23 Jan Client Name Presenting Concern: Include reason the client stated for coming to counseling. Case Conceptualization: Include specific information about client symptoms and presentin
- 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
Addiction Case Conceptualization Template
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Client Name Need to select a case study from this week – James, Alejandra, Ben, or Kevin |
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Presenting Concern: Why did the client come to counseling? |
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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. |
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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. |
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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. |
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Assessment: Identify and describe 1–2 assessment tools to be used with this client and the rationale for selecting the assessment tool. |
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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? |
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Diagnostic Impressions: Note: Include the provisional diagnosis for the client and any rule-out or alternative considerations noted. |
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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. |
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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. |
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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. |
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Therapeutic Approach: Identify the chosen therapeutic approach to be used with this client and the rationale for your selection. |
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Select a treatment model/theory and explain why. Common examples (not exhaustive list) might be Cognitive Behavioral Therapy, Motivational Interviewing, Solution Focused Counseling, etc. |
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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. |
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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. |
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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. |
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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. |
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Ethical Considerations: Note any ethical considerations or challenges associated with this case. |
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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.
COUN 6730 Addiction Case Conceptualization Template Page 2 of 2
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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
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Client Name |
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Presenting Concern: Why did the client come to counseling? |
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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. |
|
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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. |
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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. |
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Ethical Considerations: Note any ethical considerations or challenges associated with this case. |
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Reference List:
COUN 6730 Addiction Case Conceptualization Template Page 1 of 3
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Enhancing Motivation for Change in Substance Use Disorder Treatment
TI TREATMENT I
P MPROVEMENT
35 PROTOCOL
UPDATED 2019
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TIP 35
Please share your thoughts about this publication by completing a brief online survey at:
www.surveymonkey.com/r/KAPPFS
The survey takes about 7 minutes to complete and is anonymous.
Your feedback will help SAMHSA develop future products.
iii
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TIP 35
Contents
Foreword viii
Executive Summary ix
TIP Development Participants xv
Publication Information xxi
Chapter 1—A New Look at Motivation 1 Motivation and Behavior Change 4
Changing Perspectives on Addiction and Treatment 6
TTM of the SOC 13
Conclusion 16
Chapter 2—Motivational Counseling and Brief Intervention 17 Elements of Efective Motivational Counseling Approaches 17
Motivational Counseling and the SOC 23
Special Applications of Motivational Interventions 26
Brief Motivational Interventions 30
Screening, Brief Intervention, and Referral to Treatment 32
Conclusion 33
Chapter 3—Motivational Interviewing as a Counseling Style 35 Introduction to MI 35
What Is New in MI 37
Ambivalence 38
Core Skills of MI: OARS 41
Four Processes of MI 48
Benefts of MI in Treating SUDs 63
Conclusion 64
Chapter 4—From Precontemplation to Contemplation: Building Readiness 65 Develop Rapport and Build Trust 66
Raise Doubts and Concerns About the Client’s Substance Use 71
Treatment 77
Conclusion 81
Understand Special Motivational Counseling Considerations for Clients Mandated to
Chapter 5—From Contemplation to Preparation: Increasing Commitment 83 Normalize and Resolve Ambivalence 84
Help Tip the Decisional Balance Toward Change 87
Conclusion 93
v
TIP 35
Enhancing Motivation for Change in Substance Use Disorder Treatment
Chapter 6—From Preparation to Action: Initiating Change 95 Explore Client Change Goals 96
Develop a Change Plan 99
Support the Client’s Action Steps 107
Evaluate the Change Plan 108
Conclusion 108
Chapter 7—From Action to Maintenance: Stabilizing Change 109 Stabilize Client Change 110
Support the Client’s Lifestyle Changes 117
Help the Client Reenter the Change Cycle 120
Conclusion 124
Chapter 8—Integrating Motivational Approaches in SUD Treatment Settings 125 Adaptations of Motivational Counseling Approaches 126
Workforce Development 131
Conclusion 135
Appendix A—Bibliography 137
Appendix B—Screening and Assessment Instruments 149
1 U S Alcohol Use Disorders Identifcation Test (AUDIT) 150
2 Drug Abuse Screening Test (DAST-10) 152
3 Drinker Inventory of Consequences (DrInC) (Lifetime) 154
4 What I Want From Treatment (2 0) 157
5 Readiness to Change Questionnaire (Treatment Version) (RCQ-TV) (Revised) 160
6 Stages of Change Readiness and Treatment Eagerness Scale–Alcohol (SOCRATES 8A) 162
7 Stages of Change Readiness and Treatment Eagerness Scale–Drug (SOCRATES 8D) 164
8 University of Rhode Island Change Assessment (URICA) Scale 168
9 Alcohol and Drug Consequences Questionnaire (ADCQ) 171
10 Alcohol Decisional Balance Scale 173
11 Drug Use Decisional Balance Scale 175
12 Brief Situational Confdence Questionnaire (BSCQ) 177
13 Alcohol Abstinence Self-Efcacy Scale (AASES) 179
14 Motivational Interviewing Knowledge Test 181
Appendix C—Resources 186
Motivational Interviewing and Motivational Enhancement Therapy 186
Stages of Change 186
Training and Supervision 186
Substance Abuse and Mental Health Services Administration 187
vi
TIP 35
Exhibits
Exhibit 1 1 Models of Addiction 7
Exhibit 1 2 Examples of Natural Changes 13
Exhibit 1 3 The Five Stages in the SOC in the TTM 14
Exhibit 2 1 The Drinker’s Pyramid Feedback 19
Exhibit 2 2 Catalysts for Change 24
Exhibit 2 3 Counselor Focus in the SOC 25
Exhibit 2 4 RESPECT: A Mnemonic for Cultural Responsiveness 27
Exhibit 3 1 A Comparison of Original and Updated Versions of MI 37
Exhibit 3 2 Misconceptions and Clarifcations About MI
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