Case Conceptualization

UNIT 4: Case Formulation and Conceptualization Case formulation involves organizing descriptive information. Examined are the multiple factors that affect assessment and case formulation including the client demographics (e.g.; age, class, color, culture, disability, ethnicity, family structure, gender, marital status, national origin, race, religion, sex, and sexual orientation); developing a mutual focus or the degree of choice for service; the existence or absence of natural and formal community networks; economic and social injustice; and the client system’s unique life stressors and strengths. These factors are considered with respect to formulating hypotheses that will conceptualize the case and inform the service contract. The service contract includes developing a mutually agreed-on focus of work and desired outcomes. Strategies for documentation will be reviewed. (Addresses SLOs 1,2,3,4,5,6,7, 8) Case formulation skills are fundamental to assessment and to providing effective treatment. The organizing structure of the case conceptualization is derived from a trauma-informed strengths-based framework. The case conceptualization assignment includes three parts: Part I: Gathering information about a client Part II: Categorizing the gathered information into workable hypotheses to create an assessment and case formulation. The assessment derives from the descriptive information collected in Part I. Part II also includes contracting of a service agreement to include mutually agreed upon intervention goals between worker and client. Part III: is a cognitive and affective opportunity to reflect on the experience and identify strengths and challenges of performing a case conceptualization Part I Description of Client I. Social workers use theories and models to conceptualize client concerns and to select appropriate interventions. Let’s say you choose to use a trauma-informed strengths-based assessment strategy, share what this is, how it will inform your case conceptualization, and how it might help the client best. II. Descriptive Data: (reported and observed information—no hypotheses or inferences here) A. Identification and contact information B. Person, Family and Household, and Community Systems C. Presenting Issues D. Assets, Resources, and Strengths i. Include 4-5 strengths-based questions you used to gather this data. Attach questions in Appendix E. Referral Source and Collateral Information (if relevant) F. History: describe history associated with relevant domains below CCGC-Spring 2019 met SW 546– Direct Practice Skills In Social Work I: A Trauma-Informed, Strength-Based Framework Page 17 of 24 a. Developmental b. Personal, familial, cultural c. Childhood adversity and/or trauma history i. Include 4-5 childhood adversity/trauma-based questions you used to gather this data. Attach questions in Appendix d. Sexual/gender e. Alcohol and drug use f. Medical/physical/biological g. Legal h. Educational i. Employment j. Recreational k. Religious, spiritual, philosophical i. Include 4-5 spirituality based questions you used to gather this data. Attach questions in Appendix l. Prior mental health, social, or medical services m. Other G. Identify one standardized instrument and use it to assess a single relevant aspect of psychosocial functioning/wellbeing with your client (e.g. resilience measure, coping measure, depression inventory, anxiety symptoms, trauma symptoms, drug use, motivation for treatment, etc.) Make sure to attach the completed instrument.  Part II: Assessment and Case Formulation (this is the assessment of the case which includes explanatory and change-oriented hypotheses) A. Focal Issues a. Nature, duration frequency, severity, and urgency b. Risk and protective factors; exceptions B. Contributing Factors a. Client system factors b. Situational, environmental, and systemic factors (in addition to prose, please include two relevant diagrams—genogram, culturagram, ecomap, spiritual ecomap, personal timeline) CCGC-Spring 2019 met SW 546– Direct Practice Skills In Social Work I: A Trauma-Informed, Strength-Based Framework Page 19 of 24 c. Motivation and readiness, stage of change C. Case Formulation (requires synthesis of information, proposes change-oriented hypotheses—often targets factors both within the client system and outside the client system (e.g., social and physical environment) D. Include two specific service goals based on a mutually agreed focus of work (the information identified in the assessment process) A. How would you engage the client in both the identification of such treatment goals (complete an action plan) and the complete the action steps needed to fulfill the treatment goals.  Part III: Self-Reflection Write a 2-page self-reflection of your experience in the case conceptualization process of assessment and treatment goal planning. Describe the feelings and thoughts you had while conducting the interview with the client. Did you feel connected? Was the client engaged? Reflect back on what skills you found yourself using most in the assessment interview and identify them here. Why do you think these were the skills you used most and which ones do you find were missing? How will you incorporate such skills in the next assessment?” Did you feel comfortable during the process? What barriers and or challenges did you experience in conducting this assessment? If you had to do the assessment over, what would you do differently? Grading Rubric: CCGC-Spring 2019 met SW 546– Direct Practice Skills In Social Work I: A Trauma-Informed, Strength-Based Framework Page 21 of 24 Points Exceeds Expectations M.

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