CASE CONCEPTUALISATION & ASSESSMENT in COUNSELLING
CSL566
CASE CONCEPTUALISATION & ASSESSMENT in COUNSELLING
Assessment 2: CASE REPORT (Parts A & B)
The link below is the case study of Lucy, her first session in counselling with symptoms of depression.
https://www.youtube.com/watch?v=7LD8iC4NqXM
We will be working on this same case study during the seminars/workshops.
The case study consists of two parts, which will be submitted at two different points in time: Part As biopsychosocial grid (10% of marks) is due by 8:00pm on Sunday 28th April and Part Bs plan and rationale to work with the client Lucy (25% of marks) is due 8:00pm Sunday 12th May.
Part A
Complete the template provided on myMurdoch Learning, which will be used in practice during the seminars. The template will be filled-in on Lucys case, using dot points and will not have citations. You should use a biopsychosocial grid and the 5Ps template to help you complete the information required in the grid (on myMurdoch Learning).
Part A is worth 10% of marks
Due: Refer to myMurdoch Learning and Unit Guide
Part B
You will choose a method of case conceptualisation discussed during seminars (i.e. from the major schools of counselling; CBT, Psychodynamic, Humanistic OR using an integrative approach) to apply to Lucys case.
There are three sections to Part B:
Hypotheses & Plan to work with the client: You should have one main hypothesis that may be a possible explanation for the problem the client Lucy is experiencing. You can state one or two secondary hypotheses. You should outline how you will work with the client. This is expected to be consistent with your hypotheses. (Look at the case report example for formatting).
Case note (of no more than 650 words) using a format (such as SOAP or DAP discussed in Topic 6) as would be written in Lucys progress notes. As in clinical practice, this case note will not have citations.
Part 3: Write a brief rationale (no more than 750 words) explaining why you have chosen your method of conceptualisation for Lucys case. This will touch on your worldview, support the tentative hypotheses you have drawn regarding the clients issues brought to counselling, and provide justification for the way you have chosen to work with the client in the case study. This section of the assessment will require citations as per APA referencing convention.
Part B is worth 25% of marks
Due: see myMurdoch Learning and Unit Guide
There will be opportunities to work on this case in class during the semester. An example of the assignment, marking keys, and rubrics will be available on myMurdoch Learning.
PART 1: TENTATIVE HYPOTHESES
Tentative Hypothesis/hypotheses:
TREATMENT PLAN
Plan to work with this client:
NEXT SESSION
What needs to be explored at next session?
PART 2: Case Note
Remember to use your APA shell from Part A, and adapt it for Part B. You will still need a cover sheet, starting page with your title at top and an introductory paragraph. You can follow your introductory paragraph with your case notes. Remember to use a clear SOAP or DAP format as a working document that you include in your appendices. Then rewrite your case within this template provided. Also, include your original BPS and 5Ps grids and notes in your appendices- the same ones you submitted for Part A.
After you write your template notes in the grid above in dot points, your case note description will follow. Your Rationale follows.
PART 3: Brief Rationale
Your rationale should contain information similar to the Shirley example provided, and be approximately of similar length. Remember to start with a clear introductory mini paragraph for the Rationale section in which you outline the main points you intend to cover. Such a paragraph is usually written after you write the section. Organize your ideas into paragraphs with a clear topic each. You may not need further subheadings, but if your rationale goes to two pages, consider organizing your ideas with subheadings.
Conclusion
Your paper should conclude with a conclusion paragraph. Your reflection on the rubric should be appended in the appendices. Remember to use section breaking for anything you need to change to landscape format. (or back again). Remember: no hanging headings without text following on the same page. Dot points in a grid can be Times 11pt instead of 12, and do not need to be double-spaced. Remember to use page breaking rather than tabbing down to move things to the next page, so that formatting is not compromised when you share your document.
Murdoch University
Unit: CSL566
Case Conceptualisation and Assessment in Counselling
Case Report Part A
Case Conceptualisation of Lucy
28TH April 2024
Student Name: Nasra Warsame
Student number:34172212
Tutor: Duncan Phillips
COUNSELLING INTAKE FORM
SECTION I: DEMOGRAPHIC INFORMATION
Date: 26 April 2024 Clients name: Lucy
Age: 18
Gender: Female
Marital status: Single
Address: 22 Address circle, Thornlie 6199
Phone:012376782
Referral source: GP
Other features relevant to case (ethnicity, education, occupation)
Caucasian young female, living with friends.
