CLINICAL EVALUATION

The clinical evaluation should include an assessment and diagnosis from a systemic perspective. From a systemic perspective, a diagnosis describes the behaviors that a person has adopted to maintain balance in his or her current web of relationships; given a different set of circumstances, it is possible and even likely that the person will have a different set of behaviors (Gehart, 2009). Remember that a systems perspective is not linear. In other words, therapy is not a process of providing an intervention to fix a problem, but an ongoing process which includes growth and setbacks.

 Mary is a 39-year-old, Caucasian, female.  She professes to be a practicing Catholic.  She is the oldest sibling in her family.  She lives wit her husband and two children… … …She has been married for 10 years.  All of the background information contained in this report was obtained from… …

Presenting Problem: This section should include a discussion of the presenting problem(s), how information was gathered to assess clinical issues, and the formulation of a diagnostic impression consistent with the client’s interpersonal and cultural context.  This section should include information gained from the initial interview with the client, demographic information, and history of the current problem, historical information, information about the family and information about the children or parents.

Assessment of Presenting Problem: The assessment of the presenting problem should include information about how information was collected, including both formal and informal assessment measures.

Observations: This section should include information observed during the interview and/or therapy sessions. This section should include a brief description of  behavioral symptoms, reactions, physical appearance, general behavior, activity level, language style, general response style, affect and any changes in affect during interview, description of cognitive functioning etc.

DSM-5 Diagnosis and Rationale: List diagnosis by number and provide rationale for client’s diagnosis, including symptoms and client’s report of symptoms.  If appropriate, provide a differential process.  Do not forget to diagnose each client you are treating in the treatment unit.

Mary reports excessive worry and anxiety occurring more days than not for at least 6 months relating to a number of areas in her life including her family, her work, and her social network.  Mary finds it difficult to control the worry as evidenced by how much time in a day she spends on worrying and how often the focus of session is on discussing the things that worry her.  Mary reports symptoms of restlessness, fatigue, irritability, and problems sleeping for over 6 months and states that she experiences these symptoms more often than not. Mary states that her preoccupation with her “stress” has caused significant negative impact at work to which she has been placed on probation as well as alienated her friends.  I am diagnosing Mary with GAD and not Acute Stress Disorder because she has not been exposed to a traumatic event that would have caused these and other symptoms;  I am ruling out OCD because her excessive worry and anxiety are about real life events and problems and because Mary does not report nor seem to have compulsive rituals that she does to alleviate the worry… …

Contextual Factors: As part of the clinical evaluation, therapists should consider contextual factors that may have an impact on diagnosis and treatment. These contextual factors may include: sex, ethnicity, family dynamics, language, religion, gender, economic issues, trauma history, etc.

Systemic Diagnosis: Identify and describe the interactional and relational patterns in the client’s family and social network. Include information on the client’s strengths and limitations, family structure, interactional patterns, previous solutions, narratives and social discourses, and intergenerational patterns.

CRISIS ISSUES AND PSYCHOSOCIAL STRESSORS

This area assesses the student’s ability to identify, evaluate, and clinically manage crisis situations and psychosocial stressors specific to the case.

This section should include the identification of any relevant past or current stresses and crisis issues. Evaluate severity of crisis situation, assess for trauma, risk factors, substance abuse, safety issues, sexual and/or physical abuse, domestic violence, child or elder abuse, and suicidality. Determine the impact on the client’s current life circumstances.  Describe how crisis issues were managed. Include a discussion of client’s sense of hope, support systems, referrals provided and compliance with recommendations. Also discuss the implantation and management of safety plans.

THEORETICAL ORIENTATION

Choosing a theoretical model to work from provides a framework for interpreting the information obtain in the clinical evaluation. The chosen theory should not be a solution for the client’s “problem”, rather a tool that helps the therapist help the client. This section of the written case report should provide a thorough discussion of a clearly-defined, marriage and family therapy orientation, including a brief overview of the central tenets of the approach; discussion of how the chosen approach is appropriate for the diagnosis, and treatment goals.

TREATMENT PLAN

This area assesses the student’s ability to implement, evaluate, and modify clinical interventions consistent with treatment plan and theoretical model.

Treatment plan should be consistent with a theoretical mode and discuss the following: therapeutic relationship, client expectations for treatment, referrals and use of evidence based treatment, and treatment process. This section should reflect the heart of your clinical work.

A clear and coherent treatment plan is presented that includes the presenting problem, three long-term goals and three short-term objectives, and interventions that correspond with the objectives; the goals/objectives are measurable, obtainable, positive, and specific (i.e., the MAPS acronym); the student also discusses how to integrate the client’s culture and faith into treatment in a sensitive way; the treatment plan is congruent with the selected theoretical orientation.

LEGAL ISSUES

This area assesses the student’s ability to apply and manage legal standards and mandate in clinical practice specific to the case.

This section should include a discussion of the identification and management of any legal obligations and mandates that apply specifically to the case. This section should not consist of a list of all legal issues, but rather a thoughtful discussion of legal concerns related to the case being presented, including the impact on treatment and case management.

ETHICAL ISSUES

This area assesses the student’s ability to apply and mange ethical standards and principles in clinical practice to advance the welfare of the client specific to the case.

This section of the Written Case Report should provide a narrative discussion of the ethical concerns specifically related to the case being presented. Possible issues to explore in this section include: confidentiality, diversity, scope of competence, dual relationships, defining the client, child rights to confidentiality, and personal concerns. This section should not consist of a list of all ethical issues, but rather a thoughtful discussion of ethical concerns related to the case being presented, including the impact on treatment and case management.

DIVERSITY

This area assesses the student’s ability to identify cultural factors influencing the presenting problem and provide interventions consistent with the client’s context.

This section should include the identification and management of clinical issues with respect to gender, age, culture, sexual orientation, spiritual values, and other issues of diversity.  Discuss the impact of these issues on the therapeutic relationship and treatment plan.

SUMMARY AND CONCLUSIONS     

Review your observations, assessment results, and conclusions, as well as any referrals you would make at any stage of treatment with this client(s).  Countertransference experiences should also be included in this section along with the strategies used to address them. Include personal reflections gained from this process, including:

1. What worked well with this client(s)?
2. What did you learn?

APPENDIX A: Review of Psychotherapy Model Effectiveness Research (3 pages)

Include a three-page literature of the model used for the case report. This section should be based on the identifiable MFT theoretical model used in the case report.  This model will be used to guide and shape the Review of Psychotherapy Model Effectiveness of the paper.  Students should discuss 6 peer-reviewed articles demonstrating the effectiveness of their chosen model. The appendix should be no more than 3 pages in length, excluding references.

APPENDIX B: Christian Perspective (3 pages)

Students should discuss their perspective on the role of the Christian faith in the clinical write up. Discuss should focus on the role Christian spirituality may play in the treatment as presented. There should be discussion on how the identified therapeutic model understands human nature, and how this perspective relates to the Christian doctrine of the image of God. Bible verses should be used to demonstrate the Christian perspective.