Case Study Phil

COUC 546

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Case Study Assignment Instructions


Case Study Assignment is designed to help you apply the course content to a counseling situation. In this
Case Study Assignment you will have the opportunity to think through a clinical case, identify and prioritize key issues involved, consider and clarify relevant diagnostic issues, provide one assessment to clarify the case, and formulate treatment recommendations that are most likely to be helpful to the client. This
Case Study Assignment will directly apply to your work in COUC 667 and with clients when you begin practicum.


For this assignment you will read the case study then generate a report that uses the following outline. Each section should be separated by the appropriate APA headings (Level 1, Level 2…)

Client Concerns




(Examples) Sadness

Trouble sleeping

Parents’ divorce


No appetite


Client Concerns: Using a table as in the example above, identify and list the client’s symptoms and any other key issues/concerns noted. (Modify the chart size as needed.) For example, these may include biological, psychological, social, and/or spiritual problems. If symptoms/behaviors overlap, you only need to list them once.


Provide one assessment that will be used to clarify the diagnosis — a valid assessment that a counselor can use. Give a short (3-5 sentences) overview of the assessment, what it would help you learn about the client, and why you chose it over other assessments (for example: Beck Depression Inventory: identifies clinical depression, strong research base, short, easy to administer and score).
Provide one peer-reviewed journal article reference to support the use of this assessment.

Diagnostic Impression

Provide the primary diagnostic impression based upon the DSM-5-TR. Include the ICD-10 code and full name of each diagnosis. Be sure to consider secondary disorders in addition to the primary disorder. Is there more than one diagnosis? Provide the following for all diagnoses.

Signs and Symptoms

List the signs (client’s report) and link them directly to the symptoms (criteria you find in the DSM-5-TR) in table form (example below) to make sure you have linked every client sign to every DSM-5-TR symptom you will use to support the diagnosis.
Be sure to adjust the size of the table accordingly. If there are client reported signs that do not fall into the DSM-5-TR diagnosis, make note that you considered them, but they did not align with the DSM-5-TR.

DSM-5-TR Diagnostic Criteria:
disorder name and code number

Client’s Signs/Reported Symptoms:

Criterion A:

Criterion B:

Criterion C:

Criterion D:

Criterion E:

Criterion F:

Other DSM-5-TR Conditions Considered

List other DSM-5-TR conditions you considered and the process you went through to decide they were not the correct diagnosis. For example: “The client reported three symptoms of Major Depressive Disorder, but five symptoms are needed for this diagnosis, so the disorder was ruled out.”

Developmental Theories and/or Systemic Factors

Discuss theories of normal and abnormal development and/or systemic and environmental factors that affect human development, functioning, and behavior. For example, consider questions such as “What Erikson stage is the client in?” or “What is occurring within the client’s family system that may be influencing the client’s current functioning or behavior?”

Multicultural and/or Social Justice Considerations

Discuss multicultural or social justice considerations that went into your diagnostic thought process. For example, what would the client say about their symptoms/situation from their cultural point of view? Is/Could the client be experiencing concerns related to discrimination, marginalization, oppression, etc.?

Treatment Recommendations

Key Issues for Treatment

· In bullet point form, identify the top 2-3 symptoms/issues you believe are involved in the case study, in order of importance.

· The goal here is to clearly delineate what you believe will be of the most help to your client.

Recommendations for Individual Counseling

Identify two treatment recommendations for individual counseling based on the 2-3 key issues you identified.
You will need to cite these recommendations using peer-reviewed journal articles, focusing on the treatments a counselor would provide.
Medication or referral to another type of therapy may be a recommendation, but since these are case management, they do not count towards the two required recommendations and should not be the primary recommendations listed. Consider recommendations that will be motivating to your client and reflect a collaborative approach. Be mindful of multicultural, ethical, and social justice considerations. Approach this part of the assignment as your exploration of what you would do with this type of client in individual counseling.

Specific Considerations

For each case study you will have one specific consideration. You will need to provide one paragraph responding to the questions that correspond with each case study. In your response to these questions, address how these considerations affected your diagnostic impression and your treatment recommendations.

Anna – Case Study 1:
How important of a role does cultural background play in this case? What additional information would you need about her culture? What kinds of values conflicts might you experience due to the client’s culture? How would you manage your personal values while working with this client?

Sam – Case Study 2:
How does a client being in crisis change the focus of your assessment and treatment planning? How might a client being in crisis affect a diagnosis?

Jeff – Case Study 3:
How do multiple diagnoses affect the decision-making process for diagnostic impressions and treatment planning? How do you decide what disorder you might address first, or do you address both simultaneously? How does a substance use disorder affect the process of diagnostic impressions and the order you make treatment recommendations?

Jane – Case Study 4:
How does a triggering event affect how you prioritize treatment interventions? How important is it to collaborate with the client when treatment planning? What are some barriers you might encounter treatment planning with this client and how might you address those barriers?

Phil – Case Study 5:
How might the client’s age affect diagnosis and treatment recommendations? What kind of consideration must be made for the family system?

Case Study Assignment is to be 3 – 5 pages in length. This excludes the title page and reference page. Use current APA format. The
Case Study Assignment does not require an abstract. The
Case Study Assignment requires a minimum of 3 resources from peer-reviewed journals. This can include the maximum of one textbook reference. All resources need to be less than 10 years old.

Be sure to review the
Case Study Grading Rubric before beginning this
Case Study Assignment.

Note: Your assignment will be checked for originality via the Turnitin plagiarism tool.

