Case Study Analysis

Case Study

Markus is a Caucasian 45 year old male, who has been smoking cannabis since he was 18 years old. He now grows his own plants. He used to drink alcohol mixed drinks (2 drinks per night) and 4 or more on the weekends. In the past 6 months the amount has doubled. He is married and lives with his wife and their 15 year old daughter. The presenting problem is physical. He has high cholesterol, irregular heart beat, and is beginning to have memory problems. He went to the hospital because he was having problems, heart palpitations and high blood pressure. He has never sought treatment before but has tried over the past five years to stop smoking cannabis on his own and has not been successful. He says he is too shaky and nervous without it. He has also tried to cut back on his drinking but he is too nervous when he gets home from work and feels he needs the drinks. He is adopted so he has no family medical history. He is currently employed as a producer at the local news station. He has no incidence with the law. His wife would like him to stop smoking and drinking so that his health will improve. His drinking and smoking has caused some problems in his family life.

Case Study Analysis

You will have two primary headings and numerous subheadings. The primary sections include client description and treatment considerations. The subheadings are identified below.

Client description

Provide all of the pertinent information about Marcus. Please include each of the following sections.

1. client’s drug of choice -

0. the drug of choice is typically one substance and then followed by other substances used or tried.

1. timeline of when the substance use began and the nature and course of its progression (full description of etiological factors)

1. This information is needed for each substance. Think about: age of onset, when did the use increase, think about frequency and duration of use, method of use changes, periods of abstaining, etc.

1. causative and reinforcing factors related to family dynamics (both immediate family and extended family);

2. Think about the theory of addiction (moral, social, biological, psychological, etc) and what factors support your theory (parental use, witnessing it as a child, etc)

1. cultural factors

3. Use the ADDRESSING format, identify how culturally attributes impact use and recovery

1. diagnosis (according to DSM 5 criteria) including severity level and other relevant specifiers;

4. identify each criterion that is met for the diagnosis, if higher criteria are met it typically means that lower criteria are met

4. be sure to identify mental health diagnoses and V codes, if they apply

1. students choice of theoretical approach implemented on this case;

5. What is your counseling theory and why? Example: If you are using CBT, you will need research stating that that theory is appropriate for this client (male, child, African American) and this diagnosis (Cannabis Use Disorder, Moderate).

5. Identify what theoretical techniques or skills you will use to treat this client.

1. prognosis;

6. Think about the stages of change, support system, protective factors, risk factors, research on prognosis, look at the DSM for prognosis information too.

1. detailed treatment plan (including spirituality and wellness variables)

7. This must include the problem, goals, (3) objectives, dates for each diagnosis.

7. The goals must be to reduce ___________ (symptom). The objectives must be HOW the client will reduce the symptom in session. The intervention is what the counselor used to help the client meet the objective. All of the objectives and interventions must align with the theory of counseling that you chose in step 6.

Treatment

This section will detail how you will treat the client – from beginning to end. Please demonstrate consideration of each of the following areas, in accordance with state credentialing requirements (Core Functions). If you need more information on these sections please see the attachment in the “student supplemental material” section (12 core functions).

In this section, you will essentially identify what the client will experience in each step of the treatment process. Your textbook discusses each of these areas of treatment. Be sure to read your textbook and cite and reference the information as needed. You are also encouraged to use additional scholarly sources to complete this section.

Short example of some information that might be included in the sections:

The purpose of an screening is _________________ (citation). The initial screening may take place via phone or in a private room if the client is a walk-in. During the screening, the client will be asked a series of questions about their needs, insurance, and times of availability. They will also be assessed for suicidal and homicidal ideation. If the client is deemed appropriate for services an appointment time will be scheduled.

An intake has many functions including _______________ (citation). An intake may be conducted by an intake specialist or a mental health clinician. The intake can include the MSE, biopsychosocial questionnaire, _________, __________. During the intake the client will complete several forms including an informed consent, resease of information, ___________, ____________,

Possible sections to include.

1. Screening, - identify how counselors screen clients, how would you screen this client

1. Intake – identify a particular intake(s) that would be used, what information would be gathered, why is that intake chosen over others, what assessment would be used, why would you choose this method over other methods, who does the intake

1. Orientation – what type of information is included in the orientation and why, who provides the orientation,

1. Counseling – the type of counseling (group, individual, family), counseling theory (Narrative, CBT, Adlerian, etc), length of counseling

1. Case Management – client needs, referrals, rationale for case management services

1. Crisis Intervention – identify crisis needs, crisis plan, treatment considerations in the event of a crisis, include an emergency number if the client has a crisis when they are not in session, what paperwork is completed for crises

1. Assessment – identify assessment tools that you would use, why this tool was chosen over others, identify information that needs to be collected, who will give the assessment, how long will the assessment take, etc

1. Treatment Planning – identify and rank problems, identify immediate and long term goals, treatment method, what paperwork is completed for treatment planning,

1. Client educational needs – psychoeducational needs, AoD classes, parenting classes, tutoring, GED classes, etc.

1. Appropriate Referral – identify needs, agencies to meet those needs, rationale for the referral, identify support systems, who provides the referrals, what paperwork is completed for the referral

1. Reports and record keeping – identify what records would be kept, what information might be in those records, why one keeps records

1. Consultation needs – identify the counselor's scope of practice, with whom the counselor might consult, rationale for consulting, ethics, need for releases of information, etc.

The paper should be no more than 10 pages in length and follow APA style. There should be no less than five sources included in the reference section, with a minimum of two coming from professional/peer-reviewed/scholarly journal articles.