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COUC 546
CASE STUDY ASSIGNMENT INSTRUCTIONS
OVERVIEW
This 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.
INSTRUCTIONS
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
Symptoms
Behaviors
Stressors
(Examples) Sadness
Trouble sleeping
Parents’ divorce
Fatigue
No appetite
Hopelessness
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.
Assessment
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 ICD10 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
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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
Criterion A:
Client’s Signs/Reported Symptoms:
Criterion B:
Criterion C:
Criterion D:
Criterion E:
Criterion F:
Other DSM-5-TR Conditions Considered
List symptoms of other disorders and other DSM-5-TR diagnoses 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 (insomnia, depressed mood, and trouble
concentrating), 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?”
Provide one peer-reviewed journal article reference to support your discussion.
Multicultural and/or Social Justice Considerations
Using the RESPECTFUL model acronym (below), choose at least one of the client’s
identities and discuss multicultural or social justice considerations that went into your diagnostic
thought process. The case study may or may not explicitly discuss each of these; based on what
is known about the client, explore how this identity may influence their lived experience. 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.? Provide one peer-reviewed journal article reference to support your discussion.
Religious/spiritual
Economic class background
Sexual (and/or gender) identity
Psychological maturity
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Ethnic/racial identity
Chronological/developmental challenges
Trauma/threats to well-being
Family background/history
Unique physical characteristics
Location/language differences
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
Individual counseling recommendations: Identify two treatment recommendations for
individual counseling based on the 2-3 key issues you identified. You will need to cite these
recommendations using one peer-reviewed journal article for each recommendation (at least two
references for this section), focusing on the treatments a counselor would provide. Examples of
these include but are not limited to dialectical behavior therapy, cognitive behavioral therapy,
eye movement desensitization and reprocessing, etc. Referral to another type of therapy (e.g.,
group counseling, family therapy, inpatient) 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.
Medication considerations: Discuss whether you would refer the client for a medication
evaluation and discuss why or why not. If you would refer, provide a brief discussion of the
research regarding the use of medication for this diagnosis. For example: which symptoms would
be the most likely to benefit from the use of medication? What broad classification of
medications might be prescribed (e.g., anti-anxiety, anti-psychotic, mood stabilizers, etc.)? Be
sure to provide at least one scholarly reference to support your discussion.
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. Provide one peer-reviewed journal article
reference to support your discussion.
Amara – 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
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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?
Theo – Case Study 4: How might you use a trauma-informed treatment approach with this
client? 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?
Victor – 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?
Each Case Study Assignment is to be 6-8 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 7 resources from peer-reviewed
journals. This includes the use of the DSM-5-TR textbook as a 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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SAM CASE STUDY
Sam is a 25-year-old single Caucasian female. She is currently in a master’s in social work
program at a local university. She came in for an assessment after her roommate insisted she gets
help immediately. “My roommate told me that she could not tolerate my mood swings anymore.
This last one has been really bad, and I have been thinking about killing myself.” Sam stated that
she’s always had a good relationship with her roommate and does not want this recent shift in her
moods to be the reason they stop living together. Her mood swings have negatively impacted her
schoolwork and she is currently at risk of being removed from her program due to low grades.
Sam reported that about two years ago she had a “high” episode. She didn’t think much of it as it
started suddenly and ended almost as suddenly. She reported that during that episode she only
needed to sleep for about 5 hours at night and felt pretty good. She was able to get lots of
housework done, completed all her schoolwork, started writing a novel and screenplay and had
time to socialize. She reported these 10 days were one of the best times of her life and then it
suddenly ended. About four weeks after this “high” period, Sam began feeling depressed. She
reported that this episode lasted about 4 months and she experienced feelings of sadness, a lack
of enjoyment in any of her normal activities, fatigue that led to her sleeping 10 hours per day and
still feeling lethargic, no appetite, and difficulty concentrating. These symptoms occurred daily
for the entire four months and seemed to slowly fade. Six months after these symptoms ended
Sam noticed she had started to feel the same overwhelming sadness again. She reported the
sadness lasted for about 2 weeks and then the other symptoms began. She stated this time she
also struggled with feeling worthless and had a few weeks where she thought she might be better
off dead. “I didn’t make any plans to hurt or kill myself, but for those few weeks I thought a lot
about what it would be like to just go to sleep and never wake up.” This episode lasted for 3
months and she stated, “And then I started feeling like myself again.”
