Initial Case Conceptualization

In this assignment, you will discuss the theoretical approach you chose for working with a specific client during your fieldwork experience and how you used this perspective as you collected information about the client and developed counseling goals.

As you begin your work on this assignment, refer to what you have learned about counseling theories from:

• The material that you covered in previous courses you’ve taken during your program.
• Experiences during the Master’s Residencies.
• The discussions you have had with your site supervisor and fieldwork course instructor during practicum and Internship 1.

Complete this assignment by addressing the following topics in a four-part format.

Part 1: Client Information

Select a client with whom you have worked in individual counseling sessions over several weeks during your fieldwork experience. As you present information about the client in this assignment, be sure to use a pseudonym and omit or change all identifying material.

Present a brief description (no more than two pages) of the client, including the following:

• Demographic information (such as age, gender, race/ethnicity/country of origin, religion, sexual orientation, ability or disability, and socioeconomic status).
• Current situation (including living situation, support systems, work and employment, and health).
• The client’s presenting issues or concerns.
• Relevant history. Include a brief description of key events from the client’s past that have some impact on the presenting issues or that you believed were important to consider during your work with the client.

Part 2: Theoretical Approach

Describe the specific theoretical approach you used to conceptualize this client’s case. 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.”

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 three articles from current journals in the professional counseling literature that provide evidence for 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).

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.

Part 3: Assessment and Diagnosis

Write out the diagnosis you developed for the client, using the definitions and format in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and identify the related ICD 10 code.

Discuss the process you used to formulate your assessment and diagnosis for this client.

• How did you incorporate information collected from the client during the first sessions to reach this diagnosis?
• Did you utilize any self-report instruments (such as symptom checklists, anxiety inventories, depression scales or other assessment processes)? If so how did this information help you to formulate a diagnosis?
• Did you consult with any other persons about the client (with his or her written permission) such as parents, teachers, physicians, and past therapists?
• Which sociocultural factors did you need to consider when conceptualizing your client’s case and formulating your diagnosis?

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 theoretical perspective more effectively? If so, provide examples; if not, discuss the reasons why.

Part 4: Counseling Goals

List three specific goals that you developed for working with this client. These should be goals that are related to the client’s presenting issues and the focus of therapy. Each goal should be measurable—meaning both you and the client have a clear way for assessing whether the goal has been reached.

• Describe how you incorporated assessment information and the client’s diagnosis into your choice of appropriate goals for counseling.
• Discuss how you considered your client’s sociocultural background and unique personal history when selecting these goals.
• How is each goal reflective of your theoretical approach, drawing from the key concepts and assumptions of that theory?

Assignment Specifications

Your Unit 5 assignment should be 5–8 pages long and include a minimum of four references from current articles (no more than 10 years old) in professional journals. You may also include books and Web sites from professional organizations in your references. Please use direct quotations sparingly; you should paraphrase most of the information drawn from outside sources and present ideas in your own words. Remember to follow APA format for your citations.

Client is a 36-years old Caucasian American man who was referred for services . The client was
anxious, frustrated, and sad. The client reports in the past three (3) weeks his symptoms have increased due to personal stressors,lack of a job, and homelessness related to the COVID 19 pandemic. The client isolates himself daily and refuses to interact withothers. The client is withdrawn and irritable most days of the week. The client has crying spells and cries often.  The client has

Lost his appetite and hardly eats. The client has difficulty sleeping and gets about 2 to 3 hours of sleep a night. The client reports he feels
drained and lacks the energy to carry out his daily activities.  The client has lost interest in the things he loves to do. The client
reports he is feeling increasingly hopeless but has no intention of hurting himself.  The client has difficulty concentrating due to his
personal stressors.
Theclient was diagnosed with depression and anxiety about 2 years ago and was prescribed Wellbutrin 50mg.  The client reports  that he has notfollowed his appointments and taken his medication as he should as a result his symptoms have increased.  The client denied having
any medical problems and allergies.
The client obtained GED but currently has no source of income. The client was raised by his mother because his father died
when he was a child. The client has a sister with whom he gets along well. The client reports growing up with his mother was
difficult because she was a single parent.  The client does not have family support.
The client  needs  Services to prevent a higher-level  treatment due to increased symptoms in the
past three (3) weeks, the feeling of hopelessness and worsened depressive symptoms. He reports he is unable to manage his
medication, his symptoms, and locate services he needs to meet his presenting needs.

Diagnosis: F33.2 Major Depressive Disorder, recurrent severe