Create a section in your Crisis Response Portfolio called Sexual Assault and Violence.? Review the Case Conceptualization you created for this weeks Assignment. Review local and na
Create a section in your Crisis Response Portfolio called “Sexual Assault and Violence.”
- Review the Case Conceptualization you created for this week’s Assignment.
- Review local and national community resources for sexual assault and interpersonal violence to support and consider for a safety plan.
- Use the Walden Library to find 3 evidence-based practices for working with trauma
Assignment: Part 4:
In your section called “Sexual Assault and Interpersonal Violence” of your Crisis Response Portfolio, include:
- A safety plan example using the client in the case conceptualization from this module’s assignment.
- Please remember that Maria in this case is a parent and you will want to address her as such by including safety of the child, both sexual abuse and domestic violence.
- If you are working with the child, please include how you will work with Maria for safety planning with the child.
- Please be sure to address sexual assault and interpersonal violence in your safety plan.
- A brief summary of local and national community organizations that provide resources for sexual assault and interpersonal violence.
- Three Evidence-Based Practices (EBP) for working with trauma survivors.
Resources:
https://www.domesticshelters.org/articles/safety-planning/a-safety-planning-worksheet
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Counselor’s Name: Date:
Case Conceptualization Form
I. Assessment
Discuss background characteristics, presenting complaints, history of the problem, and social and cultural considerations. Describe the differential diagnosis, including any related diagnoses that were considered and ruled out. Explain the legal and ethical considerations that are relevant to the client situation.
II. Case Conceptualization
Use your theoretical orientation to provide a concise summation of the client’s psychological strengths and difficulties. Integrate your client’s history with the theoretical orientation you have selected to support your explanation.
III. Treatment Plan
List two long-term treatment goals for client issues with at least two short-term objectives that are steps in how you plan to meet each goal. The objectives need to be specific and measurable and are driven by your theoretical orientation and the element you are asking the client to change (e.g., thoughts, feelings, actions, etc.)
Problem, Issue, Challenge, Obstacle, Symptom:
Treatment Goal 1:
Objective:
Objective:
Problem, Issue, Challenge, Obstacle, Symptom:
Treatment Goal 2:
Objective:
Objective:
IV. Interventions
Discuss how you will work toward the treatment plan goals. Base your interventions on the theoretical orientation you discussed in your case conceptualization. Be sure to use evidence-based practices that are supported by your research. Describe any referrals that you believe will be beneficial.
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Counselor’s Name: Dr. Friess Date:
I. Assessment
Jaz is a 21-year-old female. She lives with her father. Her parents are divorced, and
both are originally from Mexico. Their primary language is Spanish while Jaz states that
she speaks English better. She is in college majoring in English Literature. Jaz recently
attempted suicide and was in a coma for 3 months. She then received outpatient
treatment. She did not want to continue taking meds for depression because that is
how she attempted suicide. She has been hospitalized two times for attempted suicide.
She has not seen a counselor in the last 6 months. She came into counseling stating that
she needed some support because she was very anxious and depressed. She stated she
hated herself and she couldn’t stand to be around other people because she felt out of
place. She reports feeling distant from her husband and mother after her last suicide
attempt and feels guilty that she is not a good daughter. She hasn’t talked to her mother
since her last attempt because she feels she must choose her mother or husband. She
stated that they blame each other for her suicide attempts. The Beck Depression (BDI)
inventory suggests that her depression is moderate. The Beck Anxiety Inventory (BAI)
indicates her anxiety is also moderate.
Diagnosis: Major Depressive Disorder moderate-severe with anxious distress (F32.1)
Differential diagnosis:
Case Conceptualization Form
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R/O Mood disorder due to another medical condition. Client will seek physical to rule
out medical conditions. She does report slow heart rate after coma.
R/O Bi-polar disorders such as Manic episodes with irritable mood or mixed moods.
There has been no history of manic or hypomanic episodes.
R/O Substance/medication induced depressive or bipolar disorder. There is no
indication of substance use or medication
R/O Attention-deficit/hyperactivity disorder disturbance in mood is not irritability but
sadness and loss of interest.
Legal and ethical issues: Informed consent and client rights. Professional disclosure and
exceptions to confidentiality. Continual assessment for suicide potential. Suicide safety
planning. Cultural considerations and anxiety. Client reports his culture does not value
counseling and she has been raised to not share anything with outside of family members.
II. Case Conceptualization
Client was raised in a culture different from her parent’s upbringing. She has been
taught that “girls are taken care of and spoiled” per her words, in her upbringing. She
reports that she was not taught how to problem solve to care for herself. Her anxiety
and depression seem to stem from negative thoughts about herself. She talks about
self-hate and constantly feeling not good enough. These are cognitive distortions that
Cognitive Behavioral therapy (CBT) targets for improvement of her condition. Some
cognitive distortions that she is displaying include “all or nothing thinking”, such as all
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good or all bad. Mental filter in that she tends to focus on the negative aspects while
ignoring other positive evidence. She also disqualifies the positives and doesn’t
recognize her strengths. For example, although she is successful in college, she reports
she isn’t as far along as she should be, like her high school classmates. She jumps to
conclusions about herself not being good enough instead of looking at other
interpretations of events.
III. Treatment Plan
Problem, Issue, Challenge, Obstacle, Symptom: Excessive worry and depressed mood that is
difficult to control more days than not for at least 6 months.