English student at university
Both her parents are present leaves aways from home for university
Remarks on clients presentation (appearance, behaviour)
Polite, very shy, medium eye contact, well spoken.
Body language: closed off, fidgeting with hands, looks anxious and distressed.
Self-aware of her low mood and reasons for being sad. Notably feeling emotions that make her feel upset and sad.
Feels embarrassed talking about emotions and laughing which could be a form of coping mechanism.
Ease of speaking openly in the counselling environment given the fact that she doesnt like to speak about how she feels.
SECTION II: RELEVANT HISTORY
History of problem:
Started feeling low and wound up about situations around 6 months ago.
Put a lot of stress on herself during exam times.
Lucy reported that she wanted to always do better for herself and her parents and that the stress of exams was overwhelming A lot of uni pressure was weighing on her.
Parents where also going through troubled times during that period. Lucy put pressure on herself to do well in exam as she felt guilty of parents marital problems.
Lucy feels as though she made it worser for her parents hence the guilt.
Found it hard to focus and be motivated to do activities that she once liked to participate in.
Feeling continued to persists and lucy has been missing classes at uni.
Feeling like she is putting a lot on stress on her as she trying to feel better about herself.
Feels isolated as she feels as though she doesnt have anyone to talk to about her feelings.
How long has problem(s) persisted?
Feelings of feeling isolated and low has persisted and has continued to weigh on Lucy.
Concerns of her mental well-being has weighed heavily on lucy.
She is self-aware of her mood changes but unaware of problems causing it. Shes feels stuck as she doesnt know how to cope with it.
Of recent she feels numb and lethargic. Symptoms are getting worse and is feeling lower than usual.
SECTION III: PRESENTATION (5Ps Perspective)
Problem list/concerns:
Social isolation from both her friends and family
Difficulty with focusing on university.
Feeling numb, tired and emotionally sad
Worried that her parents marriage is getting worse, and she feels guilty.
Not feeling bothered to do anything at all.
Feeling conflicted, lower than usual.
Thoughts of underperforming or comparing herself to others
I should have been doing better)
Finding it hard to get motivated to do what she likes such as sports.
Low mood, sad, frustrated.
Negative thoughts such as feeling unworthy thoughts described as pointless.
Presenting issue(s):
Feeling lonely, isolated (cant confide with friends or family)
Health issues regarding her feeling tired, drained.
Fatigue feeling of constant exhaustion, lack of energy (lethargic).
Mental (stress and pressure) contributing to her likeliness of depression.
Loss of worthiness /loss of interest (participating in sports)/ unworthy
Lack of satisfying sleep at night
Precipitating circumstances (triggers):
feelings of low mood
Stress of exams and university.
Parents marital issues 6 months ago
Social isolation
Predisposing factors (vulnerabilities):
Negative thinking of being unworthy
Guilty feelings for what going on between her parents.
Limited contact with family
No or little conversation between her and her friends despite living in same home.
Limited interaction to outside world (staying at home or in bed)
Unable to cope or get better (feels lower than usual)
Perpetuating factors (maintainers):
Negative thinking (unworthy, self-doubt, lack of self-love)
Low motivation, feelings of sadness and low mood
Lonely, No contact, isolation from family
Isolation from friends
Stress and uncertainty of university.
Uncertainty of feelings and emotions (coping)
Protective factors (client strengths) & diversity:
Willing to attend therapy and talk to councillor about emotions and thoughts.
Self-aware of mood change and is aware of her symptoms.
Wanting to improve so she gets back to feeling better.
Worried about parents even though it isnt easy with them, when she visits.
SECTION IV: INTERPERSONAL STYLE
Orientation towards others:
Doesnt want to burden other people with how she is feeling.
Wanting to over impress and do better to make her parents happy (hoping to save their marriage).
Communication styles:
Open and willing to share personal information and talk about her feelings.
Using 'I' phrases to be assertive and communicate sentiments and feeling
