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Instructions

For this final assignment, apply what you have learned in this course to complete the Case Study Treatment Plan media presentation, using the client information you developed for your Week 3 assignment. You will complete each section of the treatment plan, following the directions provided for each section.

You will be required to:

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  • Update the first sections of the treatment plan you completed in the Week 3 assignment, based on your instructor’s feedback. They are:
    • Biopsychosocial Information for Case Conceptualization.
    • Genogram.
    • Ecomap.
    • Legal and Ethical Considerations.
    • Annotated Bibliography .
  • Determine an appropriate DSM-5 diagnoses.
  • Develop a minimum of three appropriate long-term goals.
  • Develop a minimum of two short-term goals for each identified long-term goal (a total of six or more).
  • Choose two counseling theories and compare and contrast the application of these theories to the client’s treatment.
  • Develop interventions supported by the literature based on the counseling theories chosen.
    • Develop two individual counseling interventions. Be sure to ground a minimum of one of these interventions in play therapy.
    • Develop two family counseling interventions. Be sure to ground a minimum of one of these interventions in play therapy.
    • Develop two group counseling interventions. Be sure to ground a minimum of one of these interventions in play therapy.

Be sure to support your work with a minimum of eight recent (5 years or newer) peer-reviewed journal articles in addition to other academic resources (DSM-5, APA code of ethics, et cetera). Also, communicate in a manner that is scholarly and professional, adheres to current APA standards, and is consistent with expectations for members of the counseling professions.

Additional Requirements

As you complete your assignment, be sure to:

  • Write coherently to support your work with correct grammar, usage, and mechanics as expected of counseling professional.
  • Correctly apply current APA Style and Format
  • Cite only recent (published within the last 5 years), relevant academic literature to support your work.

CLIENT

 Hallie is an eleven year old white female in the 5th grade. She typically arrives at school very early and stays very late, spending the extra time studying for her classes. Her mood has changed substantially at school recently, going from appearing happy and enthusiastic, to appearing depressed, tired, and uninterested. Hallie is displaying a noticeable weight loss causing teachers to be concerned. When a teacher asked Hallie how things were going she began to cry and said that her mother was drinking and staying away from home a lot. Hallie visits her dad every other weekend. He has recently become engaged to be married to a woman and they are expecting a baby. 

Week Three Assignment Template

Client Demographic Data

Name: Hallie Smith (H.S.)

Gender: Female

Race: Caucasian

Ethnicity: Not Hispanic or Latino

Religion: Catholic

Other Relevant Information: Client H.S. seems to have been brought up in a single parent, low-income household. She attends Bromwell Elementary School in Denver, Colorado and is a AB student. She is currently residing with her mother and has visits with her father on the weekends.

Social-Cultural Information:

Client H.S. appeared to be very quiet but respectable throughout the session. She reported that while she grew up in a mostly Caucasian neighborhood, she now lives in a very diverse apartment complex with her mother and has two best friends of mixed races. She also attends a very diverse school setting and reported that, “I like it better than at my old school.

Presenting Problem

Client H.S. is reported to be in the fifth grade and reports to school early and appears to be diligent in her classes as she stays late to study for her schoolwork. She was referred to counseling services after school officials and teachers reported an observed substantial weight loss in client and lack of interest in her school work. When asked what is wrong by her school teacher, client H.S. reportedly burst into tears and explained how her mother is always gone and intoxicated and that she goes to visit her father on the weekends with his soon-to-be wife and new child (Capella University, n.d.). Client H.S. reported to having feelings of mistrust towards father, feeling he does not truly care about her or her mother and only wants to “be happy and live with his new family.”

Current Stressors

Client H.S.’s stressors appear to be her parents, her current weight loss, her lack of interest or apathy in completing her school work, and her feelings regarding her father’s fiance and new baby. Client H.S. shows stress towards her mom’s drinking habits and disappearance from home for unknown amounts of time (Capella University, n.d.). She claims to be upset with her father for “abandoning” her and her mother and “finding a new family” with someone else. She reports to have little to no contact with her father’s fiance and claims to have “no interest” in her future sibling. Due to these chaotic factors, client H.S.’s appetite appears to have diminished greatly, as evidenced by her weight loss, and appears to be apathetic and uninterested in her schoolwork where before she showed great interest and typically arrived to school early and left school late to study for her classes (Capella University, n.d.).

