband has been unnerving. However, mostly she thinks she is distraught because her life is meaningless. Isabella says that she worries a lot, and wonders what will happen to her kids if she can`t take care of them. Her husband, Marco is still involved in their lives. He spends time with the kids, and provides some support. However, money has been scarce. She knows she should be doing more to get a better job, but she finds herself too fatigued to do anything about it. She worries there will not be a reconciliation for her and Marco. He left because of her constant worrying and drinking. She feels a sense of hopelessness, and said she also worries about death. She also feels confused, and it is difficult to control her thoughts and feelings. Her mother died from Type 2 Diabetes.
She also feels sad that she is not successful, and has nothing to offer her children. Isabella is concerned about her future, wondering if she will ever do better. Worrying Isabella the most is the fact that she is not getting any younger, at 27 she will reach 30 very soon, and feels that she has not accomplished much.
NOTE: If you have worked with the over several weeks, here you can chart the progress (or lack of it) as you counsel with Isabella over a number of sessions (See Tipper, McCollum, Jong, Korman, Gingerich, Franklin, C. (n. d.).
(2) Present a brief description (no more than 2 pages) of the client, including the following
*You can begin with a psychosocial history such as the following:
Isabella immigrated to the United States from Puerto Rico with her parents as a child. She is the oldest of two sisters and a brother. Her mother and father immigrated to the United States when she was very young. They struggled to offer Isabella and her sisters and brother a better life than they had in Mexico. However, after many years of working in the family produce store, her mother and father barely made enough money to take care of the family. She believes their hard work eventually contributed to their deaths, dying within years of each other. Although her mother also suffered from Type 2 diabetes. She remained in the states while her sisters and brother returned home immediately after her parents` deaths. She met and married Marco a few years later. Now, she is a 27-year-old single mother of two children, Mildred age 2 and Mike, age 4. Although she and Marco are separated, they have not divorced. Isabella is a practicing Catholic, and thinks divorce is wrong. The kids are crying a lot since Marco is not in the home, and she has trouble controlling them. She feels guilty for being away from them so much, but since Marco left, finances are strained and she has to work. Isabella works as a gift wrapper in a local department store. She has thought of taking college courses to further her education and get a better job, but never followed through. She also needs to lose weight. She blames her lack of motivation on the early arrival of her kids soon after getting married. But she knows that is not true.
Her aunt, Anna, her sole support in the states would keep the kids while she works, and would keep them anytime she asked. Isabella has been experiencing a lot of anxiety, and finds herself worrying about the smallest matter. She began to have fears of what would happen to her family and finances right after the separation. Soon after the separation, it has almost been a year, her anxiety has increased to the point that she drinks just to make it through the day. Anna is concerned about Isabella, because several times she has picked up the kids, and smelled liquor on her breath. She convinced her to see a doctor after Isabella remarked drinking helped her to relax. Her physician acknowledged the potential side effects from her diabetic medicine, but tells her she should not be experiencing anxious thoughts, and refers her to a mental health counselor.
(3) Demographic information (such as age, gender, race/ethnicity/country of origin, religion, sexual orientation, ability or disability, and social-economic status)
• Client Is 27 years old
• Mexican American
• ability/disability/moderate health; obesity/Type 2 diabetes
• employed/low economic status
*Current situation (including living situation, support systems, work and employment, and health).
Presenting issues. NOTE: this could be added to your 2-page report on the client. (e.g., you could add more discussion regarding the drug abuse problem).
• A typical day for Isabella consists of waking up, having copy and turning on the internet to check her Facebook page before going to work.
• She usually has a bowl of cereal (she admits to sometimes taking a drink to steady her nerves0
• Next, she drops the kids off at her aunt and goes to work.
• She lives alone with her two children, Mildred 2 and Mark 4.
• Her support system is her aunt and uncle
• She works as a gift wrapper for a local department store
• The client presents with anxiety (here you can move back into talking about her thoughts and perceptions at work that could include (lack of motivation, disinterest in the job dreams of a better job).This allows you more information to discuss her functioning.
