Humanistic and Existentialism approach therapy ( Case write up)
CLINICAL CASE WRITE-UP:
a) Identifying characteristics: Describe identifying characteristic of the client: age, biological sex, gender identity, relationship/marital status, sexual orientation, race, ethnicity, socioeconomic class, education, immigration status, religious or spiritual identification.
b) Presenting Complaint: In the client’s words, describe the reason for pursuing psychotherapy/treatment. Be sure to identify the source and context of the referral (e.g. parent, school, DCFS, self-referred, employer, correctional or judicial system, etc.), and for child cases, the guardians’ understanding for the need for treatment.
c) Mental Status Examination (MSE): Complete a full Mental Status Examination
(APPENDIX A)
d) Client History: A detailed history of the client’s life struggles and functioning must be provided. If no information is available, state so and remark on actions taken to collect this information. Information in each domain below should be organized chronologically within that domain. Domains that must be addressed and require subheadings include:
Family History & Relationships: Composition, history, and functioning of client’s family of origin, including quality of past and current relationships with parents,siblings, and extended family members (if relevant).
Composition, history, and functioning of client’s own family (partner/spouse, children and grandchildren), if applicable, including the client’s expressed quality of these relationships.
Living situations and remarkable family experiences, events, transitions in either family system should be mentioned.
Developmental History: History of cognitive, emotional, social & behavioral developmental milestones and any remarkable deviations from them.
Social History:
History of peer relationships, friendships, & romantic relationships.
This section should include the client’s history of sexual activity.
Potential Abuse & Trauma History: History of physical, emotional, and/or sexual events that may be deemed as abusive or traumatizing. Natural or manmade disasters may also be considered. Also mention if there is a history of domestic violence or events witnessed that may be characterized as traumatic. the examinee may also include major illnesses and significant losses to death or abandonment that could potentially be characterized as traumatic.
Academic/Educational History: History of experiences in school with academic material, grades achieved, level of completion, level of education aspired for and areas of academic interest and reported strengths.
Employment/Vocational History: History of work or work-related experiences (including parenting, home-making, caregiving, internships, government subsidies, volunteer positions). Mention the client’s current source of livelihood, support, or income. Discuss any financial issues or concerns the client has expressed, as well as patterns of conflicts with supervisors or co-workers.
Religious and Spiritual History: History of religious affiliation/participation, current religious affiliation or participation, important beliefs & practices as well as the value the client places on any of the above. If the client identifies as spiritual, describe how the client expresses or practices their spirituality, which could include spiritual feelings, thoughts, and or behaviors.
Socio-Cultural Status: Client’s (and their family’s) racial, ethnic, nationality background, including immigrant status, country of origin, families’ country of origin, military culture/standards, or geographic location where the person resides. Also describe languages spoken in the family and levels of acculturation of various family members (if applicable). Also discuss the client’s socio-economic status, disability/ability status, sexual orientation and gender identity. Please discuss any struggles and adjustment or identity issues related to these statuses.
Medical History: History of client’s medical diagnoses, diseases and conditions, medical treatments, medications taken (including when prescribed, dosage prescribed, dosage taken, duration of prescription and any notable side effects experienced). Also include relatives’ historical and current important medical information that directly or indirectly impacts the client.
Mental Health History: History of client’s prior (if any) psychological diagnoses, psychological treatments, hospitalizations, suicidal and homicidal ideation or attempts, and medications taken (including when prescribed, dosage prescribed, dosage taken, duration of prescription and any notable side effects experienced).
Discuss the chronology, setting/provider, duration, and outcomes of prior psychological and psychiatric diagnoses and treatments, if known. Include historical information on relatives’ suicidal and homicidal ideation and attempts.
Also include relatives’ historical and current important mental health information that directly or indirectly impacts the client. Elaborate substance use information in the corresponding section.
