CLN602 Adult Psychopathology and Intervention Case Study Assessment Guide

When Maeve first came to your clinic, she appeared immaculately dressed in a crisp white business shirt and a knee-length grey skirt. She had shoulder length dark brown hair that was tightly pulled back into a ponytail, and she seemed visibly nervous and spoke softly. At times, you had to ask her to "speak up". She tended to stare at the ground instead of making eye contact. Maeve disclosed that she often struggled to open up to strangers and even found it difficult to reveal personal secrets to her friends. Although she was able to describe her history with you, you had a feeling that she wasn't being completely transparent during your initial session. She expressed concerns that you might think less of her and believed you'd think her "an idiot" for having issues. She thought that she "should be able to put her feelings aside and get to work". As you continued your assessment, you discovered that Maeve had a history of seeking help from mental health professionals, including counsellors and psychiatrists. Her GP had referred her to you on a MHCP for depression and anxiety and had prescribed her 50mg of Sertraline daily, but Maeve admitted that she didn't take the medication much because it made her feel nauseous.

Maeve is currently 36. She mentioned that she grew up in a relatively affluent Anglo family that did not encourage open discussions about emotional issues, so such experiences could be challenging for her. Her parents, James and Maria, were English immigrants, but she was born in Melbourne. Her father, who is 70, is a semi-retired engineer, and her mother, who is 65, is a homemaker. Maeve's mother had trained as a nurse but stopped working after Maeve was born. Maeve has one older sister Janine, 38, who she has a strained relationship with; describing her sister as the familys golden child when they were growing up. She sees her sister as being a little miss perfect, who now has the nice house, husband and kids and she sees this in vast contrast to her own life, back living with her parents. Maeve did not express much enthusiasm when talking about her parents. In particular, she referred to her mother as a "bit of a bitch" who constantly criticized her while she was growing up, belittled her feelings, and minimized her problems by saying things like "Don't be such a little princess, get over it." According to Maeve, her mother has always been like this, and her mother even called her "the tantrum child" when she was young. However, Maeve currently spends a lot of time socializing with her mother and her mother's friends. Maeve described her father as "a nice man," but he tends to be distant and prefers to retreat to his study to work from home. Maeve suspects that her father may have experienced depression and potentially issues with alcohol in the past, but this is not discussed openly at home. Although Maeve laughed while describing her mother's critical nature, which struck you as unusual, her overall demeanour was appropriate during the conversation.

Maeve was visibly embarrassed when admitting that she had moved back in with her parents a year earlier, following the collapse of a two-year relationship with her partner Robert, with whom she'd been living. Maeve had hoped to marry Robert, but he had not been "as into" her as she had been into him, causing her to feel devastated. The COVID-19 pandemic had only served to exacerbate the tensions in their relationship. Despite their rocky end, Maeve lit up when speaking about the exciting whirlwind romance that had led to her quickly moving in with Robert at the start of the relationship. However, Maeve harboured suspicions about Robert's fidelity, which caused several arguments, including a particularly heated one that arose after she discovered messages from a female friend of his on his phone. When checking through his phone she found messages, in which the friend was on a beach wearing almost nothing. While Robert insisted that this friendship was platonic it had led to the last of a series of stormy arguments. Recently, Maeve had found solace in a new relationship with Jason, whom she had met on an online dating app roughly four weeks prior. They have mostly stayed in and been intimate, only going out in public once, but Maeve worries that Jason might still be using the dating app to meet other people. Despite her concerns, Maeve believes that Jason is her "soulmate" and that she's in love with him. Nonetheless, she has yet to meet Jason's friends, and the uncertainty surrounding their relationship stokes her anxiety.

Maeve describes herself as somewhat of a "loner", having only ever had a small circle of close friends. During her youth at a private Catholic high school in the Eastern suburbs, she was targeted by bullies around her weight which at the time was an issue; particularly by the popular girls who could be quite cruel. Despite this, she had been "tight" with a couple of close friends, one of whom she still spoke to occasionally over the phone despite their moving interstate. Maeve didn't elaborate on what happened with her other friend, only hinting at some sort of argument. In general, she finds it challenging to make friends due to her shyness in social situations.

During her time at school, Maeve experienced her first period of feeling "down", although she assured you that she never had any intention of self-harm during those times. She has since experienced a couple of other similar periods. She said that according to one psychiatrist, she has obsessive compulsive disorder, although she is uncertain about the reasoning behind this diagnosis. Around the age of 21 her family home where she was living had an intruder break in intending to rob the house while she was at home, and she was injured when she confronted him. She said her mother blamed her for this and it was all very traumatic. When asked about other traumatic events, Maeve became quiet and mentioned that there were "other things" but she didn't want to talk about them. You also inquired about obsessive thoughts, and Maeve mentioned that she worries a lot about getting contaminated, but this only began after the COVID pandemic.

