CASE PRESENTATION DOCUMENTATION EVALUATION.
CASE PRESENTATION DOCUMENTATION EVALUATION.
Perform a clinical intervention of a case provided by the facilitator. In this clinical process of psychosocial intervention and individual psychotherapy you must develop a clinical conceptualization presenting the following:
- Identify the client system by collecting basic screening information.
- Use social work instruments or techniques such as: interview, genogram, ecomaps and other tools.
- Formulate diagnosis according to DSM-5
- Consider the stage of human development
- Apply models or theories applicable to the situation
- Establish a treatment plan
- Explain the therapeutic procedure or follow-up sessions of the treatment plan
- Analyze the ethical aspects of the therapeutic intervention process.
The patient’s name is Marci; she is a 22-year-old female college student who is currently not married. The patient was forced to attend counseling sessions after she was arrested five months ago for driving while impaired with a blood-alcohol level of 0.13. The patient was also charged with the possession of a small amount (about 1 gram) of marijuana. Recently, the patient has expressed concern to her friends about the feeling depressed and anxious; however, she has not reported any suicidal ideation or panic attacks. Also, the patient has reported being concerned about being pregnant as she claims she has missed her period. The patient does not admit to any physical problems and claims she was not hurt after she was involved in two accidents while drunk driving. The patient also claims she has been sexually active for the past two years with her “semi-permanent” boyfriend. The patient claims she had a false alarm of being pregnant a year ago. She also says now and then, especially during allergy season, she tends to get a dry, hacky cough.
The patient admitted that, since she began smoking marijuana, her previously good and trusting relationship with her parents has soured. She claimed that since she started using Marijuana, she began hiding and lying to her parents and has increasingly felt negative about herself, especially as her grades have suffered and her general interests have narrowed. She admits to having tried using cocaine and LSD be she stopped after she had an unpleasant experience with the drugs. The patient also said she felt guilt and remorse after she was arrested due to her drinking and marijuana use problem since she feels her drug abuse problem has negatively impacted her relationship with her parents and interfered with her desire to be an attorney. She also agrees that marihuana use has affected her motivation, her schoolwork, and her spiritual life, but she has not expressed concerns about her use of alcohol. The patient stated that, although she has not used marijuana since she was arrested, she still has doubts about its harmfulness. The patient has five prescription pills (Xanax) for depression and anxiety that were given to her by a college classmate (for whom they were prescribed) but she hasn’t used them yet.
The patient comes from a family history of people with substance use and alcohol problems. She is the oldest of three children. She has one brother, Jacob, 17-years-old; and one sister, Sarah, 14-years-old. The patient’s mother Joan is a successful attorney, and her father, John, is a school administrator. The patient’s family has always 3 attended weekly services at their church and has, on a couple of occasions, going as a family on church-sponsored humanitarian missions to Latin America. It is during this time, while she was 13 years old when she started drinking wine while on these trips after her family incorporated drinking during dinners. Local customs observed in these countries majorly influenced this decision to incorporate drinking wine during dinners. The patient’s siblings do not have substance use or drinking problem; however, his brother admitted to drinking beer once with friends but did not like it. He also tried smoking his mother’s cigarettes when he was 15 but stop since he wanted to play sports. On the other hand, her sister hates the smell of cigarettes, alcohol, and marijuana and would never try them.
However, the patient’s parents have a history of substance abuse and alcohol problems. Her mother who is 45 years old now, admitted to using marijuana while she was growing up and has struggled with depression and anxiety since she was quite young. Her mother is also a tobacco addict for over 30 years, however, for over three years, she has had quite her habit. The patient’s mother does not drink; however, she enjoys two glasses of wine occasionally. The patient’s mother claims her parents had an alcohol problem, her oldest brother has an alcohol problem and her other siblings never touched alcohol. The patient’s mother also claims that there are rumors her grandparents had a drinking problem too. The patient’s father was a heavy drinker while he was young but stopped after he got married 25 years ago. However, he drinks wine occasionally during dinner and reports no problem with mood disorders although he worries regularly about his work problems and can provide for his family. The patient’s father claims his parents struggled with depression and anxiety. His parents were not heavy drinkers; however, he stated that his grandfather was an alcoholic.
The patient has never been in an in-patient or an out-patient program.
The patient is currently in her junior year of college where she has not been doing remarkably well to live up to her academic potential. She has experienced a declining performance in terms of her academic grades in college. In her high school years, the patient was a good student, generally achieving all the normal milestones. The patient used to get A’s and B’s during her high school education. The patient lives at home with her parent while attending college.