Substance Use & Addictive Behavior History: History of all substances used by the client (excluding prescribed medication used as prescribed) including detailed information on when the substance use started, expressed symptoms related to substance withdrawal, attempts to cut back or stop using those substances and evidence of substance tolerance and dependence should be remarked on.
Include information on HANDBOOK FOR THE INTERVENTION CLINICAL QUALIFYING EXAM (I-CQE) 23 the quantity/amount/dose used, frequency, time(s) of day used, duration, route of administration, client’s described triggers and/or cravings for every substance.
Describe the development or exacerbation of medical or psychiatric symptoms or conditions that have occurred in the client’s history as a result of substance intoxication or withdrawal. Also include any other behavior or habit that might be compulsive, impulsive, or a process related addition (e.g. gambling, sexual behavior, gaming, etc.).
A similar history of family substance use should also be included when the client has a history of substance abuse and or compulsive behaviors and when the family history is known.
Legal History: History of a pattern of illegal activity, arrests, incarceration, or other legal involvement, along with the client’s overall engagement with the legal system (including parole, probation, lawsuits, etc.).
e) DSM 5 Diagnosis & Rationale: In this section the examinee will provide the diagnosis or diagnoses that the examinee believes describe the client’s struggles as supported by evidence included in the prior sections of this document.
While consultation is expected in diagnosing a client, the diagnosis(es) given here should be the clinician’s conclusion solely supported by the clinician’s gathered evidence. Therefore, the clinician’s diagnosis may be the same or different than those made by supervisors or other on-site clinicians.
The diagnosis(es) should include: DSM-5 Diagnosis: Here the examinee will provide diagnosis (es), and if applicable the subtype(s) and or specifier(s).
f) Strengths, Assets, & Supports: Discuss any historical or current areas of the client’s personality, life or social context that has been identified in the empirical literature as an area of resilience that counters the client’s struggles or their continuation, and enhances their participation in treatment and recovery.
Consider client behaviors in a variety of contexts in the client’s current life or history, and explore what behaviors may be adaptive or points of resilience in specific contexts that could also be considered maladaptive behaviors, weaknesses, or deficits in other areas in the client’s life.
g) Case Conceptualization: This section of the document is the clinician’s first opportunity to provide an explanation for the client’s diagnosis(es) and/or struggles based on the primary theoretical orientation (defined as the conceptualization and treatment plan that coincide with the psychotherapy work being conducted) that was utilized in the actual psychotherapy with the client. While consultation is expected in conceptualization of a client, the work given here should be the clinician’s conclusion solely supported by the clinician’s gathered evidence.
Therefore, the clinician’s understanding may be the same or different than those made by supervisors or other on-site clinicians.
The explanatory power of this task comes from the development of a dynamic description of the interaction(s) between any or all client variables that contribute to repetitive patterns in thinking, feeling, interactions with others, behaviors, or physiological experiences that are central to and descriptive of the client. The case conceptualization should be in the format of a narrative that considers the interaction of factors covered below by identifying relevant client variables and organizing the known or plausible interactions between those client variables that the examinee provided in the prior sections of the case write-up:
Identify, describe & cite what the empirical literature has found to be genetic, psychological and environmental vulnerability factors and maintenance factors for the diagnosis(es) and/or struggles
Brief overview, with original source citations, of the theoretical orientation & its founder(s).
Brief but detailed description (with original source citations) of the theoretical model or concept(s) to be utilized to explain the client’s diagnosis (es) and/or struggles. These theoretical concepts should pertain to the theory’s view of human nature, psychopathological causation and maintenance, and therapeutic change.
Link the theoretical model or concept(s) to the client’s life, diagnosis (es) and/or struggles.
Identify, describe & cite ideas about areas of culture and/or diversity that should be taken into consideration for the diagnosis(es) and/or struggles.
Treatment Plan:
In this section of the document the clinician provides a detailed treatment plan that coincides with its corresponding case conceptualization. While consultation is expected in creation of treatment plan of a client, the work given here should be the clinician’s conclusion solely supported by the clinician’s gathered evidence.
