I created this brief case conceptualization and treatment planning document for CNS 762: Issues in Clinical Mental Health (Assignment 2.2). It shows that I can identify vital information, formulate an appropriate treatment plan, and understand the underlying factors behind a client's presenting concern. Click here to download a PDF version.
Case Conceptualization & Treatment Planning Example
Presenting concern: Feelings of hopelessness and depression have led to the symptoms of frequent tearfulness, sleep disturbance, weight loss, social isolation, inability to concentrate or complete simple tasks, and passive suicidality.
Client’s stated goal(s) for counseling:
Eliminate suicidal thoughts
Decrease physical symptoms of depression including gastrointestinal discomforts
Improve work performance through better concentration
Client strengths/resources: Jane has a support system at her church and relies on her spirituality. Jane has a college degree (business) and does not use alcohol or drugs. Client has some contact with her younger siblings, although they are not particularly close. She is currently employed and appears to be financially independent.
Client liabilities: Jane has unresolved distress over her parents’ divorce, which occurred 14 years ago. She also is at risk of losing her job and does not have much family support.
Diagnosis: This client is presenting with Major Depressive Disorder, Moderate, Recurrent Episode 296.32 (F33.1) as she meets the criteria for six of the nine symptoms listed in the DSM-V. This is qualified as recurrent due to her previous treatment 13 years ago and three years ago for depression-related symptoms.
Integrative interpretation: Relying on a combination of Bowen Family Systems Therapy and Existential Therapy theoretical orientations, Jane’s divorce was likely precipitated by unresolved self-identity issues brought on through her family of origin’s dysfunction. As Gladding and Newsome (2017) explain, “These individuals have not separated themselves from their families of origin in a healthy way, nor have they formed stable self-concepts” (p. 250). Jane has struggled to find meaning outside of her romantic and familial relationships, which has led to an episode of major depression.
Treatment Planning
Problem statement: Depression due to divorce and unresolved distress due to parents’ divorce.
Goal statement and expected date of achievement: Client will create a family genogram over the next week to evaluate interpersonal patterns within her family of origin (Gladding and Newsome, 2017, p. 251). Client will make a list of values and interests over the next two to start the process of seeking meaning independent of her relationships. Client will read the Bible daily and make a record (journal) of her prayers to integrate her spirituality into the therapeutic process.
Treatment modality: Jane will meet with a Licensed Professional Counselor for 50-minute individual sessions one time per week. She will also attend a monthly support group for divorced women at her church, led by a Licensed Clinical Social Worker.
Clinical impression or diagnosis: Major Depressive Disorder, Moderate, Recurrent Episode 296.32 (F33.1)
Names and credentials: Treatment plan was written by Callie Dyer, who is also the therapist assigned to Jane M. Signed and dated 6/24/2018.