Case Conceptualization and Diagnosis

a. Choose a specific diagnosis relevant to the age and setting with which you wish to work
b. Locate a fictional case that exemplifies that diagnosis. The case should be similar to the cases you have been doing in class and as homework.
c. Using the modified model below, construct a detailed case conceptualization (using the case you find) focusing on the factors that contribute to the diagnosis you selected. If there is no information in the case for one of the criteria in the model, say “no information available.”
d. When you get to the Diagnosis Section, construct a diagnostic justification just as you have been doing in class and for class Assignments in this class.
Case Conceptualization Model

1. Detailed Demographic Information- Sex, gender identification, age, race, sexual orientation, living circumstances, school or employment status, specific safety issues, if relevant
2. Referral Information-Date & source of referral. Self-referred or by parent, teacher, court, other? May include motivation for counseling.
3. Previous Counseling and Other Services Received- Did the client ever go to counseling before? Was it voluntary or mandatory? What were they satisfied with that you can build upon? What didn’t work? Did they stick with it, or drop out? Why? Note, also, psyc hospitalizations, psyc medications (past or present), psychiatrist, other doc prescribing psych meds, use of community groups (e.g., AA), chaplains, ministers, faith healers
4. Cultural factors and considerations – What are cultural (racial, ethnic, gender, LGBTQ+, religion/spirituality, age, ability, etc.) factors that might be contributing to, exacerbating, or mitigating the presenting problem? How might culture impact help-seeking or intervention considerations?”
5. Stressors- Current environmental, developmental, and family stressors. Includes daily hassles, losses, interpersonal conflicts, peer pressures, complicating medical conditions, involvement with the legal/judicial system, trauma. Could also include living in high crime area, poverty, homelessness, presence of racism, discrimination, lack of services. Any big changes recently experienced (e.g., recent change of job, residence, becoming sober/drug free, pregnancy, or new baby). Also, history of victimization or neglect. Could also include, family history of substance abuse, family medical issues.
6. Strengths and Resilience Factors- What individual strengths does the client have (like healthy coping skills)? What social supports do they have? What larger systemic supports do they have? What things are working in their favor?
7. Risk Assessment/Client Problem List- Evidence of risk factors? Include personal factors (e.g., substance use, lack of or poor coping skills, lack of insight into problem, ID), systemic factors (e.g., no support, chaotic environment, homelessness, access to weapon), harm to self? Harm to others?
8. Barriers (Social, Historical, and Cultural in Context)- What factors may make it difficult for the client to achieve the established goals for counseling? Anything that might get in the way? What individual, social or systemic factors might get in the way of success?
9. Client’s Presenting Problems (Counselor’s View/Client’s View) – Well-defined presenting problem. Describe how the problem impacts client’s ability to function. Fulfill social roles as a student? Employee? Parent? Affecting quality of life? How does the client describe the problem? Frequency, intensity, duration? Times when it is not an issue? How does the counselor describe the problem? Can be several, separate problems.
10. Diagnosis/Differential Diagnosis-
    . What DSM-5TR diagnosis would be most appropriate? Give the diagnostic justification based on the DSM criteria here
    . What other diagnoses (differential diagnoses) are you considering?
    11.Comorbidity-Evidence of other developmental, medical issues, or a long-term history of a psychological disorder for which they are not currently seeking counseling that may by affecting the presenting problem(s) (including addictive disorders & trauma)
11. Client Goals-Based on the presenting problem(s), client and counselor collaboratively establish clear, well-defined, measureable goals for counseling. What are those goals?

Sample Solution