Diagnostic Impression Assignment 1
Case Presentation of Michael Richardsion
SaQuisha Oliver
School of Behavioral Sciences, Liberty University
Diagnostic Impression Assignment
Identifying Data
Date of initial assessment: 09/28/2025
Client’s name: Michael Richardson
Age: 48
Race: Black
Ethnicity: African American
Diagnostic Impression Assignment 2
Gender: Male
Sexual Orientation: Heterosexual
Marital Status: Married
Employment Status: Employed
Client Background Information
Reason for Referral
Michael Richardson is a 48-year-old African American male who has just come for
outpatient counseling after being discharged from an inpatient rehabilitation program
mandated by the court. He denies any substance use but is currently faced with increased
psychosocial stressors such as marital discord, as well as undue grief due to the death of a close
friend. He states, "The temptation to relapsing is high and I experience mood swings," adding
that he is finding it difficult to manage daily stress and trauma-related symptoms. The present
referral is for the clinical management of emotional regulation, relational repair, and relapse
prevention through culturally competent, spiritually integrated treatment modalities.
Observational Data/Mental Status Exam
Michael appeared calm, lucid, and emotionally attuned throughout the interview. He
carried himself with warmth and gentlemanly poise, appearing well-groomed and fully oriented
to time, place, and person. His speech was coherent, focused, and purposeful. His emotional
expression was congruent with the topics discussed, especially during times that were difficult
or salient. Insight and judgment appeared good, and there were no signs of psychosis, paranoia,
or disorganized thought. He generally demonstrated a solid degree of psychological resilience
and emotional complexity.
Biological Assessment Information
Michael is a 48-year-old married African American heterosexual man residing with his
wife and two children. The history of physical and mental health regarding the long-term effects
of substance use includes a range of complaints from insomnia to restlessness. This has been
from the time of active addiction into early sobriety. He recalls sleep improvement for a while;
however, of late, insomnia has returned, particularly during heightened stress or emotional
situations. Moreover, mood swings have now been added to the symptom list—these consist
Diagnostic Impression Assignment 3
mainly of unpredictable surges of irritability, sadness, and emotional withdrawal—which seem
to be aggravated by relational turmoil and unresolved grieving.
Although dietary habits were not discussed, walking and the gym were mentioned as
deliberate activities included in his plan for recovery, promoting emotional regulation and
physical wellness. Medical history cites diabetes and hypertension as being treated. His major
opioid use started around age 17 from a sports injury, then the misuse of prescription
medications like Vicodin was a fair contribution toward the development of that addiction. The
alcohol use was also part of this mix during that same time frame, reinforcing the pattern of
early exposure to substances in a developmental and environmental context. There were no
details provided concerning sexual or reproductive health, and no issues surrounding hormonal
functioning were reported.
Psychological Assessment Information
Michael never had any official psychiatric hospital stays. He described going through several
counseling attempts in the past, but all were not worthwhile at that time because of avoidance
of emotions, lack of readiness, and inability to establish a trust relationship with providers. His
most critical treatment intervention came when he was mandated to enter a 180-day inpatient
rehabilitation program through the court, which really marked the beginning of his recovery
journey. This structured environment provided his first stabilization but came from Michael to
further indicate that deeper emotional work took place after discharge through voluntary
therapy, peer support, and spiritual integration.
Social Assessment Information
Michael's early substance misuse was molded by culturally reinforced norms present in
his peer group and family system, wherein drinking at family gatherings was regarded as a rite
of passage into adulthood. Though normalized, these occurrences established the groundwork
for maladaptive coping strategies that subsequently developed into addiction. He now sees his
recovery within the context of grace, spirituality, and service, adding healing is restorative to
identity and purpose and not mere abstinence. Michael's interpretations on addiction and
Diagnostic Impression Assignment 4
recovery might have further been complicated with community-wide stigma against substance
use, distrust of mental health systems, and limited access to culturally congruent care (Stritzel,
2022).
Michael mentioned that he had always had a good relationship with his mother and that
her reaction to the news of his arrest was quite shocking to him. The whole issue of how
devastated she was, became one of the key moments that made him realize how he was turning
into an addict, in very emotional terms, both within the family setting and with those who are
closer to him. This is indicative of a family dynamic that is very complex, involves broken trust,
but finally is able to care for one another and have been slowly mending it through Michael's
continual changes in behavior and taking account of his actions. Michael now lives with his wife
and children in the home they share as a family. He says "being there" as a husband and father
is one of his most significant achievements through sobriety. Though he acknowledges the
presence of tension in the marriage, he admits that the wife has continued to give him strong
support on his recovery journey.
Michael was academically qualified until he completed high school and spent some time
in college but dropped out after one semester due to behavioral issues and increasing
substance abuse. He sees those months as a source of shame and bewilderment, translating
into a sense of lost potential. Recently he expressed a desire to return to school and put it right,
indicating a renewed sense of agency and future orientation. Professionally, Michael had drifted
through brief, unstable jobs during his period of active addiction; today, he thrives as a peer
support counselor, taking immense satisfaction and joy in helping others on their own recovery
paths. His current support system consists of a sponsor, weekly therapy, a men's recovery
group, and active involvement by his family. His spiritual community and active commitment to
service work provide vital layers of meaning, connection, and resilience.
