COUC 510 Liberty University Jodi Kreyman Counseling Session Report
Counseling Project: Case Summary and Presenting Problems InstructionsOverviewThe Counseling Project is divided into 3 parts: The Case Summary and Presenting Problems and 2 Conceptualization and Treatment Plans. This counseling project is designed to help you make application of course content to a counseling situation so you can understand how to effectively engage in case conceptualization and treatment planning. The Case Summary and Presenting Problems paper is the first of three papers for the counseling project. It is meant to provide a foundation for the other two papers. You will provide a summary that discusses the history of the fictional client and identifies three problems that you as the therapist will be helping the client work on in the two-case conceptualization and treatment plan papers. InstructionsIn this first paper the student will develop a short case summary about a fictional character (a TV, movie, or historical character is acceptable—but no cartoons or superheroes). This paper must be written with the fictional character as the “client,” and you as the treating therapist. This summary will be the basis for your Conceptualization and Treatment Plans 1 and 2 that you will develop later in the course. Your paper will have two sections: Client History and Presenting Problems (show these as level 1 headings). Follow the rules listed below:1. You will develop a two to four-page Case Summary and Presenting Problems paper about a fictional character from a television show or movie.2. Pay attention to Chapter 3 in your Schwitzer and Rubin textbook regarding Step 1: Problem Identification of the Inverted Pyramid Model as you write this section of your project. It gives you some tips about how to do a biopsychosocialspirtual assessment and how to use the mental status exam. You will not do these assessments, but hopefully you will get an idea of what information to write about based on the character you chose. Feel free to be creative and embellish some information about the character to make them more like a realistic client in order to practice developing your case conceptualization skills.3. Current APA format must be followed throughout the paper, and only third person should be used.4. At least one reference should be included indicating where you found the information providing details of your character (web sites are allowed for this assignment only).5. The client must not be a real person, but someone portrayed in television, a movie, literature, etc. No cartoon characters are acceptable. Real and presently living people WILL NOT be accepted for grading.6. The client must be an adult (age 21 or older) since the theories you will write about are mainly directed towards adults.7. The following problems/disorders are not allowed to be used due to the limitations of the theories as they are being taught in this course (future courses will go into greater detail on these topics):Suicidal and self-harming thoughts or behaviorsBipolar Disorder, schizophrenia, and personality disordersSexual Abuse/TraumaTitle PageRefer to your current APA manual for directions on formatting a title page. Include a running head, page number, paper title, your name, and the institution name (Liberty University). No abstract is required for this short paper.Client History (1–2 pages)Counselors typically gather information about their client in an intake interview where they do a biopsychosocialspirutal assessment. You are not able to do an assessment with your client, but you need to at least make sure you chose a tv or movie character with that provides enough information to adequately report a client history. Feel free to be creative and embellish some information about the character to make them more like a realistic client in order to practice developing your case conceptualization skills. Remember to write in third person. Pay attention to Chapter 3 in your Schwitzer and Rubin textbook regarding Step 1: Problem Identification of the Inverted Pyramid Model as you write this section of your project. It gives you some tips about how to do a biopsychosocialspirtual assessment and how to use the mental status exam. You are mainly using this information to develop your Client History Summary. See the information below regarding important information to consider discussing.1. Source of Information: Where can this client be found (television, movie, book, etc.)? Provide the source and the way data was obtained in the preparation of this report. In a real session this information would include both formal and informal assessments in the summary as well as throughout the case presentation; however, you have not had classes to teach those skills yet so we are mainly focusing on what you know from your observation and relevant information found on websites about the television show or movie.(This is the only time a website can be cited for this project. Make sure you paraphrase and cite sources to avoid plagiarism.)2. Family and Home Background/Religious Background: Identifying information about parents and siblings (names, ages, occupations, etc.).Client’s perception of the home environment and relationships within the family. Critical family incidents may be included. Also note any events that triggered the client, family coming to counseling, e.g., precipitating events.3. Educational History: Description of pertinent information in relation to educational background including academic achievement, school instances that were significant for understanding the individual and the client’s attitude toward education.4. Mental Health History: historical and as well as present signs, symptoms as well as any reported. You have not taken a diagnosis class yet. You are not to provide a diagnosis. However, if one is reported by the client or by the source of information you can document it here.5. MSE: When first meeting the client, what are your observations that would include speech; mood; affect; orientation to person, place, time; thought process; concentration. Remember clients that report self-harm, delusions and hallucinations should not be used for this assignment.6. Client’s Physical Health: A statement of the client’s significant health history, current treatment and medications.7. Occupational History: A description of the client’s vocational history. Emphasis should be placed on current occupational functioning, history of work problems and reason for change. Quality of work and satisfaction and interests. Work relationships.8. Sexual Adjustment: Current status, significant problems or disturbances in functioning, alternate lifestyles.9. Substance Use History: Description of client’s alcohol/drug use, patterns of use, and last use; as well as how often client uses and how much.10. Spiritual History: Does client believe in God? Is spirituality important to the client? Attend church? What role does religious affiliation play in the client’s life? Are spiritual resources or issues important to client? How does client describe God? What is the state of the client’s spiritual awareness? Additionally, an assessment of the religious background of the family is included.11. Cultural Factors: Does the client have any factors such as acculturation, discrimination, etc. that impact the client and may be source of signs, symptoms? How would the client explain the problem from their cultural lens?12. Barriers to Treatment/Success: Are there personality factors, stages of change influences, or contextual factors that would influence the success of treatment? How open do you believe the client will be to counsel? How can rapport be built with the client if he/she is hesitant about counseling?13. Other pertinent data: Provide any other data points not captured from the sections above such as signs, symptoms, severity, onset, conditions, context that provide a clearer picture for the development and discernment of the diagnosis as well as client insight and motivation to treatment.Presenting Problems (1–2 pages)In this section you will write up the identifying information and reason for referral/presenting Problems. It should address the following questions: Why is the client seeking counseling? What does the client say his/her problems are? What in the client’s life/background makes counseling a viable option for him/her? Use issues that you are aware of in your client’s life, but you can also fabricate some of the client history if there are not enough details provided in the fictional storyline. Pay attention to Chapter 3 in your Schwitzer and Rubin textbook regarding Step 1: Problem Identification of the Inverted Pyramid Model as you write this section of your project. Please use subheadings for this section. This section must be at least three paragraphs and emphasize at least three problem areas for the client. For example, a client may have issues in personal functioning (depression, anxiety, insomnia, etc.), relationships(spouse, children, parents, significant other, etc.), occupational functioning (trouble with boss, coworkers, unemployment, etc.) You may also address any problems the client may be experiencing with his or her spiritual health.NOTE: It is okay if two of the three paragraphs focus on personal issues (e.g., depression, then anxiety), and the other paragraph is on a different type of problem, or even if all three paragraphs focus on three personal issues. Just be clear about what is going on with this client. You are not diagnosing the client, rather, you are just describing the problem/symptom the client may be experiencing. So, for example, “depression” describes a problem the client is experiencing but is not the same as a DSM diagnosis of “Major Depressive Disorder.” Separate each problem area (e.g., Personal, Relationships) into a paragraph, using level 2 headings (flush left and bold).ReferencesSince you are using a fictional television, movie, or literature character, you can use a website for this paper only. However, all citations and references must follow current APA format. NOTE: many students get the website citation format wrong, so make sure you look in the current APA manual to properly do these if you use them. It is your responsibility to have this manual and use it.Note: Your assignment will be checked for originality via the SafeAssign plagiarism tool.TEXT BOOKSchwitzer & Rubin, Diagnosis and treatment planning skills (2015).