Current Symptoms

Client H.S. appears to show symptoms of depression. It was reported that her mood has changed drastically at school from once appearing “happy and enthusiastic”, but now appearing “depressed, tired, and uninterested” (Capella University, n.d.). Client H.S.’s depression has affected her schooling where she does not feel motivated to complete or show any interest in her work. Her depression has also appeared to affect her appetite and/or eating habits, evidenced by her “noticeable weight loss” (Capella University, n.d.).

Family History

Family members’ names and ages to include parents, grandparents, and siblings:

Client H.S. (age 11) has a total of seven immediate and extended family members, nine if we are counting her father’s fiance. Beginning on her dad’s side, we have her paternal grandparents, Christian (age 53 at the time of death) and Jean Smith (age 60), who had their son, William Smith (age 31), client H.S.’s dad. On her mother’s side, we have maternal grandparents, Phillip (age 71) and Charlotte Martin (age 65), who had twin daughters, Julianna (age 29) and Teresa Martin (age 19 at the time of death), Julianna being client H.S.’s mother. After separating from her mother, her dad met his new fiance, Kate (age 28), and they are expecting their first child together.

Provide a detailed narrative of the genogram you created:

Client H.S.’s paternal grandfather, Christian Smith, was a mechanic who grew up and lived in Seattle, Washington. In the Fall of 1980, he met and married his wife, Jean Smith, who also resided in Seattle, Washington and worked as an elementary school teacher at Greenwood Elementary School. Christian and Jean were married for twelve years and in that time had one son who they named William. When William was eight years old, his parents separated and he lived with his mother growing up, and has maintained a harmonious, loving relationship with. His father passed away in an car accident on June 25, 2005 at the age of 53.

Client H.S.’s maternal grandfather, Phillip Martin, was a pastry chef who resided in Manchester, Washington. He met and married his wife, Charlotte Martin, who also resided in Manchester, Washington and worked as a nurse. Phillip and Charlotte have been married for 18 years and in that time had twin daughters, Julianna and Teresa Martin. It was reported that when Julianna and Teresa were 19, Teresa passed away in a car accident. It was also reported that due to the aftermath of her sister’s untimely passing, Julianna and her parents became estranged from one another. Currently, Phillip and Charlotte still reside in Manchester, and Charlotte has now become a caretaker to Phillip who was diagnosed with onset of early alzhemer’s.

Shortly after Teresa’s passing, Julianna met William Smith and they dated and got married within a years time after finding out Julianna was pregnant with client H.S. and moved to Denver, Colorado where William worked as a mechanic at Gary’s Auto Service and Julianna worked as a nurse at Kindred Hospital Denver. Client H.S. reported that her parents “used to argue and yell a lot” before getting a divorce when she was seven years old. Though client H.S. reports to love her mother, she reports feelings of mistrust towards her father as she feels “he abandoned them and threw them away when he got his new family.” She reports having little to no feelings or interest towards her father’s fiance and upcoming role as big sister.

Special family circumstances or events:

Client H.S.’s paternal grandparents, Christian and Jean Smith, separated when their son was eight years old. Christian Smith died at the age of 53 after being involved in a car accident. Client H.S.’s mother lost her twin sister, Teresa Martin, at the age of 19 also in car accident. Client H.S. ‘s maternal grandparents, Phillip and Charlotte, became estranged and cut off ties and communication with their remaining daughter, Julianna. Soon after, client H.S.’s parents met each other, dated, and married all within a year’s time frame. Client H.S.’s parents moved to Denver, Colorado after receiving the news they were pregnant with their first child, and both held jobs as a mechanic and a nurse respectively. Client H.S. reports that when she was seven years old, her parents filed for a divorce and her father moved out of the house. Her father met and is now engaged to and living with Kate, and they are expecting their first child together.

Current Living Situation and Environment

Housing (apartment, single-family home, etc.):

Client H.S. currently lives in a two-bedroom apartment. Before the divorce, her parents owned a three-bedroom home, but her mother decided to sell it and downsize as she could not afford the payments (rent) on a single income after the divorce. On the weekends she visits her father, she stays in a four-bedroom home.

Who is living in current household? (Parents, grandparents, siblings, etc.):

Client H.S. currently lives with her mother in their two-bedroom apartment. When she is with her father, she stays with dad, Kate, their two dogs Landon and Max, and they have a room for the baby.