Despite enjoying her job and believing she's good at it, the main reason that Maeve is currently feeling down and says she came to the appointment is due to work-related issues and her wish to create a plan to manage "work stress". When discussing these issues, she becomes teary. Currently on a 12-month contract working in HR, she reports that her coworkers have been bullying her by excluding her from their social outings and lying to the manager, telling him that she is not following proper rules and procedures. She suggests she has been set up by them. She can think of no reason why all this might be happening, other than that the other people in the office all have families and discuss their children, but Maeve does not have a family of her own. Despite these difficulties, she's hesitant to leave the job due to past difficulties maintaining employment, which she attributes to factors such as work restructuring, long commutes, and "awful" bosses, and she also cant stand the disapproval of her parents when she is not working. Before her current work she had been in a volunteer position, but she ceased that due to issues with another volunteer. Currently, her work difficulties lead to her feeling sick, anxious and panicky on days when all her colleagues have to go into the office. There are only a couple of older female colleagues who she feels she can trust. At the office, when her co-workers are around she feels the need to be extra careful to avoid making mistakes that could lead to her being fired, in order to cover her back. These feelings have left her feeling stressed and down, with difficulty sleeping and it being a tremendous effort to get out of bed in the morning. On weekends, she worries about work on Monday and finds it hard to concentrate or enjoy herself.

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CLN602 Adult Psychopathology and Intervention Case Study Assessment Guide

Assessment: Assessment 2

Mode of Assessment: Written case report and report letter to referrer on a provided initial interview with a client

Rationale for Assessment:

This assignment gives you the opportunity to demonstrate your understanding of assessment (including diagnosis), formulation and treatment. It brings together key aspects covered in the unit and provides a practical real-world application. It gives you the opportunity to consolidate your understanding of these and demonstrate your skills with a more complex presentation.

Weighting: 60%

** Please note CMI policy re extension requests. In particular, your need to provide supporting documentation (such as a Doctors certificate). Your request needs to be made via the Application for Extension form on myCMI https://my.cairnmillar.edu.au/application-for-assignment-extension/ and must be done prior to the due date.

Task Length:3000 words in total with a 10% allowance

Approximate word limits:

Case Report 2500

Report letter to referrer 500 words (maximum 1 page)

Learning Outcomes Assessed:

This assignment aligns with learning outcomes 2-5 from unit description. It assesses your skills in the following areas:

Utilize their understanding of assessment measures through the selection and interpretation of assessment measures across a range of adult mental health disorders.

Apply diagnostic criteria (primarily the DSM-5) to a range of client presentations and construct a diagnostic hypothesis and client formulation from a biopsychosocial perspective with consideration to differential diagnostic possibilities and cultural Influences.

Identify major evidence-based treatment approaches utilised in a range of adult mental health disorders including their strengths and limitations.

Apply an understanding of mental health systems to referral processes, reporting requirements and legal obligations, including written communication to refers.

Description of Assessment:

You are provided with a detailed case study on which to write a case report that includesbackground, formulation, including diagnosis and rationale, intervention plan with reference to the appropriate literature, and a letter back to the referrer updating them on your assessment and intervention plan. Use the guide below and the marking rubric to provide a guide on what include in the sections of the report. Please note the word count for each section is an approximate only. Note that the audience for the report is your marker, excluding the referrer letter, so you should write it to include the information required below.

Synopsis of case study:

Maeve has been referred you by her GP under a mental health care plan. At this stage you have only seen her for an initial interview. The practice you work at also has a policy of writing a brief report letter back to the referrer (in this case Maeves GP) following a clients initial assessment, this also forms part of this assignment.

Assessment components

Initial information (approx 150-200 words)

In this section you are providing context relating to the referral (who referred and why), brief context of the organisation and the number of sessions and what has been covered to date (e.g., initial assessment).

Presenting Problem (approx. 200 words)

This section sets the scene, it describes the clients presenting problem in detail including triggers, onset, duration, intensity, course and impact. Also include in this section your clinical observations in the format of a Mental Status Examination and risk assessment (this information will be apparent throughout the case, but you should put it into an appropriate structure. Note that where no information is apparent you can assume there was nothing notable to report).