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COUC 546


Phil is a 15-year-old Hispanic male who lives with his mother and three sisters. Phil is a sophomore at the local public high school. He been struggling with feelings of sadness and angry outbursts over the last four months. His mother has brought him in for an assessment and treatment recommendations at the urging of his school and per his mother “to help bring some peace in the family. It has been a very rough year and we all need some peace.” Phil stated that he swings from being sad to being angry and he does not like getting into trouble at school or with his mother.

Phil is the second of four siblings. He has an older sister and two younger sisters who live in the home with Phil and his mother. Two and a half years ago Phil’s parents separated and a year ago the divorce was finalized. Phil reported that he was sad when his parents separated but since the divorce has been finalized and his father remarried four months ago, he has been “sad but mainly angry.” Phil stated “before my dad got remarried, I had hope that they would get back together… even after the divorce I hoped. But now he is remarried… there is no way they are getting back together. All my hope for my family to be normal again is gone.”

Phil’s mother reported that prior to the separation, Phil had a good relationship with both parents and was close to all the members of the family. When the separation occurred, Phil cried a lot and according to his mother “he would beg his father and I to get back together. He always told me he missed his dad and wanted us to be a family again.” After the divorce was finalized Phil continued to ask his parents to reconcile, even after his father introduced him to his fiancé. Phil voiced several times to his mother and other family members that he believed his parents would sill reconcile. Shortly after his father’s wedding, which Phil refused to attend, he began stating that he knew it was hopeless now.

Since the remarriage, Phil has been argumentative with his mother 3-5 times per week, daily with his sisters, and has refused to speak to his father. Phil and his mother both reported that Phil does not generally engage in verbal fights, and he has never engaged in a physical fight. Phil’s mother stated “I have had to find new consequences for this new Phil. It has been a very difficult change to manage… I never had to ground him or provide severe consequences. In the past I would only have to have a stern voice and let him know my expectation. It is like he is a different person… and I am not sure how to get my sweet son back.” In addition to feelings of anger and increased engagement in verbal arguments, Phil reported “I still feel sad about my family, and some nights I cry, and some days I get angry, and every night I have a hard time getting to sleep. I’m not interested in hanging out with my friends right now or playing sports. So, I wish my mom would stop pushing me to leave the house. Nothing seems fun and no one understands how much this all stinks!”

Around the time of his father’s remarriage, Phil’s mother began getting calls from Phil’s teachers and principal about his verbally aggressive behavior at school. Until this time Phil has never had any behavioral problems. His mother stated, “I was so shocked; I could not believe that Phil was getting into verbal arguments with everyone… friends, teachers, the principal. He had always been so good at school, done well in his work, and got along with everyone.” Phil’s mother reported he has been reprimanded at school weekly for the last four months for fighting and speaking disrespectfully to teachers. He was given three days of in-school suspension two weeks ago, which prompted his mother to set the counseling appointment. Phil has also been struggling academically. His mother reported “Phil has always been a solid B student. His grades are now a few C’s but mainly D’s.” Phil stated, “I have had a really hard time concentrating in school since the divorce.”

Phil reported that he has a large friend group at school and in his neighborhood. He normally plays every school sport he can but liked basketball the most. Phil stated that one of the things he was looking forward to the most was turning 16 so he could drive himself to sports practice and drive his friends around. Phil is eligible to start driver’s education but has not signed up for the course. He stated, “I just don’t care right now.” Phil and his mother agreed that his social life has been negatively affected by his change in mood, even though his closest friends continue to pursue engaging with him, and his many cousins who live in the area, who he is close to, drop by the house 3-4 times per week to attempt to engage with him. Phil stated “My family is trying to help me… but we are the first broken home in the family… they will never understand what is it like to be different and to know things will never go back to the way they were.” Phil’s mother is worried that if Phil’s refusal to engage continues, he will not have any friends.

Phil reported that he has never been diagnosed with an illness and only takes vitamins. He broke his leg doing a skateboard stunt when he was 6 years old and broke his wrist two years ago playing basketball. Phil’s mother reported that she took Phil to the doctor last week for a check up to make sure there was not something physically wrong with him. She stated, “The doctor seemed to think he was a normal adolescent boy who was having a hard time with life being different. On one hand I agree, but his reaction just seems to be so much bigger than what his sisters’ and other kids’ reactions are.” Phil has no history of any past mental health issues. Phil’s mother reported “Phil has always been sensitive, and things seem to affect him more, good and bad. He has always been good about expressing his emotions instead of bottling them up… which might be why things are so hard right now.” Phil’s mother reported that Phil’s father has always been a bit unsure of how to manage Phil and his ability to express emotions. She stated “My ex-husband and I had very different ideas about how to raise children and what a family should look like. I encouraged Phil to be himself while my ex wanted Phil to be more macho and hide his feelings. Our differences in how to raise the kids and what it meant to be marriage partners were a big part of why I chose to divorce him.” Phil’s mother stated that she and her ex-husband have maintained an amiable relationship so far. Phil’s sisters have continued to visit their father weekly while Phil has refused contact with him since the wedding.

Phil and his family are involved in a local church and Phil’s mother reported that her faith is very important to her. She stated that the church has been a strong support for her through the divorce and as these issues with Phil have arisen. Phil reported that he used to enjoy going to church and he has a lot of friends there. He stated all the adults there were always kind to him. He stated he is not sure how important his faith is to him, even though he knows it should be. “I feel a bit guilty because my mom thinks faith is the center of life… but I am just not sure right now.”

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