Isabella grew up with very strict parents. Her environment was very controlled. She remembers that her parents never displayed warmth and love in her presence. The family didn.t demonstrate much affection. She feels guilty for not spending a lot of time with her kids.
(4) Part 2: Theoretical Approach
Describe the specific theoretical approach you used when working with this client. Identify a single theory as your main approach; if you integrated a second perspective into your work (such as integrating reality therapy into a cognitive therapy approach), you will need to identify how each theory contributed to your work with the client. Do not present more than two approaches or identify your work simply as being eclectic).
(a) Family System Approach
(a) In choosing Family System therapy this family faces several challenges including: (1) Marco`s absence from the home (2) visitation schedules for the children, ad (3) child support. The potential problem as presented in this case study appears to be focused primarily on Isabella`s anxiety problems. However, as a choice of therapeutic intervention, the Bowen model of Family system therapy will be utilized to aid this family in efforts at achieving more effective communication. In the present case scenario, based on Bowen` theoretical Family Systems model, the focus of therapy is to reduce anxiety by providing a rational "un-triangulated" third party (not taking sides) intervention. It is clear from Isabella wish to not divorce her husband indicates emotions are still there. A Family System`s approach will aid the practitioner in coaching the family members to aid in differentiation (not focus on the self); but deal with the emotional problems of nuclear family and begin to bring the family back together again.
(b) Solution-focused Therapy (SFT, deShazer & Berg, 1977) offers the advantages of being a brief, strength-based therapy. The therapy was designed to help clients arrive at solutions to their problems in a few sessions. The success is measured by the progress that clients make toward reaching their goals as opposed to the amount of times they spend in counseling. Research points to the effectiveness of SFBT with children and families. It is viewed as a strengths-based therapeutic approach, emphasizing resources that people already possess, and can be applied to a positive change process (Cooley, Graham, Craig, Opry, Cardin, et al., 2013)
(5) Discuss your rationale for selecting this theoretical perspective, and why you believed it was the most appropriate and effective approach to use. Support your statements with a minimum of 3 articles from current journals in the professional counseling literature that support the use of this theory with the types of issues your client presented, and/or with clients similar to yours (in age, gender, ethnicity, background, or in other ways).
Bowen`s definition for "differentiation of self" is `one who maintains emotional objectivity while in the midst of an emotional system that is in turmoil, yet at the same time relate to key people in the system (Bowen, 1978 as cited in Bartle-Haring & Lal, 2010, p. 106). Thus, the therapist would attempt to reconnect with the nuclear family focused on a change occurring within the entire family relationship. The notion is to treat chronic anxiety that feeds symptoms and raising differentiation of self, coping with anxiety in the family system, and with families struggling with alcoholism
(6) Describe how using this theoretical approach influenced the information you collected about the client during the first sessions. (For example, was it important for you to take a detailed history that included information about the client`s parents and early childhood experiences?) Again, support your ideas with references to the professional literature.
Understanding the lack of intimacy in Isabella`s family of origin could help to explain the emotions she is dealing with She remembers her parents always working and never displaying much emotion with each other or ,the kids. Her mother was quiet and reserved, and she remembers that her father drank a lot. This could help explain Isabel`s feeling of hopelessness, and confusion; and her struggles with alcoholism.
(7) Part 3: Counseling Goals
List three specific goals that you developed for working with this client. These should be goals in which you expected to see some progress during the time you were working with the client.
• Effect awareness and change
• Develop a better family relationship
• Reduce her anxiety
Note how these goals incorporated the client`s current strengths (to your knowledge), as well as areas of limitation or challenge for the client.
