Component Two 1

In this paper I present a case study from my practicum training, that best reflects the use

of my theoretical orientation as a psychotherapist. After presenting clinically relevant

information about the client, changing all identifying information I will discuss the case based on

the NCPP competencies from the UST model of training, paying attention to assessment

strategies, treatment goals, interventions, and evaluation of the outcome.

Clinically relevant information

Demographics

Ask who the patient currently lives with. Ask about the patient's marital status, sexual

orientation, sexual activity, children, etc...drugs?

Chief Complaint

This is the patient's chief complaint, and you should write down what the patient states is

the reason for coming in to be evaluated. Do not use technical terminology unless the patient

does - rather, put down exactly what the patient says usually in quotations. Example: Patient's

chief complaint is: "I feel depressed;" patient's chief complaint is: "I need a refill of medicine."

History of Present Illness

Write down an organized, chronological history of what brings the patient into the

hospital now, including all significant symptomatology, precipitating factors, etc... If the patient

is presenting to you with a six month history of depression which started when the patient's

father died, start six months ago with the death of the father and report what has been going on

since then, in chronological order, up until the current time of the interview. Include significant

modifiers of the illness, including possible organic factors, drug, and alcohol abuse. List all

pertinent positive and negative symptoms, which will help you to make an accurate DSM-IV

(differential) diagnosis.
 Component Two 2

Past Psychiatric and Medical History

Put in all contact the patient has had with therapists (psychiatrists, psychologists, social

workers, and counselors), inpatient units, and other outpatient experiences. Be sure to include

prior rehabilitation programs. If the patient has been on psychotropic medications in the past, list

these by date, how long the patient took each one, at what dose, and the effect the medication

had on the patient. List any ECT the patient might have had. Also list prior suicide attempts and

methods.

Family History

A genogram is often useful here for clarity. List all illnesses that patient's family has had,

including medical, psychiatric, and substance abuse history. Write down any psychotropic

medications which have been beneficial in family members. Include suicide attempts or

completed suicide in family members. Include whether the family members are currently living

or are dead. Include patient's parents, siblings, and children.

National Council of School and Professional Psychology

Relationship is the capacity to develop and maintain a constructive working alliance with

clients. Relationship is seen as foundational for the development of the remaining competencies

Assessment and Diagnosis

Axis I: Clinical syndromes that are the focus of the diagnosis

Axis II: Long standing chronic conditions that may affect the clinical syndromes listed in
Axis I

Axis III: Medical conditions

Axis IV: Psychosocial and environmental stressors that may affect the clinical syndromes
listed in Axis child abuse

Axis V: GAF Score (1 - 100)

 Component Two 3

is an ongoing, interactive, and inclusive process that serves to describe, conceptualize,

characterize, and predict relevant aspects of a client.

Intervention: interpretation, metacompetence, transference and counter, resistance and

defense mechanism. involves activities that promote, restore, sustain, or enhance positive

functioning and a sense of well being in clients through preventive, developmental, or remedial

services.

Research and Evaluation involve a systematic mode of inquiry involving problem

identification and the acquisition, organization, and interpretation of information pertaining to

psychological phenomena. Professional psychologists systematically acquire and organize

information about psychological phenomena and often engage in the general practice of science.

In addition, psychologists are aware of evidence-based practices and are knowledgeable of and

can critically evaluate empirical literature relating to evidence-based practices.

Consultation is a planned, collaborative interaction that is an explicit intervention process

based on principles and procedures found within psychology and related disciplines in which the

professional psychologist does not have direct control of the actual change process. Education is

directed facilitation by the professional psychologist for the growth of knowledge, skills, and

attitudes in the learner.

Supervision is a form of management blended with teaching in the context of a

relationship directed toward the enhancement of the competence of the supervisee.

Diversity refers to an affirmation of the richness of human differences, ideas, and beliefs.

An inclusive definition of diversity includes but is not limited to age, color, disability and health,

ethnicity, gender, language, national origin, race, religion/spirituality, sexual orientation, and

social economic status, as well as the intersection of these multiple identities and multiple
 Component Two 4

statuses. Exploration of power differentials, power dynamics, and privilege is at the core of

understanding diversity issues and their impact on social structures and institutionalized forms of

discrimination