Background information (approx. 350 - 400 words)

This section provides more detail about your client, family, growing up, friends and relevant client history, such as past psychiatric history. Please do not include a genogram, all information needs to be provided in prose.

Assessments (approx. 500 words)

What psychometric tests were used, brief comment on explanation of these tests and their psychometric properties, and on why they were used. You also need to interpret the results from the information that is provided to you, and also include an item analysis of the clients response (such as particularly items of interest, such as where they scored high, or unexpectedly low).

Clinical case formulation (approx. 400 - 500 words)

Here you are tying all the information together, from your interview and the assessments. Use the 4P framework, and no dot points, everything should be in prose. In your formulation it should be clear what aspects are subjective and what are objective.

Diagnosis and differentials (approx. 300 words)

In this section state the diagnosis and differentials, and why the differentials were rejected (see example below). You need to detail all the criteria that was met and not met. A provisional diagnosis is acceptable, but you need to justify why this is the most likely and also list differential diagnoses you have rejected.

Example of an exclusion of a differential diagnosis can be found below in italics. Note that there is reference to the DSM-5 criteria as to why it was considered, and also as to why clients symptoms did not meet criteria.

300.82 Somatic Symptom Disorder was considered due to clients excessive thoughts, feelings, or behaviours related to somatic symptoms (B). This was rejected as her symptoms were not related to disproportionate health concerns (B: 1, 2, 3).

For the diagnosis itself, please indicate what symptoms met the criteria.

John's symptoms meet the criteria for acute stress disorder as he was in a life-threatening car accident (A1).

Treatment plan (approx. 400 words)

Describe the evidence-based treatment approach you plan to take with this client, with reference back to the literature. Provide a descriptive treatment plan, linked to the diagnosis and evidenced based approached. You are not providing a session-by-session plan, but an overall outline. Also address any practical issues, and further assessments, including monitoring of outcomes that you are considering.

Reflection (approx. 250 words)

Briefly reflect on factors that you feel influenced how you conceptualised the case study. In particular with reference to your formulation and treatment hypotheses. On reflection would you consider other factors or approaches? (NB This isnt thoughts about doing an assignment but about the case itself as if they were your client).

Report letter to referrer (approx. 400 words)

Your report letter back to the referrer, is a synopsis of your more detailed report. It needs to include background and presenting problem including assessment findings and diagnosis. Note the treatment goals, overview of treatment plan, including intervention approach and anticipated treatment duration.

Important:

Please refer to Unit Outline and Course Information Handbook for further information about Cairnmillar Institute assessment submission requirements and policies.

0-706755Adult Psychopathology and Intervention

Assessment Rubric Case Study

00Adult Psychopathology and Intervention

Assessment Rubric Case Study

Assessment: Case Study Student name:Date:

Criteria Standards

High Distinction Distinction Credit Pass Not Satisfactory

Initial Information Succinct overview regarding the referral, all key information noted, including the organisation that the client has been referred to, who referred and why, number of sessions and an overview of the sessions to date. Clearly written without

writing errors. Good overview covering the key information. Could have been clearer, or more succinct and minor writing errors may be present. Competent overview of the initial information.

Limitations noted in omitting or over detailing the key elements of this section. Minor writing errors may be present Adequate overview of initial information. A lack of clarity in the information provided was apparent, and the key elements were either omitted or over detailed.

Writing errors may also be present. Inadequate overview of the initial information to provide and initial summary.

Information was omitted or overdetailed at the cost of more important aspects.

Writing errors may also be present.

5 marks Presenting Problem

10 marks Excellent description of the clients presenting issues including triggers, onset, duration, intensity, course and impact. Mental Status Examination covered all components and competent risk assessment covered well.

Clearly written without writing errors. Good description of clients presenting issues. Some aspects however not covered to the needed level of detail. Minor writing errors may be present. Competent description of clients presenting issues. Some aspects however not covered to the needed level of detail. The narrative of how the components of the presenting problem may also be disjointed. Minor writing errors may be present. Adequate description of clients presenting issues. Difficult to get complete sense of client as there due to insufficient detail, or contradicting information.

Writing errors may also be present. Inadequate description of clients presenting issues. Important aspects of the clients presentation were either omitted, or not adequately/accurately described. Writing errors may also be present.

Background information

(10 marks) Excellent detail highlighting the clinically relevant information regarding client background. The information was presented in a logical and sequential manner, without writing errors.