Isabella feels a loss of the sense of self. However, she is seeking of a change in her life, although she has not acted upon it. A significant part of her worrying is that she has not been successful up to this point, and she has nothing positive to hand down to her children. With an integrated approach consisting of a Family System (FS) therapy, the therapist is more focused on the family goals as opposed to the individual goal than the specific goals of the individual (Bartle-Haring, & Lal, 2010).. The key is to bring about an understanding so that the entire family benefits from understanding one another and SFBT approach, the desired goal is to encourage thoughts and perceptions of issues within the client`s life that are positive, and based on SFBFT aid her in achieving the desired condition of her life (www.sfbfa.org).
(8) Discuss how you considered your client`s social-cultural background when selecting these goals.
Consider multicultural practices and incorporation into your evaluation and/or assessment approach. The idea of raising awareness of multicultural factors into the counseling process was introduced by Sue, Arredondo, & McDavies (1992), and is focused on issues of diversity that may be beneficial to psychologists working with clients having a culturally diverse background. According to Sue et al, multicultural competency occurs when a counselor/practitioner`s attitudes/beliefs, knowledge are integrated into clinical practice.
Thus, implementing multicultural practices into the treatment process for Isabella would be to consider culturally relevant issues. For instance, research suggests that economic challenges have forced Mexican Americans who immigrate to the U.S. to live apart. These challenges include: (a) the stress of navigating through a new culture, (b) strained roles, (c) lowered access to resources; and (d) living in a system filled with anti-immigrant sentiment and racism (p. 361). Moreover, most Latinos prefer addressing their problems within the family (Bermudez, Zak-Hunter, & Silva, 2011).
(9) Discuss how each goal is reflective of your theoretical approach, drawing from the key concepts and assumptions of that theory.
The goal of Bowenian therapy includes:
• Reframing the presenting problem
• Lowering anxiety to have effective parenthood
• Strengthening the emotional wellbeing of the family unit
• Opening up ties that have been closed to the family
The setting of specific, concrete, and realistic goals is an important component of SFBT. Goals are formulated regarding what clients want different in the future. Consequently, in SFBT, clients set the goals. Once a formulation has occurred, the therapist focuses on exceptions related to goals, regular scaling (clients are close to their goals or a solution), and co-constructing useful next steps to reaching their preferred future (www.sfbt.com).
Specific goals are an important component of SFBT. Whenever possible, the therapist tries to obtain small goals rather than large ones. Clients are encouraged to frame their goals as a solution as opposed to a problem, rather than the absence of a problem (see, Tipper et al, n. d.)
(10) Part 4-Assessment and Diagnosis
Write a diagnosis for the client, based on the definitions in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
*DSM 5 diagnosis
300.02 Generalized Anxiety Disorder
303.90 Alcoholism Use Disorder
E11 Type 2 diabetes Mellitus
(11) Discuss the process you used to formulate your assessment and diagnosis for this client.
It is clear from interviewing Isabella that she is suffering from anxiety problems. Although she also shows signs of depression, I am reluctant to provide a severe diagnosis for a major depressive disorder, because her condition appears to be linked to her current situation and lifestyle. This condition involves being separated from her husband, her low economic situation and the stability of her home after the separation. My first impression is that she is suffering from anxiety; however, I am still reluctant to suggest a severe disorder in Isabella`s case. She does not meet the criteria for a Major Depressive disorder. The anxiety could be brought on by the worrying linked to her current lifestyle change. Therefore, a provisional (could change) diagnosis is suggested based on the Diagnosis and Statistical Manual of Mental Disorders (DSM 5 [APA], 2013) criteria for Generalized anxiety Disorder (GAD).
Based on the DSM 5 [APA], 2013), diagnostic criteria, GAD consists of exhibiting excessive fear and anxiety. The excessive anxiety and worrying occurs for at least six months regarding a number of activities and events, and the individual finds it difficult to control the worry (DSM 5, p. 189).
(12) Did you rely on information collected from the client during the first sessions?
Information that cannot be obtained from the client clinical records can be obtained at intake, or first session if the client is not willing to disclose information at intake. For example, information from observing the client and from her psychosocial history (e.g., generational habits, patterns in the family of origin etc.), could be helpful in conceptualizing her case, and diagnosing the problem.
