CASE CONCEPTUALIZATION

Client Name Need to select a case study from this week – James, Alejandra, Ben, or Kevin

Presenting Concern: Why did the client come to counseling?

What brought client to counseling? Self or other referred? Explain. Consider this a clinical document that you might be using in a clinical work setting. Remember, substance use/addiction should be primary focus. Other presenting issues should be considered.

Case Conceptualization: Note: Include specific information about client symptoms and presenting concerns. Include demographic information. Review biopsychosocial factors and considerations including: biology, family, culture, environment, and other relevant systemic considerations; assess how the addiction impacts all major life areas.

This section should be detailed. Work though case. Consider all areas listed in instructions for this section. Explore them. How might they impact addiction/assessment/treatment? Demonstrate that you understand these factors and the importance of paying attention to them.

Assessment: Identify and describe 1–2 assessment tools to be used with this client and the rationale for selecting the assessment tool.

Identify specific tools, describe them, and based on description how they are a good fit for this case. Why did you select these particular tools?

Diagnostic Impressions: Note: Include the provisional diagnosis for the client and any rule-out or alternative considerations noted.

Need to be specific here. Should be using DSM-5 for this, list diagnosis/diagnoses with codes. If you have a diagnosis you are considering but need to know more about, discuss that here as well. This is an addictions counseling course; you should be focused on the substance use as primary.

Rationale for Diagnostic Impressions: Note: Use the DSM-5 to explain how the client’s symptoms are reflected in the diagnostic criteria for each diagnosis that you render.

Work through criteria for the diagnosis you are considering, as it applies to client (don’t just list/cut and paste DSM criteria). Again, DSM-5 should be used here to inform this section.

Therapeutic Approach: Identify the chosen therapeutic approach to be used with this client and the rationale for your selection.

Select a treatment model/theory and explain why. Common examples (not exhaustive list) might be Cognitive Behavioral Therapy, Motivational Interviewing, Solution Focused Counseling, etc.

Treatment Goals: Identify three initial treatment goals you are considering in working with this client and note how you will measure/know when goals are attained. Note: Significant issues will need treatment goals.

Be sure to list goals (not interventions). Interventions can be listed under goals, but make sure you know the difference between the two. Interventions are done to meet goals. Goals should be measurable, so you know when they are being met. If you identified substance use and a mental health issue, may want to include goals for both.

Relapse Prevention and Continuum of Care: Describe relapse prevention needs and challenges for the client. Discuss the continuum of care plan and recommendations for the client.

Consider what the client might need after your provided treatment….family counseling, ongoing mental health counseling, 12step groups, etc. are common ideas. Build from this with case specific ideas. Address specific relapse prevention ideas for the client.

Ethical Considerations: Note any ethical considerations or challenges associated with this case.

Confidentiality is general and applies to all cases. What specifically applies to your case? Should have some general and specific ideas here.