Good detail including all or most clinically relevant background material. Some aspects may have been omitted, or not clearly presented. Information presented logically and sequentially. Some minor writing errors maybe present Competent section regarding the clinically relevant background information. Minor relevant detail may have been omitted or not clearly articulated or linked well to the overall background material. Minor writing errors may be present. Adequate section regarding the clinically relevant background information.

Key detail may have been omitted or not clearly articulated or linked well to the overall background material. Writing errors may also be present. Inadequate section regarding the clinically relevant background information. Key detail omitted and/or unclear and not linked well to the overall background material. Writing errors may also be present.

Assessments Excellent review of the assessment measures used that were well referenced back to the clients presentation. Accurate scoring and interpretation of scores. Excellent item analysis present, and a clear explanation also given to any particular items of interest. Clearly written without writing errors. Good review of the assessment measures with a competent link back to the clients presentation.

Minor issues may be present with scoring, interpretation or item analysis. Some minor writing errors maybe present Competent review of the assessment measures used but with little reference specifically to the client. Greater detail re item analysis and there may be issues with scoring and interpretation. Minor writing errors may be present. Adequate review of assessment measures used, but further detail as it related to the specific client was needed. Item analysis needed greater detail and there may be scoring and interpretation issues.

Writing errors may also be present. Poor review of assessment measures with no or minimal reference to the client in the case study.

Scoring and interpretation issues and present, and the item analysis was inadequate. Writing errors may also be present.

(15 marks) Clinical case formulation

(15 marks) Excellent biopsychosocial formulation with all details from case, including assessments clearly included within a 4P framework. This logically leads to a diagnostic hypothesis.

Subjective and objective aspects of formulation clearly identifiable. Clearly written without writing errors.

Very good biopsychosocial formulation with all or most details from case included within a 4P framework.

There may be some omissions, or a lack of clarity with aspects of the information, e.g., in integrating all information. A logical transition to the diagnostic hypothesis.

Subjective and objective aspects of formulation clearly identifiable. Some minor writing errors maybe present

Competent biopsychosocial formulation with key details from case included within a 4 P framework. A number of omissions are present and /or a lack of clarity with integrating the information and understanding subjective and objective aspects of formulation.

Minor writing errors may be present.

Adequate biopsychosocial formulation, some relevant information missing or wrongly interpreted within a 4 P framework, but not to the extent that it impedes the diagnostic hypotheses. Some lack of clarity and narrative in presenting the information so that is unclear as to what aspects are subjective or objective. Writing errors may also be present.

Poor biopsychosocial formulation, relevant information missing from 4 P framework, impeding the diagnostic hypotheses. An understanding of the sections of the formulation is not evident. A lack of clarity and narrative evident in the section, so that is unclear as to what aspects are subjective or objective. Writing errors may also be present.

Diagnostic hypotheses

(15 marks) Excellent consideration to diagnosis and differentials. Clearly linked to DSM-5, inclusion/exclusion criteria. Diagnostic hypotheses well argued as possibilities in the case. Clearly written without writing errors.

Very good consideration given to diagnosis and differential, with clear link back to case study.

Diagnostic hypotheses well argued as possibilities in the case. Minor issues with clearly articulating DSM-5 inclusion/exclusion criteria in a parsimonious manner may be present. Some minor writing errors maybe present

Competent consideration given to diagnosis and differential, with clear link back to case study.

Diagnostic hypotheses adequately argued as possibilities in the case. Issues with clearly articulating DSM-5 inclusion/exclusion criteria in a parsimonious manner may be present. Some minor writing errors maybe present.

Adequate consideration given to diagnosis and differential, some omissions may be evident and link back to case study not well demonstrated or articulated. Issues with clearly articulating DSM-5 inclusion/exclusion criteria may be present. Writing errors may also be present.

Poor consideration given to possible diagnosis and differentials. Those suggested are minimal, or poorly linked to case study and not well articulated.

Diagnostic hypotheses not presented where inclusion/exclusion criteria are clear. Diagnostic hypotheses presented may not be relevant to the case. Writing errors may also be present.

Treatment plan

(15 marks) Excellent description of the evidence-based literature and for this intervention approach. An excellent intervention plan outlined, demonstrating understanding of the intervention approach and its application to the client in the case study and addresses practical considerations. The plan is clearly articulated so as to convey treatment components during the initial, mid and later treatment phases. Further assessments and monitoring of outcomes appropriate. Clearly written without writing errors.

Very good description of the evidence-based literature and for this intervention approach. A good intervention plan outlined, demonstrating understanding of the intervention approach and its application to the client in the case study. Some aspects of this plan maybe unclear, or not clearly addressing practical issues adequately. Further assessments and monitoring of outcomes is well noted. Some minor writing errors may be present.