The treatment plan should include the following specific subheadings and information:
Measurable short-term goals and corresponding techniques/interventions in the actual and specific time sequence in which they will typically be utilized in that psychotherapy over the course of therapy. Please also clearly specify what are the corresponding presenting problems and/or diagnoses these treatment goals and interventions are aimed to address.
Potential long-term goals and corresponding techniques/interventions. Please also clearly specify what are the corresponding presenting problems and diagnoses these treatment goals and interventions are aimed to address.
Proposed out-of-session tasks (if applicable, i.e., homework) and the corresponding presenting problems and diagnoses they are aimed to address.
Anticipated challenges, barriers, and/or difficulties related generally to the proposed treatment plan.
Recommendations for additional services, such as medication, group therapy, self-help groups, consultation with clergy, and referrals.
The treatment plan (goals and interventions) must match the client presenting problems, diagnoses, and theoretical case conceptualization. Further, to the extent possible, treatment goals should be collaboratively developed with the client.
The treatment plan (proposed interventions) should be based on the empirical literature on evidence-based practices for the types of problems/diagnoses the client exhibits. Please discuss the empirical evidence from the literature, with citations, that provide support for your proposed interventions for these particular types of client and clinical problems.
Ethical Issues: Discuss any ethical issues or potential ethical considerations relevant to the case and any steps taken to address them. These must include (but are not limited to) assessment and management of client suicidal/homicidal risk, child abuse/neglect, and confidentiality and dual relationships. Please reference any relevant APA ethical guidelines and Illinois state laws in discussing such issues. In writing i) Ethical Issues for both the primary and secondary theoretical conceptualizations, there may not be any difference with ethical issues thus the writer will note in the secondary theoretical conceptualization to refer to the primary theoretical ethical issue part; however, if there are differences, please address those theory specific ethical dilemmas or issues in the secondary theoretical write up.
Course of Treatment:
Here the examinee will consider and describe:
Discuss the following, using the subheadings provided below.
The client’s motivation and engagement in treatment
The quality of the therapeutic relationship (e.g., therapeutic bond, therapist’s empathy, agreement on goals and tasks, ruptures, impasses, repairs, challenges, subjective experience of therapeutic alliance, and transference/countertransference). Also comment on:
The interventions used and their effect/outcome (be clear on what specific interventions (CBT) were used for what specific treatment goal and why)
The progress on client’s goals (based on goals discussed in the treatment plan).
The remaining goals to be accomplished during the rest of the treatment
The use of any outcome measures for this client. Please address the following:
How was the measure picked?
How did the examinee measure the efficacy of treatment results?
How the results inform the treatment?
If outcome measures were not used, provide a discussion about the evidence the examinee have used to measure the success and/or shortcomings of the treatment interventions provided.
The client’s prognosis and recommendations, including any relapse prevention considerations.
A self-reflection of therapist’s implementation of therapeutic micro-counseling skills (e.g., effective listening, open questions, reflection of thoughts and feelings, empathic attunement and effective nonverbal communication), and other psychotherapy interventions. Please reflect and discuss examples of effective and less effective use of these skills and interventions, as they appear in the recorded session the examinee provided.
Identify & discuss cultural differences and similarities between the therapist & patient.
Attribute awareness of own cultural identity as impacting the therapeutic relationship.
The discussion of these sections should be consistent and in line with the sections on case conceptualization and treatment plan. Any deviations should be justified and explained based on revised case conceptualizations, client progress and data, and the related empirical literature.
Provide sufficient detail for the examiner to understand the content, rationale, and outcome of all the aforementioned subsections.
Provide specific and detailed examples to highlight the content of interventions and client progress, such as what was the exact content of client negative thoughts, emotions, and behaviors, how did the therapist and client work on them, and what are the client’s current thoughts, emotions, and behaviors.
Evidence-based literature should be cited to justify the choices the therapist made or might make in the future to address the aforementioned material.
