Case Conceptualization Scenario
James is a 44-year-old male, divorced, and has one child with special needs. He comes into counseling and states “I don’t know why I am here; my life might as well be over. I have nothing left.” He looks at the floor and does not make eye contact with you. He is wearing an old t-shirt with a faded picture on it, jeans, and tennis shoes. He is partially groomed, appears to have showered but his hair is unkempt and he has not shaven in many days. He holds his hands in front of him and wrings them often. He is restless in his chair.
James slowly begins to talk about his situation. He is no longer employed and soon will be evicted from his apartment. With no job and no apartment, he will not have visitation with his son. He has few relationships in his life and those that he has are “no longer solid.” He explains that about 6 months ago he had felt agitated, restless, unhappy, and wasn’t sleeping well. He tried exercise and “doing projects,” but it didn’t help. He met up with a friend and they had a few beers. That leads to a couple of shots of whiskey, and he does not remember the rest of the night, but he woke up in his bed, alone, so assumed nothing much happened. A few days later he did the same thing, but this time he also had some prescription pain killers from a dental surgery that he had a long time ago. He felt great and had fun with a couple of friends.
James explains that over the course of 6 months his use of alcohol and prescription pain killers has increased. He has stolen pills from his friends and driven under the influence. Because he is a delivery driver for FedEx, he lost his job when they could smell alcohol on him at the end of his shift. He was not arrested and was not given a DUI, but he has lost his job, lost his insurance, and is losing his apartment because he has not found another job. His alcohol and prescription use have increased to him drinking 8-10 beers a day, taking whatever pills he can find, and blacking out at home. His friends have become angry with him and do not trust him because he has stolen from them. He has contemplated just overdosing and ending it all. He reiterates that his life is in shambles; he is hopeless, helpless, and feels worthless.
DESCRIPTION OF CLIENT(S):
Write what you observe about the client—age, sex, ethnicity, appearance, behaviors, and impressions.
Describe the problem as the client has presented it, including perspective, function impairment, and symptoms.
HISTORY OF PROBLEM:
Describe the course of the problem and specific onset and symptoms.
Mood and Affect:
Thought Process, Content, and Perception:
Cognition, Insight, and Judgment:
Suicidal and Homicidal Assessment
If a more thorough suicide/homicide evaluation is conducted, it may be documented in a separate section.
Describe the client’s present living situation:
Social History (include history of abuse/trauma):
HEALTH & WELLNESS HISTORY:
Substance use (including alcohol, drugs, tobacco and caffeine intake):
Eating habits and appetite:
PREVIOUS THERAPY / PSYCHIATRIC SERVICES:
Have you ever been in counseling before? No Yes, Inpatient Outpatient Day Treatment
Name of Provider Clinic Year Diagnosis / Problem
Have you ever seen a Psychiatrist before? No Yes, Inpatient Outpatient Day Treatment
Name of MD: _______________________________________ Clinic: _____________________________
Was any of your previous therapy related to substance abuse? No Yes
Have you ever had serious thoughts of suicide or homicide? No Yes
Have you ever made a suicide / homicide attempt? No Yes Explain: ____________________________
Do you presently feel suicidal or homicidal? No Yes Explain: __________________________________
FAMILY RELATIONSHIP HISTORY:
Describe the client’s current and historical family status and relationships, including during childhood/adolescence.
Describe assets that will facilitate progress and change, such as motivation, intelligence, self-discipline, and willingness to utilize resources.
Describe aspects’ of the client’s life circumstance that may impede progress/change, such as homelessness, major psychiatric disorder, financial hardship, etc.
Using the information gathered thus far, make a diagnosis using DSM 5.
Provide your rationale for the provided diagnosis. Describe the appropriate theory to consider using with this client. Note the basics of this theory and how it might apply to this client.