Case Conceptualization and treatment plan

Description

Intake Information  Roberto has returned home from his third tour of duty in the army infantry to his wife Lora, a 29-year-old White woman of Irish and Swedish descent, and their six-year-old son Michael. A 30-year-old Mexican American, Roberto was stationed in Afghanistan for the last two tours. Up to this point in his life, Roberto has been gregarious, warm, and emotionally expressive, an attentive husband who Zoomed and Skyped regularly from his deployments overseas, and someone who liked to host salsa dance parties at his house for friends and extended family (many family members live nearby in a major metro area). Lora, Michael, and Roberto’s parents note he is now quiet and remote and seems to be having difficulty concentrating, and visibly startles when he hears sudden sounds, like Michael dropping a metal toy truck on the family room floor, a helicopter passing overhead, or a car or motorcycle loudly accelerating past their home.  He has nightmares (he refers to them as “night sweats”) several nights a week, when he is finally able to fall asleep, but refuses to discuss their content, saying “they’re just dreams” and “no one can really understand” what he’s seen “over there.”  Roberto stays up late watching TV and old movies, delaying going to sleep, and ducks conversation with his immediate and extended family and friends. He used to love playing guitar, but he hasn’t touched it for six months. Michael recently asked, “Did I do something wrong? Daddy doesn’t play with me like he used to.” Lora says she’ll do anything to support the man she loves, but she’s increasingly concerned that “this is just not like Roberto at all.” She thinks he has returned physically, but he isn’t really present with them like he used to be. Assignment Instructions Your mission is to conduct an assessment by proposing specific assessment tools such as self-report inventories and structural interviews, interpreting the hypothetical results, and making a formal diagnosis from the DSM-5. You can embellish and elaborate on the case as much as you’d like, and include a brief transcription of 1–2 pages of a family therapy session with Roberto and his family. Then complete a treatment plan based on your assessment, including short-, mid- and long-term overarching goals, accompanied by specific objectives for each goal that scaffold or serve as stepping stones to help support achievement of those goals.    Complete a descriptive diagnosis using tools you select from the list of assessment tools provided later in the assignment. The following information must be addressed: Identify presenting concerns from the clients’ perspectives. Include relevant cultural and systemic considerations that frame the clients’ presentations. Describe what information has been provided in each case that helps to determine which disorders are appropriate for consideration (differential diagnoses) for a final diagnosis. Evaluate how two assessment tools, listed in the List of Assessment Tools, will aid in obtaining further information to back up your diagnosis. Differential Diagnosis by the Trees or Section II of your text, Desk Reference to the Diagnostic Criteria From DSM-5® may be helpful to guide this process. Present at least one DSM-5 relevant diagnosis, and include any relevant Z codes. Even if you’re not a big fan of the medical model or the DSM-5, you must select at least one diagnosis. There are quite a few available, and select one with which you are most comfortable. Provide a descriptive rationale for the DSM-5 diagnosis that best fits the information. This should be written in a narrative form using complete sentences. Support your rationale with scholarly sources. Optional readings found in the course syllabus may be particularly relevant. Determine if a medical and/or medication consultation is appropriate, and provide a rationale with support from scholarly sources.