Sam reported she felt normal for about two months and then she had what she described as “a
manic episode.” The episode lasted 12 days and ended with Sam’s roommate taking her to the
emergency room due to Sam hallucinating. Sam stated that during the 12 days, she slept 1 to 2
hours per night, she had lots of energy, and started writing her novel and screenplay again, which
had been abandoned after the last “high” episode. She reported that she got so focused on writing
her novel that she would spend 10 hours a day attempting to complete the novel so she could
move to the screenplay. “I really thought I was going to write the world’s greatest book and then
turn it into the world’s greatest movie. I saw myself as the most significant author to have ever
lived during those 12 days.” Sam stated that her roommate reported that during that 12 days, she
was impossible to live with, talking nonstop about what a phenomenal author she was and how
she would not forget her roommate when she was famous. Sam’s roommate took her to the
emergency room on the 12th day when Sam began to hear voices telling her that she was a
terrible writer which resulted in her becoming hysterical and crying uncontrollably. Sam was not
admitted to the hospital at that time due to being much calmer when she arrived at the ER and
not expressing any type of active hallucinations or suicidal ideations. Sam reported, “Those
voices were crazy! I was pretty sure it was because I hadn’t slept in almost two weeks, and after
my roommate did some research she agreed. When I was at the ER the doctor gave me some
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pills to help me calm down if I got really anxious again. I took those pills for about a week, got
some sleep and the episode stopped.” Sam was not able to recall what medication she was given.
Sam was also scheduled an appointment with a psychiatrist to follow up on the episode. Sam did
not attend the scheduled appointment.
Sam reported she believed everything had gone back to normal for about two months and then
she began to feel the sadness kick in again. She reported a mild feeling of sadness for about 30
days and then the additional symptoms began to appear. Sam reported that for the last four
months she has felt sad daily, she has little to no pleasure in her daily activities, she sleeps 12-13
hours a day, she is fatigued daily, she has no appetite, feels worthless, and struggles with
concentration. “About one month ago I started feeling really hopeless and began thinking that all
my friends and family would be better off if I were dead. Four days ago, I began thinking about
making a plan. I haven’t set a date, and I have not decided on what I would do… yet.” Sam
reported that she researched the most pain-free methods of suicide and “right now they all sound
really horrible… so I spend the days wishing I were dead. I told my roommate this and she
insisted that I come in for an evaluation. She explained how terrible it would be for her if she
came home and I was in the apartment dead. Her crying at the thought of finding me dead
convinced me to come see you.” Sam reported that she has no plan to kill herself right now, but
she just does not see how she can continue like this long term.
Sam is finishing her second year of a three-year master’s in social work program. She attends a
local university and is scheduled to start her internship next semester. Sam stated that she’s pretty
sure she won’t be able to start her internship as she has not been attending class and has turned in
very few assignments over the past semester. She stated that her grades from the semester before
were not great and she was placed on academic probation. She anticipates being removed from
the program at the end of this semester. Sam became tearful when she talked about not
continuing the program. She stated one of her goals was to help people and social work seemed
like a good fit for her. Sam reported that she has many friends in the social work program
including her roommate. Her friends have been talking to her about her mood swings and how
they seem to be affecting her school performance. Sam stated that she believes she would be
removed from the program if she approached any of the faculty and told them about her
difficulties. “I’ve had several faculty members address me one-on-one and try to get me to tell
them what’s is going on. How I have such a high undergraduate GPA and how at times I seem to
be such a good student. I’ve just never felt safe to confide in them because mentally ill people
can’t be social workers.” Sam reported she completed a bachelor’s in social work with a 3.9
GPA. She has always enjoyed school until the last 18 months. Sam has no history of being
interested in English or being an author.
Sam took a year between her bachelor’s and master’s to get practical experience working with
people. She worked as a case manager at a local mental health clinic. Her clients were
individuals with intellectual disabilities, and she enjoyed her work. She continued to work part
time at the clinic as an assistant case manager while she attended school full time. She received
good evaluations until this last depressive episode. “I was able to fake my way through the first
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two episodes, but this last one has been much worse, and I have not been able to hide my
sadness.”
