Markus is a Caucasian 45 year old male, who has been smoking cannabis since he was 18 years old. He now grows his own plants. He used to drink alcohol mixed drinks (2 drinks p
Case Study
Markus is a Caucasian 45 year old male, who has been smoking cannabis since he was 18 years old. He now grows his own plants. He used to drink alcohol mixed drinks (2 drinks per night) and 4 or more on the weekends. In the past 6 months the amount has doubled. He is married and lives with his wife and their 15 year old daughter. The presenting problem is physical. He has high cholesterol, irregular heart beat, and is beginning to have memory problems. He went to the hospital because he was having problems, heart palpitations and high blood pressure. He has never sought treatment before but has tried over the past five years to stop smoking cannabis on his own and has not been successful. He says he is too shaky and nervous without it. He has also tried to cut back on his drinking but he is too nervous when he gets home from work and feels he needs the drinks. He is adopted so he has no family medical history. He is currently employed as a producer at the local news station. He has no incidence with the law. His wife would like him to stop smoking and drinking so that his health will improve. His drinking and smoking has caused some problems in his family life.
Case Study
Markus is a Caucasian 45 year old male, who has been smoking cannabis since he was 18 years old. He now grows his own plants. He used to drink alcohol mixed drinks (2 drinks per night) and 4 or more on the weekends. In the past 6 months the amount has doubled. He is married and lives with his wife and their 15 year old daughter. The presenting problem is physical. He has high cholesterol, irregular heart beat, and is beginning to have memory problems. He went to the hospital because he was having problems, heart palpitations and high blood pressure. He has never sought treatment before but has tried over the past five years to stop smoking cannabis on his own and has not been successful. He says he is too shaky and nervous without it. He has also tried to cut back on his drinking but he is too nervous when he gets home from work and feels he needs the drinks. He is adopted so he has no family medical history. He is currently employed as a producer at the local news station. He has no incidence with the law. His wife would like him to stop smoking and drinking so that his health will improve. His drinking and smoking has caused some problems in his family life.
Case Study Analysis
You will have two primary headings and numerous subheadings. The primary sections include client description and treatment considerations. The subheadings are identified below.
Client description
Provide all of the pertinent information about Marcus. Please include each of the following sections.
1. client’s drug of choice –
0. the drug of choice is typically one substance and then followed by other substances used or tried.
1. timeline of when the substance use began and the nature and course of its progression (full description of etiological factors)
1. This information is needed for each substance. Think about: age of onset, when did the use increase, think about frequency and duration of use, method of use changes, periods of abstaining, etc.
1. causative and reinforcing factors related to family dynamics (both immediate family and extended family);
2. Think about the theory of addiction (moral, social, biological, psychological, etc) and what factors support your theory (parental use, witnessing it as a child, etc)
1. cultural factors
3. Use the ADDRESSING format, identify how culturally attributes impact use and recovery
1. diagnosis (according to DSM 5 criteria) including severity level and other relevant specifiers;
4. identify each criterion that is met for the diagnosis, if higher criteria are met it typically means that lower criteria are met
4. be sure to identify mental health diagnoses and V codes, if they apply
1. students choice of theoretical approach implemented on this case;
5. What is your counseling theory and why? Example: If you are using CBT, you will need research stating that that theory is appropriate for this client (male, child, African American) and this diagnosis (Cannabis Use Disorder, Moderate).
5. Identify what theoretical techniques or skills you will use to treat this client.
1. prognosis;
6. Think about the stages of change, support system, protective factors, risk factors, research on prognosis, look at the DSM for prognosis information too.
1. detailed treatment plan (including spirituality and wellness variables)
7. This must include the problem, goals, (3) objectives, dates for each diagnosis.
7. The goals must be to reduce ___________ (symptom). The objectives must be HOW the client will reduce the symptom in session. The intervention is what the counselor used to help the client meet the objective. All of the objectives and interventions must align with the theory of counseling that you chose in step 6.
Treatment
This section will detail how you will treat the client – from beginning to end. Please demonstrate consideration of each of the following areas, in accordance with state credentialing requirements (Core Functions). If you need more information on these sections please see the attachment in the “student supplemental material” section (12 core functions).
