MUST include the following elements:

Identify features of the case and history that suggests particular values on the four axes of cultural variability:
-Power Distance
-Masculinity
-Individualism
-Uncertainty/Avoidance
Identify the following:
1. Testing
2. Diagnostic interpretation and formulation
3. Treatment goals
4. Rank order priorities and rational for your ranking
4. An estimate regarding the clients level of readiness for change
5. Particular treatment approaches or strategies that would be contraindicated and the hypothesized reason for the contraindication.

I’ve included an example as to how to fill out the paper. Under the testing section, it must be from the DSM-5 and provide examples… also, make up a fictional Asian year old man who is 61 years old who is told by his boss that he must retire the following year and is upset because he does not know what to with his life since his family has always praised him for being a hardworking man all his life and feels ashamed now. He has worked at an autobody shop repairing cars all his life.

Case Conceptualization: The Case of Allan

Individual Assessment/Intake Information

Subjective distress

Allan is a 40-year-old male. He has immigrated to the United States from the Czech Republic. He is seeking help in counseling for increasingly angry behaviors and thoughts. He has also become more and more isolated from his friends and family. Allan’s thoughts are preoccupied with concerns of finding a job, and being deported from the United States. He is in the United States with a practical training visa; however, he is having increasing difficulties in renewing his permit. He frequently rants about illegal immigrants from the Southern border and how hard it is for him to remain in the country legally. Allan rates his dissatisfaction with life as a seven out of ten (with one meaning the perfect life and a ten meaning an unbearable life).

Impairment in daily functioning

Allan’s daily functioning has become somewhat impaired by his high level of isolation. During graduate school, he was highly social with a group of friends; however, after graduation, he has lost touch with most of his friends. He has had several incidents of verbal aggression which have further isolated him from the few friends that he has. However, Allan does attend the activities that he deems essential. He mostly leaves his home only for work and to attend church.

Client description of the precipitant

Allan believes that the cause of his problems is the uncertain and stressful situation that he is in. He is confused and angry about having done everything right, as far as immigration and school, and still facing the possibility of deportation. He does not want to return to the Czech Republic. In addition, Allan now faces financial challenges because he cannot find a job in his area of expertise. He has also recently lost his serious romantic partner. He felt that things were going well, and they even talked of marriage. However, his partner wanted to return to Poland to care for her family and Allan wanted to remain in the United States. Allan reports that these issues together are making him feel like everything in life is going wrong for him. He feels powerless to change his situation despite his best efforts to do things right. He has also expressed feelings of worthlessness.

Relevant history of the precipitant

            Allan reports that he feels that he was highly successful and on the right track in his life until recently. He has always done very well in school and has been able to attain the goals he set out to accomplish. He reports that he has never thought of himself as an angry person and did not experience angry outbursts in the past. He came to the United States two years ago because he thought that he would have more opportunities to grow in his career.

Family history

Allan was raised by his mother and his father. He and his siblings were raised in the Roman Catholic tradition. Allan’s father is the patriarch of the family and works in a factory. He has always encouraged Allan to purse higher education and to try his hardest. Allan’s mother is a homemaker and has always been supportive of Allan in all his goals. He is the youngest of his three siblings. Allan does not currently have any family members in the United States. He has remained in contact with his parents and siblings. They speak once a week over the phone. Allan had hoped to one day bring his parents to the United States.

Legal history

Allan did not report any relevant legal history. He makes a great effort to follow the law in all areas.

 

Academic and employment history

Allan completed his master’s degree in molecular biology two months ago. He graduated with a grade point average of 4.0. He had hoped to get a doctorate degree and become a college professor. Allan started working when he turned 16 years old. His father encouraged him to work so that he could help the household and buy himself the things that he needed. Since Allan’s arrival in the United States, he has worked with a temporary employment agency to get short term manual labor jobs. He is unable to sustain himself with the money that he earns and is running out of savings. Allan expressed resentment in still having to work manual labor jobs despite holding two degrees.

Mental status

Allan seems to be have a good mental statue. He is able to identify time, place, and who he is.

Suicidal/homicidal ideation/plans

Allan did not state nor display suicidal or homicidal plans; there was no indication of related ideation.

Medical history

No relevant medical history was identified.

Current medications

Allan reported that he is currently not taking any medication.

Drug/alcohol/tobacco/caffeine history and current use

Allan stated that he has never used drugs. In addition, he indicated that he has never had a problem with alcohol. Allan drinks one cup of coffee each morning. He does not smoke or chew tobacco.

Previous mental health contact

Allan reports that he has not had previous mental health contact.

Hofstede’s Axes of Cultural Variability

Power Distance

            The Czech Republic has a relatively high level of power distance (“Hofstede Country Comparison,” n.d.). Allan does seem to share this orientation with his culture. He came to the United States with the hope of furthering his education and career, but only did so with the blessing of his parents. He also intends to return to the Czech Republic to help in caring for his parents when they get older or bring them to the United States. MacCluskie (2010) points out that “children in a high power distance culture are expected to take responsibility in taking care of their elders throughout the elders’ lives” (p. 30). However, the power distance is not so high that Allan felt uncomfortable leaving the Czech Republic while his parents are still capable of caring for themselves.

