Case study: Diagnosis and Treatment Recommendations

Order Description

Read the case study provided and write a clinical report which includes:
1. A summary of the major issues facing the client needing to be addressed.
2. A working diagnosis for the client (with diagnostic summary and rationale) utilizing the following information from the CAGE screening tool and case history information.
3. A Mental Status Exam which applies the information from the case history.
4. Detailed treatment recommendations determining which modality (family, individual, group, or couples) is most appropriate for this client. Be sure to provide the rational for your choice by integrating information from the case summary.
5. Recommendations on whether individual is a good candidate for treatment placement (inpatient, residential, or outpatient) and an analysis of the pros and cons for your selection based on a summary of the issues.

Case Information
Client: Joseph Blackwell
Date of Birth: July 10, 1961

Identifying Information
Gender: Male
Age: 49
Religion: Baptist
Race/Ethnicity: Caucasian
Disability: No visible disabilities
Class: Annual income under $12,000
Educational Qualification: High School Diploma

Current Family Constellation and Living Arrangements
Married currently separated
3 children, ages 20, 15, 2
Currently homeless, staying with a friend

Other Family Information
Mother gives money to him on a consistent basis
The only person who “nags” him about his drinking is his wife
Other family members have covered for him on more than one occasion, telling his wife he was working when he was really getting high.

Employment Status
Recently lost job due to failure to show up.
Employed there for 6 months
Reports having over 10 jobs in the last 5 years
Skilled as a roofer

Legal Problems
Took a Plea for Treatment in lieu of conviction for current possession of cocaine charge
License suspended for Driving Under the Influence
Currently on Probation

Past/Current Psychological Problems
Reports a diagnosis of Bipolar Manic Depression made several years ago
States “I just wants it all go away, maybe it be better if I just went away, sometimes I cry when I wake up.”

Medication history
Records indicated that the client has been treated off and on with Seroquel and Lithium. He reported that both medications helped him feel more “calm and collected.” He has been off of medication for the past 2 months.

Substance Use history
The client stated that he drinks alcohol every day, usually 1 liter of vodka and a few beers. This pattern of drinking endured for the past 10 years. He tried to stop drinking one time and the longest that he has abstained from drugs and alcohol was for a period of 3 months a few years ago. He also uses cocaine and marijuana several times per week. He stated that he has thought about stopping the substance use, but is sure that he will never be able to abstain. The patient has a history of the shakes when he has attempted to stop drinking in the past. He has tried outpatient substance abuse counseling, though would usually relapse after a few sessions. He has never participated in inpatient detox.

Records reviewed (Psychiatric ER summary dated August 6, 2010)
Patient was admitted to the X psychiatric emergency room and placed on a 72 hour observation. He was brought in by emergency medical services and a police escort after he was found in the street yelling that he wanted to die and threatening bystanders at the local bus station. His toxicology screening was positive for alcohol, marijuana, cocaine, and benzodiazepines. After the 72 hour observation the substances had cleared, the patient was administered Librium for alcohol withdrawal complications, and by day 3 he denied suicidal, as well as homicidal ideation. Thus, he was released, in good behavioral control, and referred to an outpatient chemical dependency program. Records indicated that the pt has a diagnostic history that includes, Bipolar Disorder Not Otherwise Specified, Alcohol Dependence, and Polysubstance Abuse.

Last evaluation: Wednesday, March 9, 2011
Client presented wearing a t-shirt stained with food and smelling of beer. His jeans were tattered with random holes and burn marks. His hair was long and tangled. He was malodorous. The client required multiple redirections to lower his voice and to get him back on topic as he kept changing the topic to discuss unrelated content, such as food that he wanted to eat and about a new pair of shoes that he hoped to buy. The client’s mood was unstable in that he vacillated between irritable, depressed, and euphoric states during this interview. He avoided eye contact and moving around in his chair often. He often laughed when discussing his most recent DUI and when discussing that he lost his most recent job. Client knew that he was at Agency X for a psychological evaluation, stated that it was Tuesday and that the year is 2010. He sleeps, at times, 3-4 hours per night, and sometimes does not feel the need to sleep at all. Client denied hearing voices, seeing things that others cannot, and is not paranoid. He denied any desire or plan to hurt other people. He admitted one suicide attempt by taking pain pills that were washed down with 1 liter of vodka last year because he wanted to “escape.” The client often ponders what it would be like to not be alive anymore and reported that he thought about taking a bottle of pain medication this morning in an effort to attempt suicide.

