Final Assignment: Case Study
Final Assignment (30% of Course Grade) Total of 100pts
Final Assignment is a case study (8–10 pages, APA required, with appropriate references. At least four references).
This assignment will involve use of a current case from your field internship.
RESOURCES:
-Session 3 provides a review to think through Carla’s case that is presented in the O’Hare text—–Chapter 7. This review is an orientation to working on developing a case study that involves a Case Service Plan (as a diagram) based on application of evidence that informs practice. Also, provided is an example of a case service plan from this case that further elaborates an application involving strategies and skills that will support specific client outcomes.
-Session 6.6 provides a review on how to include skills and objectives for Noah’s case presented in the O’Hare text —-
Template
Client Service Plan –
Noah
and his Family
Noah
| Client Service Plan – Noah and his Family | |||||||
| Depression, grief, stress-related symptoms resuting from the death of his cousin | Provide a normative degree of resolutin for grief, resolve acute symptoms related to deth, cognitive appraisal of the death and further sense of danger | Carefully review child’s understanding of circumstances of cousin’s death and exaggerated fears of his own danger, review time with Damon and develop a scrapbook together | Cognitive therapy focused on resolving fears related to death and facilitiating grief: Introduce emotion identification and scaling, explore cognitive distortions Behavioral activation |
Mindful listening Engagement |
Decrease score on index of suicidal ideation and index of hopelessness | ||
| Shyness, social anxiety with kids at school | Increase comfort level and improve socializiation skills to play after school for at least one hour | Graduated objectives: measured from a few minutes up to 60 minutes in after school program; instructors record number of minutes | Coping Skills to enhance relaxation through imagery and muscle relaxation, | modeling | Therapeutic alliance Mutual agreement Systems | collaboration | Increase number of minutes playing with others in after school program from 0 to 10 to 20 to 40 then 60. Increase number of times he initiates conversation druing play from 0 to 4 Decrease SUDS (subjective units of distress scale) to below 5 when approaching other children |
| Moderate OCD symptoms, perfectionism, excessive organizing to get things just right, feelings of responsibility for external events | Reduce expectations to be perfect: tolerate messiness with reduced anxiety and compulsive behaviors | Graduated objectives: to reduce level of perfectionism with regard to tidying up room, homework, prayer by reducing amount of organizing to 1-2 mintues daily at the end of each task. | In addition to coping skills, EXRP (exposure with response prevention) exercised early on until he can leave it alone, dailiy rewards for reducing organizing time Mindfulness – relabeling, reattributing, refocusing, revaluing |
Exploration Feedback Reinforcement |
Decrease number of minutes organizing at home and school from current rate to 5 then to 1-2 Level of subjective anxiety experienced if things are not perfect to under 5 |
Sample Skills
| holding space |
| tolerating silence |
| tolerating strong emotion |
| expressing empathy |
| reflecting back/active listening |
| inspiring hope |
| being genuine |
| inspiring trust |
| expressing acceptance |
| awareness |
| insight |
| advocacy |
FinalAssignment (30% of Course Grade) Total of 100pts
Final Assignment is a case study (8–10 pages, APA required, with appropriate references. At least four references).
This assignment will involve use of a current case from your field internship.
RESOURCES:
-Session 3 provides a review to think through Carla’s case that is presented in the O’Hare text—–Chapter 7. This review is an
or
ientation to working on developing a case study that involves a Case Service Plan (as a diagram) based on application of evidence that informs practice. Also, provided is an example of a case service plan from this case that further elaborates an application involving strategies and skills that will support specific client outcomes.
-Session 6.6 provides a review on how to include skills and objectives for Noah’s case presented in the O’Hare text —-
I: CLIENT PRESENTATION: For a total of 20 pts
Please provide an introduction in outline form: (4pts)
Agency:
Service context/setting:
Modality:
Your role:
Client(s) description:
Age:
Gender:
Family:
Other important bio-psycho-social-spiritual that are important to consider:
Length of time working together:
Number of times you have met:
Respond to the following questions in a narrative form:
1. Presenting problem from both of yours and the client’s perspective (4pts)
2. Describe your therapeutic alliance with your client (4pts)
3. Data that presents the client’s strengths, risk, and protective factors (4pts)
4. Challenges (4pts)
II: CLIENT CASE FORMULATION: For a total of 20 pts
1.Based case formulation on an assessment of: (5pts)
– the client,
– Client’s situation
– The client’s involvement in the change process
2.Use evidence that informs understanding of need, their capacity to learn, grow, and change, with agreed-upon priorities (from the client, client system, your assessment, and the literature). (5pts).