The patient is currently unemployed. However, in the past she has worked as a waitress and when she turned 21, as a part-time bartender for the extra money. The patient’s longest employment was about six months as a waitress. Over a period of four years, the patient has been fired or left three other places of employment due to excessive absenteeism and once for the destruction of property.
Substance Abuse History
The patient started smoking cigarettes at the age of 16 and she is currently smoking one pack daily. The patient quit smoking about 6 months-one year ago. However, she started smoking again and does not have a plan to quit smoking again. The patient also has a Marijuana abuse problem that started during her senior year of high school at the age of 17 years after she was introduced to marijuana by her high school boyfriend. Her marijuana use problem becomes more regular after she joined college and had been smoking two to three times a week for one year. After her parents discovered the problem, they recommended she seek professional help, which she refused and started contemplating quitting school after they threatened to report her to the academic dean.
The patient also has a drinking/ alcohol abuse problem. She started drinking wine at the age of 13 while enjoying it with her family during dinner. However, the patient began seriously drinking at the age of 18 and currently drinks four or more alcoholic beverages three to four times a week. The patient’s recreational and social interests had increasingly involved the use of alcohol and marijuana, now since her arrest, it is mainly alcohol. Her drinking problem has had negative impacts on her classes as she tended to sleep in and cut class every morning after a night of drinking. The patient also started to consume energy drinks such as Red Bull, and Monster, when she drank beer at parties to get an added “boost” to her high.
Mental Status Examination
The patient was neatly dressed; her grooming was appropriate and displayed a compliant manner. The patient was very cooperative in the interview and answered all the questions politely. The patient’s mood during the interview was somewhat anxious and depressed. The patient’s affect was appropriate and looked not emotional but appears torn between embarrassment and anger at being forced to attend counseling. Her rate of speech was somehow rapid, especially when answering questions about her substance use history. She seemed pressured at times, but she generally appeared normal. The patient’s tone was modulated from high when discussing subjects that made her anxious and low when discussing subjects that were depressing to her. The patient’s thought process was logical and demonstrated proper insight into her actions and how these actions contributed to her current situation. The patient did not express the need to stop using marijuana or drinking alcohol. The patient was oriented, and she showed no problem answering the mental status questions or doing “serial sevens.”
The primary diagnosis given to the patient would include Substance/Medication-Induced Anxiety Disorder ICD code 292.89. (F12.180) mild (American Psychiatric Association, 2013). This is because the patient is said to have been experiencing a mild feeling of anxiety and depression and has a history of marijuana/cannabis use.
The secondary diagnosis will involve Cannabis Use Disorder and Alcohol Use Disorder ICD code 304.30 (F12.20) Moderate and 303.90 (F10.20) Moderate respectively (American Psychiatric Association, 2013). The patient has a history of cannabis and alcohol use lasting for more than two years.
The tertiary diagnosis given to the client will involve Tobacco Use Disorder ICD code 305.1 (F17.200) Moderate (American Psychiatric Association, 2013). The patient has a history of tobacco smoking that extends to more than 6 years whereby she smokes one pack of cigarettes a day.
Principally, the patient has been taking all three substances (alcohol, Marijuana, and Tobacco) in large amounts for a longer period. My diagnostic impression of the client is that she is suffering from substance abuse disorder. This disorder has majorly impacted her brain and behavior, leading to her inability to control their smoking, marijuana, and alcohol use (Luckovich et al., 2021). According to the Anxiety and Depression Association of America, about 20 percent of individuals with anxiety and depression usually have a substance use problem (Walters et al., 2018). Thus, the patient fits the diagnostic impression profile of a person with a substance abuse disorders that is bringing about her anxiety and depression feelings (Kalin, 2020).
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders. Am Psychiatric Association, 21, 591-643.
Kalin, N. H. (2020). The critical relationship between anxiety and depression. American Journal of Psychiatry, 177(5), 365-367.
Laczkovics, C., Kothgassner, O. D., Felnhofer, A., & Klier, C. M. (2021). Cannabidiol treatment in an adolescent with multiple substance abuse, social anxiety and depression. neuropsychiatrie, 35(1), 31-34.
Walters, K. S., Bulmer, S. M., Troiano, P. F., Obiaka, U., & Bonhomme, R. (2018). Substance use, anxiety, and depressive symptoms among college students. Journal of Child & Adolescent Substance Abuse, 27(2), 103-111.