Household Stressors impacting client (financial, space issues, safety concerns):

Client H.S. reports feeling lonely and scared when she has to stay home by herself while her mother is away at work, or when her mother has to be called in at different hours of the night. She also reports feeling out of control with what is happening around her and seeks to find something she can control. She reports feeling embarrassed to ask her friends, Matt and Peyton, for money to get herself something to eat before going home as her mother may have forgot to leave money for her.

Family History of Mental/Psychological Issues

Identify and describe each family member who has experienced mental health issues, current and past, diagnosed and undiagnosed:

Charlotte Martin has reported to have suffered from symptoms of major depression for a number of years since the death of her daughter, Teresa. After the first four years of her daughter’s passing, Charlotte remained undiagnosed and untreated due to “not feeling like anything was wrong or was bothering me.” According to client H.S., Julianna suffers not only from depression, but has used large amounts of alcohol to cope with life and the trauma she endured witnessing, and being a cause of, her sister’s death. Client H.S. was reported to suffer from symptoms of depression as well and has of yet to be fully diagnosed.

Client Personal History

Major Life Events:

Client H.S.’s parents got divorced when she was seven years old. She had to move out of her childhood home to a small, two-bedroom apartment with her mother. Her father is soon to remarry, so she will gain a step-mother and a new sibling in the near future.

History of Trauma and/or abuse:

Client H.S. does not report any history of trauma and/or abuse at this time.

Physical/Medical Information

Developmental history (birth issues, developmental milestones, etc.):

Client H.S. was reported to have had a normal developmental history. She weighed 6 pounds 5 ounces at the time of her birth and did not have any complications. Though she was trying to babble and sound out words at eight months of age, she did not begin to take her first steps until after her first birthday. Client H.S. was also reported to have been very self-sufficient even at a young age; she wanted to be very independent in choosing her outfit for the day, what food she wanted to eat, and what games or toys she wanted to play. She appears to be a very bright young lady as she initially was a very eager and studious student before her parent’s divorce.

Physical/medical history: 

Client H.S. reported to have had chicken pox at the age of five and she is allergic to bee stings and pecans.

Current physical/medical state: 

Currently client H.S. seems to be suffering from a slight case of anemia due to her low weight.

Current Medications (prescribed or OTC): 

Client H.S. is prescribed an EpiPen for allergies and an iron supplement for her anemia.

Other medical issues (allergies, etc.):

Client H.S. reports to being allergic to bee stings and pecans.

Previous Mental Health History/Treatment

Previous Mental Health History/Treatment (include in-patient, out-patient, residential, in-home, etc.):

Client H.S. has not had any previous mental health treatment at this time, but currently she presents having symptoms of depression.

Substance Abuse/Addiction History and Current Situation

Substance Abuse/Addiction History and Current Situation (include client and client’s family members):

Client H.S.’s mother, Julianna, presents a history of alcohol abuse and addiction. Client H.S. reported that “her mom was drinking and staying away a lot” (Capella University, n.d.). Client H.S. does not present any substance abuse or addiction history at this time.

Ecomap Analysis

Analyze the relationships between community systems, family systems, and school systems that could support the client through treatment, counseling and beyond:

Client H.S. has reported to love her mother very much but she does not like her mother’s drinking habit or that she stays away for long periods of time. Though she does see her often, she also has a great relationship with her Grandma Jean, remembering holiday get-a-ways and making gingerbread houses for Christmas and helping to stuff the turkey for Thanksgiving. Though she is not a social butterfly at school, she has a few friends that she is very close to, Peyton and Matt. She has known her friends for four years since they both reside in the same apartment complex and bonded over their love of academics and playing Mario Kart and Pokemon GO. It is my belief that these two relationships with her friends will be a great source of support for H.S. not only on a personal level, but on an academic level as well. Though initially a star and excelling student, client H.S. reported that she no longer feels joy or enthusiasm about the things that used to make her happy, such as participating in school or going to her academic club meetings on Tuesdays and Fridays. She also reported feeling a little upset at her teacher and school counselor. In her own words, “I know they were trying to help, but I feel like they are judging my mom and don’t understand. They do not know what is best for me!”