In this section, you will essentially identify what the client will experience in each step of the treatment process. Your textbook discusses each of these areas of treatment. Be sure to read your textbook and cite and reference the information as needed. You are also encouraged to use additional scholarly sources to complete this section.
Short example of some information that might be included in the sections:
The purpose of an screening is _________________ (citation). The initial screening may take place via phone or in a private room if the client is a walk-in. During the screening, the client will be asked a series of questions about their needs, insurance, and times of availability. They will also be assessed for suicidal and homicidal ideation. If the client is deemed appropriate for services an appointment time will be scheduled.
An intake has many functions including _______________ (citation). An intake may be conducted by an intake specialist or a mental health clinician. The intake can include the MSE, biopsychosocial questionnaire, _________, __________. During the intake the client will complete several forms including an informed consent, resease of information, ___________, ____________,
Possible sections to include.
1. Screening, – identify how counselors screen clients, how would you screen this client
1. Intake – identify a particular intake(s) that would be used, what information would be gathered, why is that intake chosen over others, what assessment would be used, why would you choose this method over other methods, who does the intake
1. Orientation – what type of information is included in the orientation and why, who provides the orientation,
1. Counseling – the type of counseling (group, individual, family), counseling theory (Narrative, CBT, Adlerian, etc), length of counseling
1. Case Management – client needs, referrals, rationale for case management services
1. Crisis Intervention – identify crisis needs, crisis plan, treatment considerations in the event of a crisis, include an emergency number if the client has a crisis when they are not in session, what paperwork is completed for crises
1. Assessment – identify assessment tools that you would use, why this tool was chosen over others, identify information that needs to be collected, who will give the assessment, how long will the assessment take, etc
1. Treatment Planning – identify and rank problems, identify immediate and long term goals, treatment method, what paperwork is completed for treatment planning,
1. Client educational needs – psychoeducational needs, AoD classes, parenting classes, tutoring, GED classes, etc.
1. Appropriate Referral – identify needs, agencies to meet those needs, rationale for the referral, identify support systems, who provides the referrals, what paperwork is completed for the referral
1. Reports and record keeping – identify what records would be kept, what information might be in those records, why one keeps records
1. Consultation needs – identify the counselor's scope of practice, with whom the counselor might consult, rationale for consulting, ethics, need for releases of information, etc.
The paper should be no more than 10 pages in length and follow APA style. There should be no less than five sources included in the reference section, with a minimum of two coming from professional/peer-reviewed/scholarly journal articles.
image1.emf
,
Stages of Change
Provided by TherapistAid.com © 2012
Precontemplation
The costs of the problem behavior (such as drug use) are not yet recognized. The
individual is in denial and is not seriously considering changing their behavior.
They may have made previous attempts to change, but have since given up.
Contemplation
The individual is experiencing ambivalence about change. They can see reasons
to change their behavior, but they are still hesitant. The problem behavior
continues.
Preparation
The individual has decided to change their behavior, and they begin to think
about how to do so. During this stage they will begin to make minor changes to
support their goal, but they might not have completely ended the unwanted
behavior.
Action
Significant steps are taken to end the problem behavior. The individual might be
avoiding triggers, reaching out for help, or taking other steps to avoid temptation.
Maintenance
The changes made during the action stage or maintained. The individual may
continue to face challenges, but at this point they have successfully changed
their behavior for a significant period of time.
Relapse
After making changes, some individuals will return to their previous problem
behavior. This can happen at any time during the previous stages. Not everyone
will experience relapse, but it is always a risk.
1
2
3
4
5
,
TWELVE CORE FUNCTIONS OF THE ALCOHOL AND OTHER DRUG ABUSE COUNSELOR
The Case Presentation Method is based on Twelve Core Functions. Scores on the CPM are based on the Global Criteria for each Core Function. The counselor must be able to demonstrate competence by achieving a passing score on the Global Criteria in order to be certified. Although the Core Functions may overlap, depending on the nature of the counselor’s practice, each represents a specific entity. Give specifics throughout and do not supply original definitions. I. SCREENING: The process by which the client is determined appropriate and eligible for
admission to a particular program.