3.What are their goals? (5pts).
4.Describe how are you are facilitating steps forward in your work together? (5pts).
III: CLIENT SERVICE PLAN – based on case formulation: For a total of 30 pts
(See examples of service plans in the O’Hare text at the end of Chapters 5–16.)
Present the Client Service Plan in the form of a Table as demonstrated in the O’Hare text.
Additions to the table include a category following interventions that described strategies and skills, and an additional category that describes outcomes that are possible because of the intervention. You could find an example of Noah on your LMS in the toolbox.
IV: SUMMARY REVIEW – based on client service plan: For a total of 30 pts
1. Discuss the evidence for the choice of intervention that takes into account client and social network factors, supporting your choice. (5pts)
2. Review how your work is culturally responsive. Use references supporting your review. (5pts)
3. Assess your work with the client that includes evidence of outcomes. Note that this should be in line with the assessment and evaluation table presented in the client service plan. How have you, with your client, evaluated progress or goal achievement? (5pts)
4. What principles influence your work? (5pts)
5. Review next steps with this client if the work has not concluded based on what has worked and what you want to do differently. Reference literature that supports these reflections.
or
Review your work if it has concluded: What was helpful? What would you do differently? What contributes to this review? Reference literature that supports these reflections. (10pts)
BIOPSYCHOSOCIAL ASSESSMENT
STUDENT’S NAME: Leticia I. Cordero
NAME OF FICTIONAL CHARACTER: Hilda Acevedo
DOB: 05-28-1997
AGE: 22
GENDER: Female
MARITAL STATUS: Single
OCCUPATION
: Employee Part time
NATIONALITY/ETHNICITY: Dominican
RACE: Hispanic
RESIDENCE/LIVING CIRCUMSTANCES: Lives with maternal grandparents
REFERRAL SOURCE: Administration For Children Services
REASON FOR REFERRAL
The case was referred program through the Field Office on 10/26/19, with allegations of substance use against client related to her child. Client tested positive for marijuana at the birth of baby. baby was born on 2019 at hospital. She tested negative for all substances
HISTORY OF CHIEF COMPLAINT
Client reports that she began smoking cannabis at the age of 18 and steadily increased to smoking three times a day. She states that she stopped when she was four months pregnant, prior to that she was unaware of the pregnancy. She reports that she then stopped smoking for the duration of the pregnancy with the exception of one month before delivery when she was upset about the uncertainty of the baby’s paternity. She indicates that her main triggers for use were negative emotions (e.g., anger, sadness).
SIGNIFICANT MEDICAL HISTORY
There are no known medical concerns.
MEDICATIONS
No medications
BACKGROUND INFORMATION
BORN & RAISED
Client is a domiciled twenty-year-old woman who was born, raised and currently resides in the New York.
FAMILY
PARENTS: Age/living-deceased, client’s age and reaction to death and consequences
Personality characteristics of Mother (discipline, involvements, characteristics)
Personality characteristics of Father (discipline, involvements, characteristics)
General physical and mental health during client’s childhood
Parental history of substance abuse, physical, emotional, sexual abuse, or traumas
MARITAL: Single never being married. 1 sister. client currently lives with her maternal grandparents. Family has lived there for over 20 years
CHILDREN (NATURAL & ADOPTED)
Pregnancies: 1 unplanned; accepted.
GRANDCHILDREN:
None
EDUCATION:
Complete 11 grade in high school.
OCCUPATION
Lifeguard
MILITARY SERVICE
None
LEGAL/CRIMINAL HISTORY
N/A
PSYCHIATRIC HISTORY
Client reports a history of trauma, including early separation from her mother due to her mother’s incarceration and subsequent deportation to country of birth, attempted sexual assault by a stranger last year and physical altercations in the community. Nevertheless, client denies any current symptoms of Posttraumatic Stress Disorder.
SUBSTANCE
ABUSE HISTORY
(Past/Present)
ALCOHOL: None
DRUGS: In terms of substance use, her reports on the ASSIST (Score = 19/Cannabis) and UNCOPE (Score = 2) are consistent with her clinical interview. She reports that she smoked one blunt one month prior to giving birth. However, prior to discovering she was pregnant, when she was 4 months along, she would smoke 3 “blunts” a day. She acknowledges that smoking cannabis helps her “forget” about the stressful aspects of her life. Client reports that she began smoking cannabis at the age of 18 and steadily increased to smoking three times a day. She states that she stopped when she was four months pregnant, prior to that she was unaware of the pregnancy. She reports that she then stopped smoking for the duration of the pregnancy with the exception of one month before delivery when she was upset about the uncertainty of the baby’s paternity. She indicates that her main triggers for use were negative emotions (e.g., anger, sadness).