Client H.S. attends St. Paul’s Catholic church and revealed that she has not been attending church lately and that she has been feeling a “strange disconnection” while amongst her peers and youth pastor. Client H.S. has reported a negative relationship between her father, future step-mother, and her maternal grandmother, Charlotte. Though she goes to stay with her father on the weekends, client H.S. stated that she is not happy with her father and does not understand why her parents got divorced and why “he had to find someone else and get a new baby! Why was he not happy with mom and me?” She revealed that she did not dislike her dad’s fiance, Kate, but she was not interested in having a relationship with her or her new sibling. Due to her mother’s estrangement with her parents, she does not really remember her maternal grandparents but has stated, “If they don’t like mom then they don’t like me and they sometimes make mom cry when she tries to call them and they don’t answer or say mean things. Mostly it’s Grandma Charlotte being mean and not wanting to talk, mom says grandpa is starting to forget a lot of things and might not even remember me.”

Legal and Ethical Considerations

Identify a minimum of three current or potential legal issues that may impact the client’s mental health:

As a future counselor of the state of Georgia, a potential legal issue that may impact a client’s mental health is not working in the capacity of a professional counselor and providing services that I am not certified or qualified to do and engaging in malpractice, such as if I am an Associate Professional Counselor and practicing professional counseling without being under direction and having a supervisor (Rules and Regulations of Georgia, 2020). According to Bray (2016), one potential legal issue that may impact a client’s mental health is not consulting with other counselors if faced with complex legal or ethical issues. As a future and new counselor, it would be my responsibility to act in the best way for my client and if I am unsure about something, I should consult with a more seasoned counselor or a counselor who knows more about that particular issue than I do so I will not cause any undue harm or stress to my client. Another issue is making sure to be knowledgeable and current on the legal and ethical issues set by the American Counseling Association and it’s specified branch(es), or laws set by the state of Georgia, as well as recognize the need to further my education to either gain new knowledge or to refresh it and gain knowledge and experience from other seasoned counselors (American Mental Health Counselors Association, 2015).

Identify a minimum of three current or potential ethical issues that may impact the client’s mental health:

One potential ethical issue that may impact client H.S.’s mental health is consent. According to Sartor, McHenry B., & McHenry J. (2016), in working with any client the counselor must obtain that client’s informed consent. In the case of children and adolescence, not only does the counselor need to obtain informed consent from the child but from the parent or guardian as well. However consent must not be simply given to the client and their guardian, but the counselor should fully inform them of who they are and what they’re here for, the counseling process and what it entails, and what information (if any) can be disclosed or treatment sought if a client’s guardian is divorced and has a divorce decree (Sartor, McHenry B., & McHenry J., 2016). Another potential ethical issue is making sure to not create a dual relationship with the client to not exploit the trust they and their parent/guardian is giving you and to not create in the client a sense of dependency (American Mental Health Counselors Association, 2015). Another potential ethical issue is for the counselor to maintain professional competence. A counselor must be aware of who they are as a person and their role as a counselor and to not extend their limits or knowledge if they have no education or experience on a intervention and/or the techniques involved (American Mental Health Counselors Association, 2015).

Annotated Bibliography

References

American Mental Health Counselors Association. (2015). AMHCA code of ethics – American mental health counselors association. Retrieved November 4, 2020, from https://www.amhca.org/publications/ethics

Bray, B. (2016, February 1). Behind the book: The Counselor and the Law. Counseling Today. https://ct.counseling.org/tag/ethics-legal-issues/

Capella University. (n.d.). Case Studies. Retrieved November 2, 2020, from https://media.capella.edu/CourseMedia/coun5254element22529/wrapper.asp

Georgia Rules & Regulations. (2020). Ga – Gac. GAR&R-Home. Retrieved November 4, 2020, from https://rules.sos.ga.gov/gac/135-5

Sartor, Teri Ann, McHenry, Bill, and McHenry, Jim, eds. Ethical and Legal Issues in Counseling Children and Adolescents. London: Taylor & Francis Group, 2016. Accessed November 4, 2020. ProQuest Ebook Central.

Hallie’s Genogram

1989

William Smith

31

1952 – 2005

Christian

Smith

53

1960

Jean Smith

60

1991

Julianna Martin (Smith)

2929

1949

Phillip Martin

7171

1955

Charlotte Martin

6565

1991 – 2009

Teresa Martin

18

2008

Hallie Smith

1111

1992

Kate Mitchell

28

Smith

?

Hallie’s Ecomap 11/1/2020

Grandma Jean

Peyton

Mom

Matt

Dad

Teacher

Hallie

Church

Counselor

Mom

Drinking

Kate

Grandma

Charlotte

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