Sam reported that she is the oldest of three children. She has one brother and one sister. She
stated that her parents divorced when she was 14 years old and have managed to have an
amicable relationship with one another. Sam stated that her mother remarried six years ago, and
she has a close relationship with her mother and stepfather. Sam’s father remarried seven years
ago, and she has a “decent” relationship with this side of her family. Sam did call her mom two
days ago and tell her about the difficulties she is having. She stated she hasn’t been fully honest
with anyone in her family about how she’s doing because she didn’t want to worry them. When
she went to the hospital for the manic episode, she did notify both of her parents but told them
she was having sleep issues that led to the hallucinations. Sam has not lived with either of her
parents since she was 23 years old. They live in a neighboring state and she visits them on school
breaks and for a week during the summer. Sam calls her mother and sister at least one time per
week and talks to her father and brother at least once per month. Sam reported that her mother
struggled long-term with depression. “Both of my parents would tell you that my mom’s
depression was a primary reason for their divorce. My stepfather seems more tolerant of her
ongoing sadness, but my father could not manage her moods. My father used to say all the time
that he did not marry a woman who was depressed and could not picture spending his life with
someone who was so sad all the time.” Sam stated that her sister also has some struggles with
depression. Sam doesn’t think that her sister’s depression is paired with the manic episodes, but
she appears to be mildly depressed most of the time. Neither Sam’s mother nor sister take
medication to address their depression.
Sam stated that she has several close friends and many “acquaintances.” She reported that her
roommate is her closest friend and she has two other female friends who she can be open and
honest with. Sam reported that her depressive episodes have started to have a strain on her
friendships. Her friends have started commenting that she seems down all the time and has
isolated herself from the primary friend group. “My roommate was so upset with me when she
found out I was thinking about killing myself that she threatened to move out of our apartment.
That really scared me. That and seeing her cry. Her friendship is so important to me and I don’t
want this depression to ruin it.” As Sam talked about how the depression was affecting her
relationships in a negative way she became tearful. Sam reported that she is not in a romantic
relationship at this time. She has dated off and on throughout her teen years. Her one serious
romantic relationship started a year before she graduated from college and ended a year into her
master’s program. She has dated other men off and on since her relationship ended. She reported
she would like to get married and have children but is not interested in “settling down” until she’s
in her 30s. “My parents got married when they were way too young. And I don’t want to make
the same mistakes they did.”
Sam reported that she has no history of any medical problems and has never been on medication.
She reported that she drinks alcohol on a regular basis. She will have two to three alcoholic
beverages a week, primarily on weekends. Sam reported that drinking is something she considers
to be a social activity so when she is not socializing due to depression she will not drink. She
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stated that she and her roommate have had the same half-empty bottle of wine in their apartment
for over six months. Sam has never taken any kind of illegal drugs or prescription medication
that was not prescribed for her. Sam reported that she grew up Catholic and attended mass every
week until she started graduate school. She stated that even though she doesn’t attend mass
anymore, her faith in God is very important to her and she would like to integrate it into the
therapy process.
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RESPECTFUL Model
R: Religious & Spiritual identity
E: Economic class background
S: Sexual [gender] identity
P: Psychological maturity
E: Ethnic/racial identity
C: Chronological/developmental challenges
T: Trauma and threats to well-being
F: Family background and history
U: Unique physical characteristics
L: Location of residence and language differences
Referring to a person’s belief in a reality that
transcends physical nature and provides
individuals with an “extraordinary” meaning of
life in general and human existence in particular
Referring to considerations of how economic
factors impact psychological health and personal
well-being; being mindful that traditional
counseling theories were developed by middleclass individuals
Referring to an individual’s gender identity,
gender roles, and sexual orientation (sexual
identity); an individual’s subjective sense of their
gender (gender identity)
Referring to an individual’s process of moving
from simple to more complex ways of thinking
about themselves and their life experiences
Referring to an individual’s identities in terms of
race/ethnicity/culture and being mindful of
“within-group” differences
Referring to development throughout the lifespan
in terms of physical growth (e.g., bodily changes
and sequencing of motor skills); emergence of
different cognitive competencies (e.g.,
development of perceptual, language, learning,
memory, and thinking skills); and manifestation
of a variety of psychological skills (e.g. managing
emotions and demonstrating more effective
interpersonal competencies)
Referring to the complex ways in which stressful
situations put people at risk of psychological
danger and harm; such harm typically occurs
when the stressors exceed the ability to cope with
them in constructive and effective ways
Referring to the traditional “nuclear” family along
with diverse family units and the unique strengths
that clients derive from these family systems
Referring to being sensitive to the ways in which
an individual’s physical nature may not fit
society’s idealized image, along with being
sensitive to and knowledgeable about issues
related to an individual’s differing abilities
Referring to geographical region/setting and
language/dialect
D’Andrea, M., & Daniels, J. (2001). RESPECTFUL counseling: An integrative model for counselors. In D.
Pope-Davis & H. Coleman (Eds.), The interface of class, culture and gender in counseling (pp. 417-466).
Sage.
Hays, P.A. (2002). Addressing cultural complexities in practice: A framework for clinicians and counselors.
APA.
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