(13) Did you utilize any self-report instruments (such as symptom checklists, anxiety inventories, and depression scales)?
After addressing the relevant procedures during a clinical interview (e., listening, attending, confidentiality, informed consentagreement, etc.); the therapist is ready to move on to the assessment phase. Thus you might benefit from the use of a basic mental health exam that helps to assess the current condition of the client. (Lakeman, 1995) Some of the observational categories on the exam may include: appearance (well-dressed vs. poorly dressed) behavior (fidgeting, trembling); attitude toward therapy or therapist (cooperative or resistant); and affect (mood during interview); rate and flow of speech (e.g., hurried, mumbled, or slurred).
These observations could aid in diagnosing the client`s mental functioning. According to Lakeman (1995), the MHE provides a way to structure data regarding the client`s mental functioning. The MME follows as format for all health professionals to follow and record under specific headings.
(14) Did you consult with any other persons about the client (with his or her written permission) such as parents, teachers, physicians, and past therapists?
It is a good idea to check with the referring physician (with the client`s permission). You could also talk to your supervisor if there is a problem proceeding with the client, or understanding how to proceed.
(15) What social-cultural factors did you consider when approaching the assessment process and formulating your diagnosis?
You should consider whether or not you have "multicultural competency", be attentive to religious and cultural factors, family of origin, the client`s low economic status; and her separation from Marco. All of these could be factors that contribute to her functioning.
(16) Describe how the assessment and diagnosis process was integrated into your theoretical approach for working with the client. Did the information you gathered, and the diagnosis you formulated, assist you in working from this perspective more effectively? If so, provide examples; if not, discuss the reasons why.
According to integrative therapists, the goal is to fit the therapy to the client. Research shows that integrative therapy is becoming increasingly popular. Discussed below are the therapies of psychoanalysis, cognitive-behavioral and person-centered therapies and the advantages and disadvantages associated with these approaches when integrated. An advantage of this approach is that childhood problems can be identified and restructures. The therapy is focused on achieving insights to develop an awareness and understanding of self (Corey, 2005).
From an integrated perspective record the effectives of the client`s progress from each perspective (each perspective has something unique to offer). For instance, based on the FS approach, the therapist would note the degree which Isabella has become differentiated from others, and (2) the way in which anxiety is formed through rigid patterns by the family structure(Corey, 2005). From the SFBT perspective, the therapy will help clients arrive at solutions to their problems in a few sessions (Cooley et al., 2013).
Bartle-Haring, S., & Lal, A. (2010). Using Bowen theory to examine progress in couple therapy. The Family Journal, 18 (2), 106-115.
Bermudez, J.M., Zak-Hunter, L.M., & Silva, L. (2011). Experiences of parenting classes for Mexican American mothers parenting alone: Offering culturally responsive approaches. American Journal of Family therapy, 39 (2), 360-364.
Bowenian family therapist. Retrieved August 14, 2015, from http://www.sagepub.com.
Cooley. C. W., Graham. J.M., NE, T., Craig, M. C., Opry, A., Cardin, S. A... et al (2013). Solution-focused family therapy with the aggressive and oppositional-acting children: An empirical study. Family Process, 42(3), 361-374.
Corey, G. (2005). A case approach to counseling and psychotherapy. Belmont, CA: Brooks/Coles-Thomson Learning.
Lakeman, R. (1995). The mental status examination. Retrieved August 14, 2015, from www.testandcalc.com.
Sue, D, W, Arredondo, P, & McDavies, R. J. (1992). Multicultural counseling competencies and standards. A call to the profession. Journal of Counseling and Development, 70 (2), 477-486.
Tipper, T. S., McCollum, E.E., Jong, P. D., Korman, H., Gingerich, W., & Franklin, C. (n. d.). Solution-focused therapy Treatment manual for working with individuals, research committee of the solution focused brief therapy association. Retrieved August 13, 2015, from www.sfbta.org/reserch.pdf.