Download the case conceptualization template from Case Studies: Case Conceptualization. In the template, you will provide the following:
- 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 to explain how the clients 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
James is 33 years old and identifies as a Caucasian, heterosexual, cis-gendered male. He prefers to be called Jim when being addressed. Jim reports he has been married to his high school sweetheart for 10 years. He and his wife share two biological children, one male and one female ages 4 and 6, respectively. He states, I am a practicing Catholic, and my faith is very important to my family on his intake forms. Jim is employed full time in an upper management position at a multinational biotechnology research and development firm.
Jim reports he has never seen a mental health provider, and expresses discomfort with the idea of counseling, as he is concerned others will view him as a crazy alcoholic if they were to find out. He notes that recently his wife told him she would take the kids and leave if he did not seek help for his drinking patterns. Jim states he believes his wife is overreacting to a few bad nights and is hyper-sensitive because both her parents are alcoholics.
Jim reports his first exposure to alcohol was at the age of 9, when he drank about half of his fathers beer at a neighborhood party. Jim states that when he was 14, he began consuming beer on the weekends with his friends. He estimates that he drank about two or three beers once a month or less throughout high school. His drinking patterns increased during his first year at college, stating, I drank Thursday through Sunday, and it never bothered me. I couldnt even tell you how much I drank. He was unable to manage school and these drinking behaviors for long and reduced his drinking to one or two nights per week.
Jim states he began drinking whiskey after work with his co-workers approximately 5 years ago. He was able to describe a significant amount of stress as he rose through the ranks at his organization. Drinking became a way to unwind and socialize and was also an expectation when on business trips. Over the past 6 months, Jim notes he has had three episodes where he was intoxicated to the point of a blackout. During each occurrence, he was at home drinking alone on a weekend night. He also reports that in the past month, he has missed three days of work due to not feeling well after a drinking episode, and this is beginning to impact his relationship with the leadership at the firm.
Capuzzi, D., & Stauffer, M. D. (2020). Foundations of addictions counseling (4th ed.). Boston, MA: Pearson.
- Chapter 7, Motivational Interviewing
- Chapter 8, Psychotherapeutic Approaches
- Chapter 10, Group Counseling for Treatment of Addictions
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