Abstract
This case conceptualization covers a weekly outpatient relationships group consisting of fifteen members, ages 25-50. All group members have been formally diagnosed with Generalized Anxiety Disorder and/or Depression, and some with more than one clinical disorder. Additionally, all members have attended this group for at least six months, most of whom attend regularly on a weekly basis. The case conceptualization includes background information on the clients, behavioral observations, clinical interpretations, and diagnostic impressions based on the DSM-5. A treatment plan and interventions for the clients are grounded in two primary theoretical orientations including cognitive behavioral therapy (CBT) and psychodynamics. A summary of the treatment, including client reactions, plus future recommendations are also provided. Ethical issues and quandaries are presented in accordance with the American Counseling Association (ACA) Code of Ethics. Finally, limitations and supervision needs are discussed in light of scope of counseling practice.

Background: Presenting Problem

Clients’ Biopsychosocial History

Of the fifteen group attendees, seven are female and eight are male. All have been in treatment for at least six months and have received formal diagnoses using clinical assessments by a referring psychologist or psychiatrist. Six of the clients have been diagnosed with Depression. Five have been diagnosed with Generalized Anxiety Disorder. Four have been diagnosed with both Depression and Generalized Anxiety Disorder. Moreover, three of the clients have been diagnosed with substance use disorder.

In terms of ethnic backgrounds, five of the clients are white, one is East Asian, one is South Asian, two are African American, four are Latino, and two are of mixed heritage. Their ages are between 25 and 40, and they are from diverse socioeconomic backgrounds and levels of educational attainment with three of the clients holding advanced degrees, and seven with undergraduate degrees. Religious affiliations are important to ten of the fifteen group members. Of those nine who affirm the importance of religion in their lives, five identify as Christian/Protestant, two as Catholic, one as Jewish, and one as Muslim. Of the other six group members who do not cite religion as being important in their lives, three claimed that they had some kind of spiritual practice or belief system that was not part of organized religion, and the other three claimed to be either agnostic or atheist.

Behavioral Observations

Using a mental status exam (University of Nevada, Reno, 2020), formal observations and assessment methods were used to provide an overview of client functioning. Specific sections of the mental status exam given include the following. First, general physical observations related to the clients’ appearance, manner of dress, and mannerisms were made, followed by observations of speech patterns, and interactions with others in the group. Second, thinking patterns and cognitive-emotional states are assessed based on the content of the client’s speech, including expressions of emotion, whether the client is more focused on the past or on the future, the client’s judgments and clarity, and level of self-awareness or insight. Because of the diversity of the clients comprising the group, behavioral observations reflect individual differences. Given their dedication to attending regular meetings, all of the group members are actively engaged in the group and cooperative with regards to keeping to the group regulations such as refraining from judgment or interruption.

Clinical Interpretations

Based on clinical observations of the clients comprising the group, the clinical interpretations reflect the formal appraisal of client performance in the group in conjunction with valid assessments that lead to formal diagnoses. Using a combination of cognitive-behavioral therapy and psychoanalysis allows for nuanced clinical interpretations that account for the intricacies and idiosyncrasies of an individual’s upbringing, social climate, educational attainment, job status, gender, and other variables. “Part of the counselor’s job is to decide which theoretical approach is a good fit with the client’s needs, and then use that approach to finish the case conceptualization,” (“Clinical Thinking Skills,” n.d., p. 31). Therefore, the clinical interpretations for individual clients will vary depending on the formal diagnoses of each client and individual client needs with regards to therapeutic interventions.

Diagnostic Impressions

The mental and behavioral health team contributes to diagnostic impressions, based on the results of formal assessments such as the GAD-7 and GAD-2, which are valid instruments used to assess clients for generalized anxiety disorder (Plummer, Manea, Trepel, et al., 2016). Comorbidity (particularly with GAD and MDD) was evident among group members. However, the tools used to assess clients may have varying degrees of sensitivity. As Van Loo, Schoevers, Kendler, et al., (2015) point out, a low threshold for diagnosing major depressive disorder is more likely to lead to a comorbidity diagnosis for a client. While the DSM-V does not offer guidelines for classifying patients as being mild, moderate, or severe, the clinician may discriminate between depression severity among patients with the diagnosis (Tolentino & Schmidt, 2018). It is also worth noting the various “overlapping mechanisms” in generalized anxiety disorder and major depressive disorder,” especially with regard to negative emotion generation (MacNamara, Kotov & Hajcak, 2016, p. 275). Differential diagnoses involved screening clients according to the DSM-5 guidelines as follows.

Generalized Anxiety Disorder (GAD)

Notoriously “challenging” to diagnose, GAD manifests differently for different people (Glasofer, 2019, p. 1). Primary symptoms include persistent worry that is “excessive,” difficult to manage, and which interferes with daily life for a period of at least six months (Glasofer, 2019, p. 1). To receive the formal diagnosis of GAD, the client must also exhibit at least three of the following symptoms: restlessness, fatigue, irritability, difficulty concentrating, muscle aches, and difficulty sleeping. Differential diagnoses allow the clinician to determine whether the client does not have some other related disorder, such as...…aware of the importance of mutual trust, maintaining boundaries, and respecting the right of all clients to privacy. Just as no group member is ever required to share anything publicly that they do not wish to share, clients are instructed explicitly to refrain from sharing the details of the group meetings with anyone outside the group. In all group work, “counselors clearly explain the importance and parameters of confidentiality for the specific group,” (ACA, 2014, B.4.a). In this case, the clients were handed out a form that they had to sign for relevant informed consent to participate. Finally, the ACA (2014) clarifies the importance of respect for diversity in all settings, calling on the group leader to ensure a respectful environment free from micro-aggressions or more overt acts.

Limitations of Treatment and Supervision Needs

The use of CBT and psychodynamics in group therapy interventions has been well-established, especially effective with a client group with generalized anxiety disorder and depression. However, there are bound to be limitations of the treatment that need to be acknowledged and addressed. Some clients will also be taking medications through a psychiatrist, which will affect treatment goals and outcomes. Unless the group leader is a licensed psychiatrist, there will also be a need for collaborative work with other members of the healthcare team. Other limitations include the inability to know the degree to which clients are following through with treatment plan recommendations at home or outside of the group context. The counselor factors in issues related to diversity, but cannot be aware of all the pertinent variables that might impact individual responses to the treatment plan, the interventions, or to other members of the group.

Supervision is inevitable to help maintain the efficacy of a group being led by relatively inexperienced counselors or those whose areas of expertise do not closely correspond to the presenting problems of the group members. In counseling, supervision is “an intensive, interpersonally focused relationship in which one person is designated to facilitate the professional competence of one or more other persons,” (American Group Psychotherapy Association, 2007, p. 35). In this case, supervision is used at the beginning during the screening process, and also throughout the group meetings whenever issues related to differential diagnoses or assessment are called into question. Supervision was and will be needed when specific assessments are administered, to ensure that all members of the team meet the legal an dethical requirements of the ACA (2014). Similarly, all the diagnoses given to clients need to be accurate, requiring a collaborative approach that in many cases extends beyond the scope of the counselor’s clinical practice. When the ethical considerations are taken into account, supervision is used, and limitations of the treatment strategies are addressed and systematically overcome, then the counselor is in a position to help clients reach…