Allan’s power distance orientation means that he is more likely to respond to directive counseling approaches. He is also likely to perceive clear differences in the role between the counselor and himself. In addition, he may perceive the counselor as an authority figure (MacCluskie, 2010). As his counselor, I should always try to keep unconditional positive regard for Allan and be gentle or neutral in any necessary confrontations. Allan will likely have some reluctance to self-disclose his thoughts and emotions because of his power distance orientation. It is important for Allan to not feel negatively judged for him to self-disclose.

Masculinity

            The Czech Republic has a high level of masculinity (“Hofstede Country Comparison,” n.d.). Allan does seem to have a high inclination of masculinity in some aspects. For example, his sense of self-worth seems to be tied to his ability to be productive and provide for his family. His current circumstances are not allowing him to live up to his role expectations, thus resulting in a great deal of discomfort for him. However, Allan is not so high on this orientation that he thinks that being verbally abusive or getting in physical altercations is acceptable.

One role of the counselor in this case, is to help Allan be aware of his masculine orientation beliefs. He may not be aware that his dissatisfaction and symptoms of depression are stemming from the disconnect between where he is in life and where he thinks he should be as a man. The counselor should not necessarily guide him to change those beliefs, but instead help him gain self-awareness and let him decide if that is something that he wishes to change. Helping Allan find the source of his internal strife while allowing him to choose how or if to fix it would be more in line with ethical standards of autonomy (American Counseling Association, 2014). Once Allan sees the underlying beliefs that he is holding, he can decide whether or not to change the ideas that are not serving him.

Individualism

The Czech Republic also has a high level of individualism (“Hofstede Country Comparison,” n.d.). Allan does seem inclined towards an individualistic orientation. For example, Allan’s sense of self-esteem seems to be tied to his personal success, and he is not affiliated with any groups. However, Allan is not at the highest level of individualism because he has not sought complete autonomy from his family. His sense of masculinity is tied to the care of his family; therefore, giving Allan some qualities of collectivism. His sense of duty to his parents could stem out of his deeply held Roman Catholic beliefs.

Counseling for Allan should include techniques that help him in gaining insight and self-understanding because of his inclination towards individualism (MacCluskie, 2014). In addition, Allan may hold some conflicting ideas about wanting to be an individual but also wanting to take responsibility in caring for his family. Allan needs to be aware of any contradicting or illogical beliefs that he may be holding to come up with realistic expectations of himself and release any feelings of guilt that he may have.

Uncertainty/Avoidance

            The Czech Republic has a very high level of uncertainty avoidance (“Hofstede Country Comparison,” n.d.). Allan also seems to exhibit a very high level of uncertainty avoidance. His orientation is evident in his strong religious devotion and dedication to the rule of law (MacCluskie, 2010). Allan does not feel comfortable with the high level of uncertainty that he is currently experiencing in his life. He is not sure when or if he will find a job in his field. Additionally, Allan does not know if he will even be allowed to stay in the country. This also explains why Allan spends so much time ranting about illegal immigrants coming from the Southern border. He wants people to follow the law, as he does, because it contributes to his sense of certainty.

In this axis, Allan also needs self-awareness. To a large extent, Allan’s problems are outside of his control. He can only control how he reacts to the situation he is in. However, the only way he can gain any control over his reaction to the situation is by having awareness of needs and his underlying beliefs. Because Allan has a high need for certainty, counseling with him should be highly structured and behavior oriented (MacCluskie, 2010).

Testing

Allan was given the DSM-5 Self-Rated Level 1 Cross-Cutting Symptoms Measure-Adult (American Psychiatric Association, 2013). Allan scored the highest in domains I and II (depression and anger). Allan was then give the PROMIS Emotional Distress-Depression-Short Form (American Psychiatric Association, 2013). He recorded a raw score of 26, which gave him a T-score of 63.5. This indicates that Allan is experiencing a moderate depression. Allan was also given PROMIS Emotional Distress-Anger-Short Form (American Psychiatric Association, 2013). He recorded a raw score of 15 which gave him a T-score of 58.8. This indicates that Allan is experiencing a mild (almost moderate) problem with anger.

Diagnostic Interpretation and Formulation

Allan’s perception of his presenting issue is the anger he is feeling and the angry behaviors he has been exhibiting; however, the tests and initial interview indicate that Allan is experiencing a moderate depression. The anger and increasing isolation are manifesting as a result of the depression. Allan meets the DSM-5 (American Psychiatric Association, 2013) criteria for mild major depressive disorder single episode 296.22 F32.2. Allan has experienced five of the nine criteria in the last two weeks. He experiences a depressed mood almost every day. He has lost interest in most of the activities that used to bring him pleasure. Allan has insomnia. He also experiences feelings of worthlessness nearly every day. Finally, Allan has a diminished ability to concentrate because he ruminates on his problems. These symptoms are causing clinically significant distress and impairment of social functions. The episode is not attributable to any substance abuse. Finally, the episode is not better explained by schizophrenia or other psychotic disorders.