Global Criteria 1. Evaluate psychological, social, and physiological signs and symptoms of alcohol and
other drug use and abuse. 2. Determine the client’s appropriateness for admission or referral. 3. Determine the client’s eligibility for admission or referral. 4. Identify any coexisting conditions (medical, psychiatric, physical, etc.) that indicate need
for additional professional assessment and/or services. 5. Adhere to applicable laws, regulations and agency policies governing alcohol and other
drug abuse services.
Explanation This function requires that the counselor consider a variety of factors before deciding whether or not to admit the potential client for treatment. It is imperative that the counselor use appropriate diagnostic criteria to determine whether the applicant’s alcohol or other drug use constitutes abuse. All counselors must be able to describe the criteria they use and demonstrate their competence by presenting specific examples of how the use of alcohol and other drugs has become dysfunctional for a particular client. The determination of a particular client’s appropriateness for a program requires the counselor’s judgment and skill and is influenced by the program’s environment and modality (i.e., inpatient, outpatient, residential, pharmacotherapy, detoxification or day care). Important factors include the nature of the substance abuse, the physical condition of the client, the psychological functions of the client, outside supports/resources, previous treatment efforts, motivation and philosophy of the program. The eligibility criteria are generally determined by the focus, target population and funding requirements of the counselor’s program or agency. Many of the criteria are easily ascertained. These may include the client’s age, gender, place of residence, legal status, veteran status, income levels and referral source. Allusion to following agency policy is a minimally acceptable statement.
1
If the applicant is found ineligible or inappropriate for this program, the counselor should be able to suggest an alternative.
II. INTAKE: The administrative and initial assessment procedures for admission to a program.
Global Criteria 6. Complete required documents for admission to the program. 7. Complete required documents for program eligibility and appropriateness. 8. Obtain appropriately signed consents when soliciting from or providing information to
outside sources to protect client confidentiality and rights. Explanation The intake usually becomes an extension of the screening, when the decision to admit is formally made and documented. Much of the intake process includes the completion of various forms. Typically, the client and counselor fill out an admission or intake sheet, document the initial assessment, complete appropriate releases of information, collect financial data, sign a consent for treatment and assign the primary counselor. III. ORIENTATION: Describing to the client the following: general nature and goals of the
program; rules governing client conduct and infractions that can lead to disciplinary action or discharge from the program; in a nonresidential program, the hours during which services are available; treatment costs to be borne by the client, if any; and client rights.
Global Criteria 9. Provide an overview to the client by describing program goals and objectives for client
care. 10. Provide an overview to the client by describing program rules, and client obligations and
rights. 11. Provide an overview to the client of program operations.
Explanation The orientation may be provided before, during and/or after the client’s screening and intake. It can be conducted in an individual, group or family context. Portions of the orientation may include other personnel for certain specific aspects of the treatment, such as medication. IV. ASSESSMENT: The procedures by which a counselor/program identifies and evaluates an
individual’s strengths, weaknesses, problems and needs for the development of a treatment plan.
Global Criteria 12. Gather relevant history from client including but not limited to alcohol and other drug
abuse using appropriate interview techniques.
2
13. Identify methods and procedures for obtaining corroborative information from significant
secondary sources regarding clients’ alcohol and other drug abuse and psycho-social history.
14. Identify appropriate assessment tools. 15. Explain to the client the rationale for the use of assessment techniques in order to
facilitate understanding. 16. Develop a diagnostic evaluation of the client’s substance abuse and any coexisting
conditions based on the results of all assessments in order to provide an integrated approach to treatment planning based on the client’s strengths, weaknesses, and identified problems and needs.
Explanation Although assessment is a continuing process, it is generally emphasized early in treatment. It usually results from a combination of focused interviews, testing and/or record reviews. The counselor evaluates major life areas (i.e., physical health, vocational development, social adaptation, legal involvement and psychological functioning) and assesses the extent to which alcohol or drug use has interfered with the client’s functioning in each of these areas. The result of this assessment should suggest the focus of treatment. V. TREATMENT PLANNING: Process by which the counselor and the client identify and
rank problems needing resolution; establish agreed upon immediate and long-term goals; and decide upon a treatment process and the resources to be utilized.
