Addiction Case Conceptualization.

Use the Addiction Case Study Conceptualization template from the media piece linked in Resources to guide your analysis of the case conceptualization. Include all of the following, applying your clinical judgment for the case conceptualization:

Describe the identifying data.
Presenting Problem: Include the initial diagnosis, problem list, and client strengths.
State the relevant history.
Identify the client stage of change.
Discuss ASAM Dimensions from your Unit 3 assignment.
Develop a preliminary diagnosis using the DSM-5.
Substantiate the appropriate level of care.
Propose a treatment modality.
Learner’s Conceptualization of the Problem:
- Organize observations, assessments, and measures to patterns and themes to accurately reflect a client’s concerns. This section includes a summary of your view of the problem.
- Explain the common themes. This section combines all the above data and the crux of the conceptualization. Apply your clinical judgment to fuse the data in order to conceptualize the client.

Review the Case Conceptualization Scoring Guide to ensure you are including all the requirements.

Sarah is a 15-year-old Black female who lives at home with her parents and is a freshman in high school. She reports her school counselor suggested she seek counseling, so that she has additional support for the struggles she is experiencing. Sarah states that her mother has had a series of bad relationships. Sarah reports that when she was 10, her mother’s boyfriend sexually assaulted her on a weekly basis while her mother was at work. She reports this lasting for “almost a year.” Sarah reports that she has not told her mother, because she feels like her mother will not believe her. Sarah reported this man was killed in a “drug deal” and that she feels “guilty for being happy about him dying.”

Sarah stated her mom has physically and emotionally abused her for “as long as I can remember.” She stated she has never disclosed this information, not even to her school counselor. She stated she is fearful that if she tells and her mother finds out that she will be in danger. Sarah reports always feeling “sad,” and can’t remember a time when she was not sad. Sarah stated she has no brothers or sisters and does not know who her father is or where he lives. Sarah reports having a grandma who lives in Florida, but she does not get to talk to her very often.

When asked about interests or activities, Sarah reports she likes to draw and write poetry. She stated she must hide her drawings and her poems from her mother because she will “rip them up” and “tell me I am stupid.” Sarah stated she does well in school, but lately her grades have fallen, because she is not completing her homework. She reports spending time with “an older guy” after school. She reports he “makes me feel good” and she states she has been taking “pills” with him daily. She stated she has been using opiates for about 6 months and that she “loves the feeling because it gets rid of my anxiety.” Sarah reports her use has increased from taking one pill a day to at least 4 to 5 pills per day.

Sarah denies any desire to stop taking opiates and reports she is only here to talk about her life at home and learn how to “deal with my mother.”

http://media.capella.edu/CourseMedia/COUN5261/ACS_Conceptualization/wrapper.asp

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