TOBACCO: None
CAFFEINE: None
ABUSE HISTORY
SEXUAL: Attempted sexual assault by a stranger last year.
PHYSICAL:
Client denies at this time
EMOTIONAL:
Client reported a significant loss when her mother was incarcerated then subsequently deported to country of birth. Client denies any negative feelings towards her mother and reports that her maternal aunt is to blame because she introduced her mother to criminal activities. Client reported that as an adolescent she initially used cannabis socially but then began using it more frequently. She often used cannabis to numb her emotions and no longer have to think about the stress that was going on in her life at any given moment. Client may be struggling with her identity as a mother given the history of her unexpected separation from her own mother. It is likely that she has attempted to fill that emotional void via substance use and poor relationships. Nevertheless, she appears motivated to engage in services that will support her and assist her in fulfilling her role as a new mother.
SEXUAL HISTORY
Client denies at this time
BEHAVIOR OBSERVATIONS
During the interview, Client was generally forthcoming and pleasant. She denied feeling overwhelmed by the involvement of ACS and she reported feeling grateful that baby was not removed from her care. Throughout the interview, Client presented with blunted affect and therefore at times it was difficult to ascertain her feelings or level of understanding on particular topics, especially related to the ACS process. Given Client’s history, it is a possibility that she lacks a sense of agency and therefore does not provide much input into decision making processes.
MOOD/AFFECT
SLEEP PATTERNS: N/A
EATING: N/A
ACTIVITIES OF DAILY LIVING: N/A
MOTIVATION: N/A
ANXIETY/AGITATION/PANIC ATTACKS: N/A
BEHAVIORAL CHANGES: N/A
IMPULSIVITY: N/A
RACING THOUGHTS: N/A
PROBLEM SOLVING
SHORT & LONG TERM MEMORY
ATTENTION :
CONCENTRATION:
MENTAL STATUS EXAM:
Orientation to:
Person
Place
Time
Situation
Familiar objects (hold up hand, pencil, watch…)
Other people (family members, doctor…)
THOUGHT PROCESSES & CONTENT
SUICIDAL/HOMICIDAL IDEATION
The client denies any current suicidal ideation, any past suicide attempts or any current non-suicidal self-injury. She reports a history of passive suicidal ideation as a teenager but did not have any plan, intent or previous attempts. She also reports a history of one event in which she engaged in non-suicidal self-injury in which she scratched herself superficially with her nails. She denies any current or past homicidal ideations.
INSIGHT/JUDGEMENT
PERSONALITY FACTORS
ADJUSTMENT
STRENGTHS:
• Client is willing to engage in MH services and substance abuse treatment.
• Client has identified sources of support in her community and family
• She exhibits a sense of self-awareness and the function of substances in her life.
• Client has been observed to exhibit warm and appropriate interactions with her child
• baby was observed to be well cared for during the evaluation and during home visits.
LIMITATIONS:
None
SUPPORT SYSTEMS:
Father, maternal grandmother, sister and mother.
PROGNOSIS
PATIENT CONCERN’S/GOALS:
CONCERNS: Client’s marijuana use and Client history of poor impulse control/lack of coping skills.
GOALS: Consistent engagement in MH services and substance abuse treatment.
DIAGNOSIS
Generalized Anxiety Disorder 300.02 (F41.1)
A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least
6 months, about a number of events or activities (such as work or school performance).
B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least
some symptoms having been present for more days than not for the past 6 months):
Note: Only one item required in children.
1. Restlessness, feeling keyed up or on edge.
2. Being easily fatigued.
3. Difficulty concentrating or mind going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse,
a medication) or another medical condition (e.g., hyperthyroidism).
F. The disturbance is not better explained by another medical disorder (e.g., anxiety or worry about
having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia],
contamination or other obsessions in obsessive-compulsive disorder, separation from attachment
figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder,
gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived
appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder,
or the content of delusional beliefs in schizophrenia or delusional disorder).
________________________________________ ______________
Signature Date
Reference
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.). Washington, DC:
Author.