Global Criteria 17. Explain assessment results to client in an understandable manner. 18. Identify and rank problems based on individual client needs in the written treatment plan. 19. Formulate agreed upon immediate and long-term goals using behavioral terms in the
written treatment plan.
20. Identify the treatment methods and resources to be utilized as appropriate for the individual client.
Explanation The treatment contract is based on the assessment and is a product of a negotiation between the client and the counselor to assure that the plan is tailored to the individual’s needs. The language of the problem, goal and strategy statements should be specific, intelligible to the client and expressed in behavioral terms. The statement of the problem concisely elaborates on a client need identified previously. The goal statements refer specially to the identified problem and may include one objective or a set of objectives ultimately intended to resolve or mitigate the problem. The goals must be expressed in behavioral terms in order for the counselor and client to determine progress in treatment. Both immediate and long-term goals should be established. The
3
plan or strategy is a specific activity that links the problem with the goal. It describes the services, who will perform them, when they will be provided and at what frequency. Treatment planning is a dynamic process and the contracts must be regularly reviewed and modified as appropriate. VI. COUNSELING : (Individual, Group, and Significant Others): The utilization of special
skills to assist individuals, families or groups in achieving objectives through exploration of a problem and its ramifications; examination of attitudes and feelings; consideration of alternative solutions; and decision-making.
Global Criteria 21. Select the counseling theory(ies) that apply(ies). 22. Apply technique(s) to assist the client, group, and/or family in exploring problems and
ramifications. 23. Apply technique(s) to assist the client, group, and/or family in examining the client’s
behavior, attitudes, and/or feelings if appropriate in the treatment setting. 24. Individualize counseling in accordance with cultural, gender, and lifestyle differences. 25. Interact with the client in an appropriate therapeutic manner. 26. Elicit solutions and decisions from the client. 27. Implement the treatment plan.
Explanation Counseling is basically a relationship in which the counselor helps the client mobilize resources to resolve his or her problem and/or modify attitudes and values. The counselor must be able to demonstrate a working knowledge of various counseling approaches. These methods may include Reality Therapy, Transactional Analysis, Strategic Family Therapy, Client Centered Therapy, etc. Further, the counselor must be able to explain the rationale for using a specific approach for the particular client. For example, a behavioral approach might be suggested for clients who are resistant and manipulative or have difficulty anticipating consequences and regulating impulses. One the other hand, a cognitive approach may be appropriate for a client who is depressed, yet insightful and articulate. Also, the counselor should explain his or her rationale for choosing a counseling approach in an individual, group or significant other context. Finally, the counselor should be able to explain why a counseling approach or context changed during treatment. VII. CASE MANAGEMENT: Activities which bring services, agencies, resources, or people
together within a planned framework of action toward the achievement of established goals. It may involve liaison activities and collateral contacts.
Global Criteria 28. Coordinate services for client care.
4
29. Explain the rationale of case management activities to the client.
Explanation Case management is the coordination of a multiple services plan. Case management decisions must be explained to the client. By the time many alcohol and other drug abusers enter treatment they tend to manifest dysfunction in a variety of areas. For example, a heroin addict may have hepatitis, lack job skills and have a pending criminal charge. In this case, the counselor might monitor high medical treatment, make a referral to a vocational rehabilitation program and communicate with representatives of the criminal justice system. The client may also be receiving other treatment services such as family therapy and pharmacotherapy, within the same agency. These activities must be integrated into the treatment plan and communication must be maintained with the appropriate personnel. VIII. CRISIS INTERVENTION: Those services which respond to an alcohol and/or other
drug abuser’s needs during acute emotional and/or physical distress.
Global Criteria 30. Recognize the elements of the client crisis. 31. Implement an immediate course of action appropriate to the crisis. 32. Enhance overall treatment by utilizing crisis events.
