Ben is a 26-year-old who identifies as a gay male of European descent. He is currently working full time as a pipe fitter’s apprentice and attending school three nights a week as part of his union contract. He reports a history of Major Depressive Disorder, recurrent, but has not had any symptoms of depression in over 2 years. Recently, he has noticed that he has had low energy, doesn’t find his job as interesting as he once did, and is experiencing hopelessness about his future. Ben reports during adolescence he had some thoughts about death and dying, but he does not believe he has ever been truly “suicidal,” stating, “I know someone who died like that, and I don’t want my friends and family to suffer like that, so it’s never an option for me.”
Ben moved back home with his parents 4 months ago, as they are concerned about his depression and level of isolation.
While he does enjoy being home with his family, he has begun to feel like “a loser who can’t get out of my parents’ house.” Three months ago, he began going to the casino that is less than 10 miles from his home. He has found that he enjoys the challenge of playing poker. Ben reports when he is playing at the casino, his mood is “incredible,” and he feels like he is “on top of the world” when he wins. However, when he loses, his depression seems to get worse. In the past month, he has lost approximately $2,500. He reports he has started playing online gambling games at work to try to win back some of the money he has lost. At first, he was winning, but once he was “up,” he found he had difficulties stopping, and ultimately has lost an additional $200 through his online games.
Lesson 4 –
Case Study 4: Kevin
Addiction Case Conceptualization Template
Client Name
Presenting Concern: Why did the client come to counseling?
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.
Assessment: Identify and describe 1–2 assessment tools to be used with this client and the rationale for selecting the assessment tool.
Diagnostic Impressions: Note: Include the provisional diagnosis for the client and any rule-out or alternative considerations noted.
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.
Therapeutic Approach: Identify the chosen therapeutic approach to be used with this client and the rationale for your selection.
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.
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.
Ethical Considerations: Note any ethical considerations or challenges associated with this case.
Reference List:
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Addiction Case Conceptualization Template
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.
Reference List:
Common ideas here: Text, DSM-5, ACA Code of Ethics, articles/readings from the course, your own research.
For this paper, you should demonstrate your learning from the course and be able to conceptualize a client and treatment needs from start to finish. The conceptualization should flow. So, if you identify presenting concerns to be substance use and anxiety, I should hear about these two issues in each section. Assessment should inform diagnosis, and both should inform treatment. This is an addictions counseling course, so the substance use should be the primary focus of your paper.
Don’t forget proper grammar, spell check, graduate level writing.
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Client Name
Presenting Concern: Include reason the client stated for coming to counseling.
Case Conceptualization: Include specific information about client symptoms and presenting concerns. Include demographic information. Review biopsychosocial factors/considerations including biology, family, culture, environment, and other relevant systemic considerations; assess how the addiction impacts all major life areas).
Assessment: Identify and describe one to two assessment tools to be used with this client and the rationale for selecting the assessment tool.
Diagnostic Impressions: Include the provisional diagnosis for the client and any rule-out or alternative considerations noted.
Rationale for Diagnostic Impressions: Use the DSM-5-TR to explain how the client’s symptoms are reflected in the diagnostic criteria for each diagnosis that you render.
Therapeutic Approach: Identify the chosen therapeutic approach to be used with this client and rationale for your selection, including appropriate treatment setting.
Treatment Goals: Identify three initial treatment goals you are considering in your work with this client, and note how you will measure/know when goals are obtained. Note: Significant issues will need treatment goals.
Relapse Prevention and Continuum of Care: Describe relapse prevention needs and challenges for the client. Discuss a continuum of care plan and recommendations for client.
Ethical Considerations: Note any ethical considerations or challenges associated with this case.
References List
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Client Name: Ben
Presenting Concern: Ben came to counseling seeking help for his addiction to gambling and the negative impacts it has had on his life. He reported experiencing low energy, a lack of interest in his job, and hopelessness about his future. He also reported losing a significant amount of money through gambling, both at the casino and through online gambling games.
Case Conceptualization: Ben is a 26-year-old gay male of European descent. He works full-time as a pipe fitter’s apprentice and attends school three nights a week as part of his union contract. He has a history of Major Depressive Disorder, recurrent, but has not had any symptoms of depression in over 2 years. He moved back home with his parents four months ago, as they were concerned about his depression and level of isolation. While he enjoys being home with his family, he has begun to feel like “a loser who can’t get out of my parents’ house.” He began going to the casino three months ago and has found that he enjoys the challenge of playing poker. However, when he loses, his depression seems to get worse. In the past month, he has lost approximately $2,500. He has also started playing online gambling games at work to try to win back some of the money he has lost, and has lost an additional $200 through these games.
Biological Factors: Ben’s addiction to gambling may have a genetic component, as studies have shown that individuals with a family history of addiction are more likely to develop an addiction themselves.
Psychological Factors: Ben’s history of Major Depressive Disorder, recurrent may make him more vulnerable to developing an addiction to gambling as a way to cope with negative emotions. He also reported feeling hopeless about his future, which may contribute to his addiction.
Social Factors: Ben’s recent move back home with his parents and feelings of being a “loser” may have contributed to his increasing isolation and feelings of hopelessness. The availability of the casino within 10 miles of his home may