Given Allan’s cultural axes preferences, personality, and presenting issues, rational emotive behavior therapy (REBT) would be a good treatment approach. Allan prefers structure and directive approaches. In addition, he is a highly logical and practical person. Corey (2013) points out that REBT has a focus on “working with thinking and acting rather than primarily expressing feelings. Therapy is seen as an educational process” (p. 292). In addition, REBT would be helpful to Allan because the environmental factors that precipitated his depression are largely out of his control. Allan needs a technique that will help him to process and deal with any of the eventualities that he may face. This makes REBT a very practical and suitable approach to use with Allan. The A-B-C framework would have a very high probability of being helpful to Allan.

Treatment Goals

1. Allan’s depression will reduce from mild to slight or none as measured by the PROMIS Emotional Distress-Depression-Short Form (American Psychiatric Association, 2013) over the next six weeks.
2. Allan will begin to engage in social functions with his friends or new acquaintances at least once per week over the next four weeks.
3. Allan’s anger will be reduced from mild to slight or none as measured by the PROMIS Emotional Distress-Anger-Short Form (American Psychiatric Association, 2013) over the next four weeks.
4. Allan’s sleep patterns will improve to one or less nights without sleep within the next three weeks as evidenced by self-reports.

Priorities and Rational

            The first goal of therapy will be to help Allan reduce his depression. The reason depression is the first and primary goal is because all the other issues that Allan is presenting are being caused by the depression that he is experiencing. Although Allan’s other presenting issues also need to be addressed, the cause must first be worked on. If the cause is not addressed, the changes in the other symptoms will not last long. In addition, addressing the depression will have a trickledown effect that will make the other issues easier to correct. For example, once Allan feels better he is more likely to reengage with his friends.

The second goal is for Allan to reestablish connections with friends and attend social functions. With all of Allan’s family in the Czech Republic, Allan has no safety or support network nearby. By reestablishing connections, Allan will have help and support when he needs it. In addition, it will help in recovering from the depression because Allan will begin to do things he enjoys again. Finally, networking may aid him in finding a job in his area of expertise. Although he will learn strategies to be okay regardless of what job he holds, it would still be desirable to find a job using his degree.

The third goal is for Allan to reduce his anger. Allan seems to be externalizing his depression and venting his frustration with those around him. As previously mentioned, addressing his depression should help in reducing his anger. In many cases, anger issues would take a higher priority because of the risk of injury to self and others; however, Allan is very unlikely to resort to physical violence. Out of the 13 common risk cues identified by MacCluskie (2010), Allan only presents one of those cues. Allan does not see violence as acceptable and is stable. In addition, Allan’s cultural axes preferences indicate that he values order and the rule of law. However, because even a small risk of hurting others is unacceptable, we will be working with this issue in our sessions.

Finally, we will address Allan’s problems with sleep. When Allan is unable to sleep, he cannot think clearly and is more irritable. He has had problems sleeping because he ruminates on his problems. By addressing his depression, Allan will reduce or eliminate the ruminating. This will result in Allan thinking more clearly and being less irritable. This goal may require the introduction of techniques other than cognitive behavior therapy to help Allan clear his mind when it is time to sleep.

Client’s Readiness for Change

Allan seems to have a high level of readiness for change. He has a very large need for certainty and structure. His current situation is lacking both of those elements and that creates a great deal of discomfort for him. Allan would like his situation to change and is preparing to take the steps necessary for his transformation to take place. This places him in the preparation stage. He has not yet reached the action stage, because he does not have a concrete plan to execute. As his counselor, I would need to help Allan come up with a concrete plan and develop a strong sense of hope. The use of cognitive-behavior theory would be helpful in guiding him into the next stage (MacCluskie, 2010).

Contraindicated Techniques and Treatment Strategies

Given Allan’s personality and axis orientations, certain techniques and strategies could be counterproductive. Strategies that lack structure such as Existential would not appeal to Allan because his preference is for high structure. Existential therapy is highly philosophical and may not work with Allan because he is highly practical and is also very religious. Gestalt therapy may also be ineffective because of low structure. In addition, certain aspects of Gestalt therapy may be too harsh for Allan. Given that Allan has a high power distance, he may shut down if confronted with some of the harsher techniques that Gestalt therapist use.

 

 

References

 

American Counseling Association. (2014). Code of ethics. Alexandria, VA

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5^th ed.). Arlington, VA: American Psychiatric Publishing.

Corey, G. (2013). Theory and Practice of Counseling and Psychotherapy (9^th ed.). Belmont, California: Brooks/Cole

Hofstede Country Comparison. (n.d.). Retrieved from https://www.hofstede-insights.com/country-comparison/czech-republic/

MacCluskie, K. (2009). Acquiring Counseling Skills: Integrating Theory, Multiculturalism, and Self-Awareness (Edition 1). Upper Saddle River, New Jersey: Pearson/Merrill