CAGE Screening Tools answers from client:
1.   Have you ever felt you should “cut down” on your drinking?
Answer:   Yes, I have tried on several occasions to drink less. The last time I tried was about 2 years ago.
2.   Have people “annoyed” you by criticizing your drinking?
Answer: That is why I left my wife. All she did was nag about what and when I drink. I got sick of it.
3.   Have you ever felt bad or guilty about your drinking?
Answer:   Kind of sort of…
4.   Did you ever take an “eye opener” a drink first thing in the morning to steady your nerves or get rid of a hangover?
Answer:   Doesn’t everyone do this every once in a while. It takes the edge off with everything I have going on.

Compelling correspondence is essential to the achievement all things considered but since of the changing idea of the present working environments, successful correspondence turns out to be more troublesome, and because of the numerous impediments that will permit beneficiaries to acknowledge the plan of the sender It is restricted. Misguided judgments.In spite of the fact that correspondence inside the association is rarely completely open, numerous straightforward arrangements can be executed to advance the effect of these hindrances.

Concerning specific contextual analysis, two significant correspondence standards, correspondence channel determination and commotion are self-evident. This course presents the standards of correspondence, the act of general correspondence, and different speculations to all the more likely comprehend the correspondence exchanges experienced in regular daily existence. The standards and practices that you learn in this course give the premise to additionally learning and correspondence.

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This course starts with an outline of the correspondence cycle, the method of reasoning and hypothesis. In resulting modules of the course, we will look at explicit use of relational connections in close to home and expert life. These incorporate relational correspondence, bunch correspondence and dynamic, authoritative correspondence in the work environment or relational correspondence. Rule of Business Communication In request to make correspondence viable, it is important to follow a few rules and standards. Seven of them are fundamental and applicable, and these are clear, finished, brief, obliging, right, thought to be, concrete. These standards are frequently called 7C for business correspondence. The subtleties of these correspondence standards are examined underneath: Politeness Principle: When conveying, we should build up a cordial relationship with every individual who sends data to us.

To be inviting and polite is indistinguishable, and politeness requires an insightful and amicable activity against others. Axioms are notable that gracious “pay of graciousness is the main thing to win everything”. Correspondence staff ought to consistently remember this. The accompanying standards may assist with improving courtesy:Preliminary considering correspondence with family All glad families have the mystery of progress. This achievement originates from a strong establishment of closeness and closeness. Indeed, through private correspondence these cozy family connections become all the more intently. Correspondence is the foundation of different affiliations, building solid partners of obedient devotion, improving family way of life, and assisting with accomplishing satisfaction (Gosche, p. 1). In any case, so as to keep up an amicable relationship, a few families experienced tumultuous encounters. Correspondence in the family is an intricate and alluring marvel. Correspondence between families isn’t restricted to single messages between families or verbal correspondence.

It is a unique cycle that oversees force, closeness and limits, cohesiveness and flexibility of route frameworks, and makes pictures, topics, stories, ceremonies, rules, jobs, making implications, making a feeling of family life An intelligent cycle that makes a model. This model has passed ages. Notwithstanding the view as a family and family automatic framework, one of the greatest exploration establishments in between family correspondence centers around a family correspondence model. Family correspondence model (FCP) hypothesis clarifies why families impart in their own specific manner dependent on one another ‘s psychological direction. Early FCP research established in media research is keen on how families handle broad communications data. Family correspondence was perceived as an exceptional scholastic exploration field by the National Communications Association in 1989. Family correspondence researchers were at first impacted by family research, social brain science, and relational hypothesis, before long built up the hypothesis and began research in a family framework zeroed in on a significant job. Until 2001, the primary issue of the Family Communication Research Journal, Family Communication Magazine, was given. Family correspondence is more than the field of correspondence analysts in the family. Examination on family correspondence is normally done by individuals in brain science, humanism, and family research, to give some examples models. However, as the popular family correspondence researcher Leslie Baxter stated, it is the focal point of this intelligent semantic creation measure making the grant of family correspondence special. In the field of in-home correspondence, correspondence is normally not founded on autonomous messages from one sender to one beneficiary, yet dependent on the dynamic interdependency of data shared among families It is conceptualized. The focal point of this methodology is on the shared trait of semantic development inside family frameworks. As such, producing doesn’t happen in vacuum, however it happens in a wide scope of ages and social exchange.

Standards are rules end up being followed when performing work to agree to a given objective. Hierarchical achievement relies significantly upon compelling correspondence. So as to successfully impart, it is important to follow a few standards and rules. Coming up next are rules to guarantee powerful correspondence: clearness: lucidity of data is a significant guideline of correspondence. For beneficiaries to know the message plainly, the messages ought to be sorted out in a basic language. To guarantee that beneficiaries can without much of a stretch comprehend the importance of the message, the sender needs to impart unmistakably and unhesitatingly so the beneficiary can plainly and unquestionably comprehend the data.>

Case study: Diagnosis and Treatment Recommendations

Sample Answer

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