Competent description of the evidence-based literature and for this intervention approach.

Greater detail may have been needed here, intervention plan may not be clearly, demonstrating an understanding of the intervention approach and its application to the client in the case study. Practical issues may not be adequately addressed and greater consideration to assessments and monitoring of outcomes may have been needed.

Some minor writing errors may be present.

Adequate description of the evidence-based literature and for this intervention approach. Greater detail needed here. Intervention plan a little unclear with stronger links both to the literature and case study needed. Plan also lacks some clarity in demonstrating an understanding of the intervention approach and its application to the client in the case study.

Treatment components throughout treatment phases are unclear.

Practical issues may not be adequately addressed and greater consideration to assessments and monitoring of outcomes may have been needed.

Some minor writing errors may be present.

Inadequate review of the literature with little detail arguing its use in the case study. The intervention may not have been the best approach for the case study and /or is poorly described and referenced with little regard to practical considerations. No evidence of consideration to how treatment will be conducted across the treatment period. Little or no consideration given to assessments and monitoring of outcomes within a treatment framework. Writing errors may also be present.

Feedback letter to referrer

(10 marks) High standard letter to referrer submitted which was an excellent synopsis of case study. Referral letter includes all relevant client information, including assessment findings, interpretation and diagnosis. It provides an overview of the treatment plan. Letter is clear and concise. Clearly and professionally written without writing errors.

Good standard letter to referrer submitted which was a good synopsis of the case study. Some omissions, or unnecessary detail may be present.

Referral letter includes all or most of the relevant client information, including assessment findings interpretation and diagnosis. It provides an overview of the treatment plan. Letter is clear and concise. Some minor writing errors may be present.

Competent standard letter to referrer submitted with adequate synopsis of case study. Some omissions, or unnecessary detail may be present and further attention may have been needed in relation to the reporting of assessment findings interpretation or diagnosis. Letter provides an adequate overview of the treatment plan. Some minor writing errors may be present.

Adequate standard letter to referrer. Synopsis of case study lacked detail, or provided too much unnecessary detail. Issues may be present with how assessments (including interpretation) and diagnostic hypotheses was presented. Report letter was not of a high professional standard.

Some writing errors may be present.

Inadequate standard letter to referrer. Synopsis of case study was not clear and lacked important information. Reporting assessment findings were not included or may have not been interpreted.

Diagnostic hypothesis not well articulated and writing not of a professional standard. Writing errors may also be present.

Reflection on your formulation & diagnostic hypotheses

(5 marks) Excellent self-reflection and showed a depth of awareness regarding factors influencing formulation and diagnostic hypotheses.

Very good self-reflection and good awareness of factors that influenced formulation and diagnostic hypotheses. Good depth of reflection

Good self-reflection and solid awareness of factors that can influence formulation and diagnostic hypotheses. Some greater depth needed.

Adequate self-reflection, that was superficial overall with minimal awareness of factors that influence formulation and diagnostic hypotheses

Inadequate self-reflection that was superficial and did not include adequate depth regarding factors influencing formulation and diagnostic hypotheses.

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Writing style and referencing

(5 marks) An excellent writing style, clear, logical and succinct. Clear linking transitions between and paragraphs, and writing is clear and easy to follow. References used are from appropriate academic sources and report follows APA 7th edition formatting at all times.

A very good writing style, mostly clear, logical and succinct with only one or two awkward or confusing sentences. Well-structured with some linking paragraphs. Writing is clear and easy to follow.

References used are from appropriate academic sources and report follows APA 7th edition formatting with only very

referencing errors.

A competent writing style, mostly clear, logical and succinct, but improvements could be made with a few awkward or confusing sentences. Minimal linking transitions between paragraphs. Writing is at times unclear and difficult to follow. References are used appropriately and mostly from academic sources. APA formatting followed most of the time, with minimal referencing errors

An adequate writing style. Writing was not clear, logical and succinct in many instances, with many awkward or confusing sentences. Minimal linking transitions between paragraphs. References not always appropriate and several APA errors.

References include a number of inappropriate sources. There are numerous errors of APA formatting.

An underdeveloped writing style, rarely clear, logical or succinct, with many awkward or confusing sentences. There are no linking transitions between paragraphs and letter to referrer is verbose and unclear. There are sections of text without adequate paraphrasing or citations. References include a many inappropriate sources.

There are numerous errors of APA formatting and referencing errors

COMMENTS

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COMMENTS

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