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3000 WORD CASE FORMULATION AND TREATMENT PLAN
Select ONE case from a choice of case studies and identify the presenting issues and demonstrate an understanding of the key factors relevant to the specific case study, placing the issue in context. Specify relevant factors from the case study, drawing on a balanced range of sources of information, and manifest a comprehensive coverage of psychological, biological, and social factors surrounding the problem in question and evidence of reading beyond the lecture notes. A depth of understanding should be evident in terms of theoretical explanations and relevant psychological, social, and biological factors drawn from various lectures. You should show an understanding of the perpetuating, precipitating and predisposing factors relevant to any planned treatment or counselling, as well as factors that could act as barriers.
You are expected to connect the case formulation to treatment and counselling options that are evidence-supported. It is necessary to read the guidelines for writing reports and to read the marking criteria prior to the writing of a case formulation.
Guidelines for writing your case formulation and treatment plan
The coursework will be supported by lectures and small group teaching sessions to allow you to develop both breadth and depth of learning. You are expected to carry out this piece of coursework using material from as many of the relevant lecture topics covered as you see appropriate for your particular case study. During the workshops, you will have
the opportunity to discuss your case study and work as a group in coming up with a solution to your problem. However, you must submit an individual case study report that you have written independently. Each case study has been created to reflect a different area or topic that is covered in the module. Case studies have been designed to present realistic problems that exist within varied counselling and clinical populations.
Case formulations are a part of clinical, medical and counselling psychology professions. These provide systematic summaries of the most relevant and specific case details as well as information/hypotheses, relating to evidence-based causes and precipitants that are thought to provide a rationale for selecting optimal evidence-based therapy or counselling options. Case formulations should relate to diagnostic classification and biopsychosocial treatment needs of the service user.
Please make reference to the DSM-5 and not the ICD
In your formulation, write about the following (generally in this order):
Provide background to the problem by identifying the key factors that you believe to be relevant to the case. This section should be a short paragraph placing the issue in context. Identify relevant, or potentially relevant, individual difference variables, especially those that could connect to the goals and needs of the service user. For example, are
there specific cognitions and behaviours that could be maladaptive and so could benefit from change?
Provide a diagnosis including co-occurring psychopathology (or dual diagnosis); differential diagnosis and which assessment tools could be used to confirm the diagnosis. Reliance on either quantitative and/or qualitative assessments should be considered.
Provide a biopsychosocial explanation of the service user’s presenting problem, exploring, where relevant, problem predisposition, precipitants,
and perpetuation. Psychosocial assessment could consider attitudes
beliefs; behaviours (e.g., coping strategies, roles); cognitions, emotional responses, responses to the service user and/or the problem from family or friends (and their attitudes or behaviours); and finally, work issues.
It is also expected that you integrate psychological material from the lectures and independent reading with the formulation of the problem. Particular reference needs to be made to theoretical explanations, especially evidence-based causal explanations, and relevant psychological factors.
The case formulation should identify any specific treatment implications of what has been described hitherto; in particular, evidence-based treatment options. Attend to evidence-based theoretical explanations that connect to counselling, pharmaceutical options and/or social support.
This is NOT an essay it is a case presentation. Make sure ‘you’ subhead your assignment and theoretically support your case presentation throughout. Remember to refer back to the case study in the main text so that the theory is placed into context.
Case Presentation Checklist:
CASE FORMULATION AND TREATMENT PLAN
CHOOSE ONE CASE PRESENTATION ONLY
Case Presentation A- The case of Marsha
Marsha is a 18-year-old girl who has recently split up with her boyfriend. The relationship, like previous relationships, was tempestuous. Indeed, Marsha reports having a pervasive pattern of instability in her interpersonal relationships, self-image along with marked impulsivity. Marsha accused her boyfriend of looking at other women which ended in an argument. Whilst violence was not reported this must not however be ruled out.
The day she split up from her boyfriend, she arrived home and immediately went upstairs to the bathroom. Marsha proceeded to cut her wrists and arms several times with a razor blade. Marsha has previously engaged in self-harming behaviours including excessive alcohol use and promiscuity when faced with a perceived stressor. When previously admitted to an acute psychiatric unit, Marsha described having feelings of emptiness and can become extremely angry towards her family and friends. Her mother told the consultant on the unit, ‘that one minute you can be her best friend, the next she wants you dead’. Interestingly, it became evident during the assessment that jealousy and anger were often indicated in Marsha’s emotional outbursts. Marsha stated that she didn’t want to die, she just wanted ‘release’. An alcohol assessment revealed that Marsha had been consuming alcohol above the recommended units over a 12 month period. She reports that her drinking has recently ‘got out of control’ where she has experienced numerous memory lapses as a consequence of her drinking. Marsha suggested that the alcohol has increased her levels of self -harming and impulsive behaviours where she can drink anything up to 2 bottles of wine daily.
Marsha found out that her father had been having an affair from the arguments her parents had been having. She described feeling intense fear and anger at the possibility of her parents separating. She describes her relationship with her parents as turbulent. Marsha started engaging in self harming behaviours since 12 and began by burning herself with a cigarette lighter explaining that it was calming’ and ‘released anger’. One day she saw her father`s razor blades and started cutting herself on her arms. “It helps me feel relief,” she said. “My mind empties and my sadness goes, I just feel better.” She said the razor slicing into her skin did not hurt, but gave her a ‘rush’ and that it feels ‘otherworldly’.
She wishes to cease her self- injurious behaviour and wants to feel ‘less sad and empty’. Marsha stated that there is a 10 year age gap between her and her older brother who lives with his girlfriend. She feels quite lonely and isolated at times and fears social gatherings and making new friends. Marsha confirmed that she is terrified of people leaving her and that she has difficulties sustaining friendships because of her anger and ‘changeable’ moods. A further history revealed that her father had been sexually abusing her since age 6 years. Marsha became aggressive when recounting the sexual incidents to the psychiatrist and has subsequently blamed her mother for not intervening.