Explanation A crisis is a decisive, crucial event in the course of treatment that threatens to compromise or destroy the rehabilitation effort. These crises may be directly related to alcohol or drug use (i.e., overdose or relapse) or indirectly related. The latter might include the death of a significant other, separation/divorce, arrest, suicidal gestures, and a psychotic episode or outside pressure to terminate treatment. If no specific crisis is presented in the Written Case, rely on and describe a past experience with a client. Describe the overall picture-before, during and after the crisis. It is imperative that the counselor be able to identify the crisis when they surface, attempt to mitigate or resolve the immediate problem and use negative events to enhance the treatment efforts, if possible. IX. CLIENT EDUCATION: Provision of information to individuals and groups concerning
alcohol and other drug abuse and the available services and resources.
Global Criteria 33. Present relevant alcohol and other drug use/abuse information to the client through
formal and/or informal processes. 34. Present information about available alcohol and other drug services and resources.
Explanation
5
Client education is provided in a variety of ways. In certain inpatient and residential programs, for example, a sequence of formal classes may be conducted using a didactic format with reading materials and films. On the other hand, an outpatient counselor may provide relevant information to the client individually or informally. In addition to alcohol and drug information, client education may include a description of self-help groups and other resources that are available to the clients and their families. The applicant must be competent in providing specific examples of the type of education provided to the client and the relevance to the case. X. REFERRAL: Identifying the needs of a client that cannot be met by the counselor or
agency and assisting the client to utilize the support systems and community resources available.
Global Criteria 35. Identify need(s) and/or problem(s) that the agency and/or counselor cannot meet. 36. Explain the rationale for the referral to the client. 37. Match client needs and/or problems to appropriate resources. 38. Adhere to applicable laws, regulations and agency policies governing procedures related
to the protection of the client’s confidentiality. 39. Assist the client in utilizing the support systems and community resources available.
Explanation In order to be competent in this function, the counselor must be familiar with community resources, both alcohol and drug and others, and should be aware of the limitations of each service and if the limitations could adversely impact the client. In addition, the counselor must be able to demonstrate a working knowledge of the referral process, including confidentiality requirements and outcomes of the referral. Referral is obviously closely related to case management when integrated into the initial and on- going treatment plan. It also includes, however, aftercare of discharge planning referrals that take into account the continuum of care. XI. REPORT AND RECORD KEEPING: Charting the results of the assessment and
treatment plan, writing reports, progress notes, discharge summaries and other client-related data.
Global Criteria 40. Prepare reports and relevant records integrating available information to facilitate the
continuum of care. 41. Chart pertinent ongoing information pertaining to the client. 42. Utilize relevant information from written documents for client care.
6
Explanation The report and record keeping function is important. It benefits the counselor by documenting the client’s progress in achieving his or her goals. It facilitates adequate communication between co-workers. It assists the counselor’s supervisor in providing timely feedback. It is valuable to other programs that may provide services to the client at a later date. It can enhance the accountability of the program to its licensing/funding sources. Ultimately, if performed properly, it enhances the client’s entire treatment experience. The applicant must provide personal action in regard to the report and record keeping function. XII. CONSULTATION WITH OTHER PROFESSIONALS IN REGARD TO CLIENT
TREATMENT/SERVICES: Relating with in-house staff or outside professionals to assure comprehensive, quality care for the client.
Global Criteria 43. Recognize issues that are beyond the counselor’s base of knowledge and/or skill. 44. Consult with appropriate resources to ensure the provision of effective treatment services. 45. Adhere to applicable laws, regulations and agency policies governing the disclosure of
client-identifying data. 46. Explain the rationale for the consultation to the client, if appropriate.
Explanation Consultations are meetings for discussion, decision-making and planning. The most common consultation is the regular in-house staffing in which client cases are reviewed with other members of the treatment team. Consultations may also be conducted in individual sessions with the supervisor, other counselors, psychologists, physicians, probation officers and other service providers connected to the client’s case.
Last Updated 9/05
7
Collepals.com Plagiarism Free Papers
Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.
Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS
Why Hire Collepals.com writers to do your paper?
Quality- We are experienced and have access to ample research materials.
We write plagiarism Free Content
Confidential- We never share or sell your personal information to third parties.
Support-Chat with us today! We are always waiting to answer all your questions.