Treatment Goal 1: Reduce depression and anxiety scores on the BDI and BAI by from
moderate to mild.
Objective: Client will Identify three strengths related to successes.
Objective: Client will describe situations, thoughts, feelings, and actions associated
with anxiety and depression and the impact on functioning by participating in mood
log daily for one week.
Objective: Cl will consult with medical to r/o health problems that may be related to
depression and anxiety.
Objective: Client will practice relaxation exercises at least 1 x per week and
report the impact on mood/anxiety in the next session.
Problem, Issue, Challenge, Obstacle, Symptom: Feelings of worthlessness and excessive guilt.
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Treatment Goal 2: Increase assertiveness, self-efficacy, and self-worth by getting needs met
through healthy communications and improving at least one positive social relationship, per
self-report by 2 points on a scale of 1-10 of getting needs met.
Objective: Client will practice communication with husband at least 1x per week
Objective: Client will practice behavioral/social experiment 1x per week, related
to evidence in jury trails of self-beliefs.
IV. Evidence Based Interventions (Beck, 2011; Jongsma, Peterson, &Bruce, 2014)
Develop level of trust, provide support and emphatic to encourage client to feel safe expressing
depression and anxiety symptoms
Provide behavioral, emotional, and attitudinal information about anxiety and depression
Educate client on mood log so client will be able to identify thoughts, feelings, and actions related to
her moods.
CBT to explore thoughts, feelings, behaviors, related to depression and self-hate.
CBT weekly to assess core beliefs and reframe anxiety provoking thoughts.
Practice jury trials to support or refute beliefs about self and self-talk.
Educate on relaxation skills – progressive muscle relaxation.
Educate thought stopping skills and mindfulness practices.
Educate healthy assertive communication, practice through role play and modeling.
Referrals
Medical doctor for physical
Potential group support to increase social engagement.
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References
Beck, J. (2011). Cognitive behavior theory basics and beyond. New York, NY: Gilford Press.
Jojgsma, A. E., Peterson, L.M., & Bruce. T.J. (2014). The complete adult psychotherapy treatment
planner. Hoboken, NJ: Wiley.
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Maria and Sofia Luna
You are working at an outpatient clinic when a woman, Maria, is referred to you for an intake session. Three days ago, the police were called to the Luna household for domestic violence. Maria has an 8-year-old daughter named Sofia.
Maria is 26 years old and speaks little English. She grew up in Honduras with her mother, grandmother, and nine brothers and sisters. She never knew her father who abandoned the family when she was an infant. Her mother had several other long-term relationships but never married. Her family was “very poor” and she did not finish school past fifth grade. Maria was raped when she was 10. At 13 years of age, she began a life of prostitution to help her mom with feeding the rest of the family. She met her husband, Jamie, when she was 18 and quickly got pregnant. She illegally entered the States and began to work in a home in Texas. After she had the baby, Jamie was able to illegally enter the States and began working odd construction jobs to pay their bills since Maria no longer was working to care for Sofia.
Maria reports that they have not been successful in having any more children, which Jamie blames on Maria’s previous sexual history. He is ashamed since in his culture, “men are supposed to have many children.” Maria reports that she had many difficulties in having Sofia and did not get the proper medical care she needed. Sofia was born premature and has speech and other motor skill delays. Maria admits she used drugs in the past but adamantly denies any current drug use because she knows it would affect their immigration status. The police found drug paraphernalia in the household, but Maria stays in a condo with two other families and reported the material was not hers.
Maria stated that when Jamie gest angry he hits and punch her. Maria says that she will not be kept in a system like the one in which she was raised in Honduras where she is supposed to be subordinate and just take whatever Jamie gives her. She accuses him of having affairs and sleeping around with everyone. She reports that they have arguments at least two to three times a week and have separated several times to get away from each other. Maria says that she is dependent on him since she is not working.
Maria says that on the night of the police incident, she caught him with another woman at the corner store, and when he got home, she asked him who she was. He became very angry that she would question him. He stated that it was none of her business and she was to stay home and take care of the house. He grabbed a knife and threatened to cut her if she questioned him again.
Maria reports having difficulty concentrating. She has flashbacks of a time that Jamie did cut her, and she thought she was going to die. She does not want to talk about that incident. She only states that he cut her, and she thought she was going to die. Now anytime she hears loud voices she feels frightened and wants to cower in the corner. She reports that she feels like walking on eggshells and worries constantly that something bad will happen.
Sofia is 8 years old. She is very shy but speaks English well. She is in the second grade and was held back in kindergarten due to her developmental delays. She is currently at risk of being held back again, and her attendance record is very poor. She reports that she hates to see her mom and dad fight all the time. She gets very scared, has trouble sleeping, and hides in her closet. She does not have many friends because the kids “pick on me for being dirty”. She mentions that one of the other male children living in the condo does come to “comfort her” at night and gives her “lots of hugs and squeezes.” Maria reports that she has caught Sofia “rubbing her private parts” on the couch arm and trying to kiss all the other little boys in the house. She denies that Sofia has been sexually abused and blames it all on Sofia.
After completing the intake, your supervisor tells you that you can decide which person in the family system you want to focus on for individual counseling sessions—Marie, or Sofia—with the understanding that the other family member will work with your colleagues with possible joint sessions in the future. For the assignment, select one member of the family to complete your case conceptualization, understanding that this family member is a part of the overall family system.
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