Diagnostic Impression Assignment 5
Spiritual Assessment Information
He grew up with a solid foundation of faith but is currently rekindled in his spiritual life
during the healing period-after going through much emotional pain and crisis in his life. Yes, he
says he is a Christian and has given his life to Jesus Christ, but he often would say that his faith
really has gone through testing, especially during those moments of deep grief, shame, and
strain in relationships. Sometimes he even struggles with doubt and uncertainty about whether
he is healing or surviving, but during those times, he believes that God is right there walking
with him through all that struggle.
Michael's daily experience of spirituality revolves in prayer, journaling, and reflection:
that act of getting into emotional relaxation, especially when anxiety comes creeping back into
his heart. He attends a faith-based 12-step program and considers recovery a sacred experience
one should engage in continuously surrendering and being emotionally honest to be of service
to others. For Michael, sobriety is not just refraining from others but walking in faith, reigniting
trust to live a life of integrity. Even when clarity feels elusive, his spiritual beliefs provide
meaning, resilience, and a sense of connection to something larger. According to Ajluni's (2025)
holistic perspective, spirituality is an essential and transformative element of treatment for
substance use disorders-his very own.
Psychometric Assessment Information (if used)
No standardized psychological assessments were conducted during the interview. All mental
health and recovery information simultaneously was obtained through client self-report.
Diagnostic Impression (Include F and Z codes)
•F11.20 Opioid Use Disorder, Severe, In sustained remission
Michael qualifies for severe opioid use disorder due to the use of everyday continued
practice of longer duration, failed attempts to reduce the amount, continued intake
despite adverse effects, and severe impairment in social and occupational functioning.
Diagnostic Impression Assignment 6
He is now in remission for a significant length of time, which exceeds six years and is
defined by total abstinence.
•F10.20 Alcohol use Disorder, Severe, In sustained remission
The history of heavy alcohol use, tolerance, withdrawal symptoms, as well as use in
dangerous situations, such as driving under influence (DUI), presents a vivid picture that
diagnoses severe alcohol use disorder. The patient is in sustained remission too.
•F41.2 Mixed Anxiety and Depressive Disorder
Michael reported going through severe moods during the first months of recovery, even
developing depressed moods and anxiety. He is not diagnosis; however, his symptoms
fall within what DSM-5 defines as mixed anxiety and depressive disorder, especially
when understood in terms of post-acute-withdrawal and stress arising from
relationships.
•Z63.0 Problems in Relationship with Spouse or partner
Michael describes his marriage as having ongoing tensions, with he and his wife “not
seeing eye to eye.” Still, his wife is reportedly supportive of Michael's recovery. This code
expresses an ongoing strain in the relationship, which may interfere with emotional
well-being and recovery stability.
Counselor’s Role & Inclusion of Client’s Influences in Treatment
While working alongside Michael, I am a partner in his healing process, always alive to
the empathic side of witnessing. Trauma-informed and culturally responsive approaches allow
me to honor his long-term sobriety, spirituality, and complex relational world. Within this
collaborative approach, trust and mutual respect grow between us and nurture a therapeutic
alliance wherein Michael feels safe to process feelings and reconstruct his identity (Greidanus et
al., 2020). Michael's story depicts resilience overshadowed by vulnerability, whereas my task is
to witness his inner struggle while advocating for his growth and healing.
Healing for Michael is a process defined by all the relationships that he is rebuilding, the
faith that he is rediscovering, and the service that he extends toward others. Such are the
Diagnostic Impression Assignment 7
aspects in treatment, which will involve his family, peer support network, and faith-based
recovery community strongly and meaningfully. With his consent, I may facilitate family sessions
to help repair trust and strengthen emotional bonds. Loved ones will be offered education
about addiction and trauma to better understand his journey and reduce their stigma. Group
therapy and 12-step participation will continue to be vital sources of connection and
accountability. Michael's spiritual practices-such as daily prayer, reflective journaling, and acts of
service-will be recognized as critical techniques for grounding himself. I shall also encourage his
attendance at opportunities in the community that best serve his aspirations, such as returning
to education, finding meaningful work, and mentoring others in recovery. Bagereka et al. (2023)
highlights how psychosocial and spiritual integration fosters resilience and mindfulness,
reinforcing the value of this holistic approach.
Diagnostic Impression Assignment 8
References
Ajluni V. (2025). Integrating spirituality into the treatment of substance use disorders: A holistic
approach to recovery. Industrial psychiatry journal, 34(1), 142–143.
https://doi.org/10.4103/ipj.ipj_260_24
Bagereka, P., Ameli, R., Sinaii, N. et al. Psychosocial-spiritual well-being is related to resilience
and mindfulness in patients with severe and/or life-limiting medical illness. BMC Palliat
Care 22, 133 (2023). https://doi.org/10.1186/s12904-023-01258-6
Greidanus E, Warren C, Harris GE, Umetsubo Y. Collaborative practice in counselling: a scoping
review. J Interprof Care. 2020 May-Jun;34(3):353-361. doi:
10.1080/13561820.2019.1637334. Epub 2019 Aug 20. PMID: 31429340.
Stritzel H. (2022). Peer and Community Influences on Adolescent Substance Use in the Context
of Adverse Childhood Experiences. Sociological perspectives : SP : official publication of
the Pacific Sociological Association, 65(2), 413–432.
https://doi.org/10.1177/07311214211018718
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