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WRITTEN CASE PRESENTATION
Written Case Presentation
COUC 698
Liberty University
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WRITTEN CASE PRESENTATION
Client Information: Deana Davis is a 28-year-old married Caucasian women with three
children. She is currently unemployed and considers herself to be a stay home mother. Her
husband is in the military and spend a lot of time overseas.
Reason for coming to counseling/Presenting problem: Deana has come into counseling today
for a substance abuse issue. Deana states that she has been given a prescription for a back injury.
She shared that when the Dr. stop prescribing them, she noticed that the pain was not gone, and
that the pills also helped her sleep and calmed her anxiety. When she take the pills, she noticed
that her feeling of being alone seemed to disappear. She is concerned about her children because
when she takes the pills, she is not available for her young children, and her six-year-old
daughter is taking care of her younger siblings. Deana shared that she does have help from her
mother who lives across the street, and for about a year she kept her substance abuse a secret and
tried to hide it. It was when her mother noticed that the children were being neglected and
suffering malnutrition, she began to ask questions as to what was going on. Her daughter was
telling her grandmother the food in the ice box was moldy, empty, and the baby did not have any
milk.
Deana feels that she needs help with this issue of addiction. She states that she is
becoming more depressed, and experiencing anxiety. When asked how long she has been using
and having symptoms of depression and anxiety she shared that it has been since she started
looking for the narcotics on the street. Deana shared that she does not have a very good social
network because everyone she knows is taking those same pills and she understands that she
needs to change her friends in order to get better.
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WRITTEN CASE PRESENTATION
Diagnostic Impressions: Deana present with Sedative, Hypnotic or Anxiolytic Use Disorder
F13.20.
A. A problematic pattern of sedative, hypnotic or anxiolytic use leading to clinically
significant impairment or distress, as manifested by at least two of the follows, occurring
with a 12-month period:
1. Often taken in larger amounts or over a longer period than Sedatives, hypnotics, or anxiolytics
intended.
2. There is a persistent or unsuccessful effort to cut down or control use.
3. A great deal of time is spent in activities necessary to obtain substance, use substance, or
recover from its effects.
4. Craving, or strong desire or urge to use .
5. Recurrent substance use resulting in a failure to fulfill major roles/obligations
at work, school, or home.
6. Continue substance use despite having persistent or recurrent social or interpersonal problems
caused or exacerbated by the effects of the substance.
7. Important social, occupational, or recreational activities are given up or reduced because use.
8. Recurrent substance use in situations in which it is physically hazardous.
9. Substance use is continued despite the knowledge of having a persistent or recurrent physical
or psychological problem that is likely to be exacerbated by the substance.
10. Tolerance, as defined by either of the following:
a.A need for markedly increased amounts of the sedative, hypnotic, or anxiolytic to achieve
intoxication or desired effect.
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WRITTEN CASE PRESENTATION
b.A markedly diminished effect with continued use of the same amount of the sedative,
hypnotic, or anxiolytic.
11. Withdrawal, as manifested by either of the following
a. The characteristic withdrawal syndrome for sedatives, hypnotics, or anxiolytics
(refer to Criteria A and B of the criteria set for sedative, hypnotic, or anxiolytic
withdrawal)
b. Sedatives, hypnotics or anxiolytics (or a closely related substance, such as
(alcohol) are taken to relieve or avoid withdrawal symptoms.
Z62.820 Parent child relational problems, Parent-biological child
Deana presents with two or more of the above, her substance us has interfered with her normal
and daily activities. Example caring for her children and providing for their daily needs i.e., food,
hygiene, and recreational activities.
Session Descriptions: Session two: Deana was able to share that she has not used for a couple
of months and is now working. She focused on her daughter and how angry she is at Deana. Her
daughter is six years old and according Deana is having uncontrollable outburst, of yelling,
screaming and slamming doors.
Skills Competency Scale Reflection: I could have done a whole lot better with all of the skills
listed. As a new counselor I found that it was very uncomfortable to sit in silence and stare at the
client. I was the one who often broke the silence and looking away. Deana was able to stare at
me longer than I could stare at her.
Assessment of Therapeutic Relationship: I believe that Deana is very comfortable with our
relationship. She keeps coming back and that says a lot. Birth Choice is a free service and most
clients do not show up for sessions.
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WRITTEN CASE PRESENTATION
Counselor Self-Assessment: Although I have worked in the mental health field for years as a
residential assistance or a direct support professional, I have come see that I need a lot of
training. Liberty University and the CMHC degree has opened my eyes to how little I know
about the helping field. I am grateful to God that He has allowed me the opportunity to learn
from those who know and serve Him.
Skills Competency Scale (SCS)
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WRITTEN CASE PRESENTATION
This is a summary of basic counseling skills. Please rate the following 15 skills items from
Not present to advanced accordingly if they have been observed with the counselor in
training.
0 1 2 3
Not present Minimal Proficient Advanced
If a skill is not shown (NA or not observed), it should be marked as a zero.
Basic Skills
Not Present Minima
l
Proficien
t
Advance
d
Eye contact, verbal tone, and attending
skills
x
Facial expression and gestures x
Appropriate Minimal Encouragers x
Empathy x
Being non-judgmental/unconditional
positive regard
x
Active listening x
Open-ended questions x
Reflection (feelings, meaning, content) x
Paraphrasing x
Summarizing x
Attentive silence x
Challenging/Confrontation x
Immediacy x
Self-Disclosure x
Goal setting x
Wrapping up the session x
