Complete the Biopsychosocial Assessment form:

• A description of what you observe about the client
• A description of the presenting problem
• History of the problem
• A mental status examination
• A description of the client’s social history
• A description of the client’s health and wellness history
• A description of the client’s therapeutic/psychiatric services history
• A description of the client’s family relationship history
• The client’s strengths
• The client’s challenges
• A theoretical case conceptualization in the Discussion/Clinical Formulation section
• A DSM-5 diagnosis, including a discussion of the DSM-5 symptom checklist used
• Your form should total a minimum of 700 words.

Research common treatment goals and strategies for the diagnosed disorder that align with the theory used in your case conceptualization. 

Complete the Treatment Plan form and Include the following in your Treatment Plan form:

• A minimum of two target problems
• Specific, short-term goals for each target problem
• Objectives for each target problem
• Strategies/interventions to achieve goals for each target problem
• A minimum of two academic, peer-reviewed sources to support the goals, objectives, and interventions for each target problem
• Your form should total a minimum of 350 words.

Format any citations within your Biopsychosocial Assessment and Treatment Plan forms according to appropriate course-level APA guidelines.

Case Study Case Identification The patient (Alaina) is a 38-year-old African American female who entered treatment voluntarily at an intensive outpatient substance use treatment center.

Presenting Complaints: Alaina reported that she relapsed to substance use 8 months ago, and her preferred drug is crack/cocaine accompanied by frequent alcohol use. She reported that she had success in treatment for the first time 4 years ago and she would like to try to get back on track, as she has hit a low point in the past few months. At the time of treatment entry, Alaina reported no stable living arrangement and that she has recently been splitting her time between the homes of her friends, ex-boyfriend, and uncle. She has one child, age 6, who lives temporarily with her aunt, and with whom she has intermittent contact. In her current environment, she reported spending most of her time alone, as she has lost contact with her sober friends.

History” Alaina was raised by her mother and her grandmother and has never met her father. She reported an extensive family history of substance use, including heroin and crack/cocaine use by her mother who still actively uses. Alaina first began using substances in high school. She graduated from high school, but at the age of 18 was arrested and spent a year in prison on a charge related to theft and possession of cocaine. Since that time, she reported regular crack/cocaine and alcohol use. She has worked intermittently as a hair stylist over the course of her life. Her most stable employment was during the past 4 years after she successfully completed a court-mandated treatment at a residential substance use treatment facility. She reported that she is committed to “learning from my mistakes” and “getting her daughter back” at this time, and that she had successfully remained abstinent up until her most recent relapse.

Assessment: The Addiction Severity Index and a clinical interview for DSM-5 were administered to determine existing psychopathology, including substance use history, frequency, and severity, environmental strengths and stressors, legal issues, and psychiatric symptoms. During the interview, Alaina displayed psychomotor retardation, clear thought processes, and no obvious perceptual abnormalities. Her speech volume and tone were within normal limits, yet her speech rate was somewhat slower than normal. Based on this assessment, Alaina met criteria for current cocaine use disorder (severe), current alcohol use disorder (mild), and major depressive disorder (MDD). She reported past crack/cocaine and alcohol use beginning at age 15 when using with peers. Her MDD symptoms include depressed mood most of the day, nearly every day, markedly diminished interest in almost all activities, feelings of worthlessness and excessive guilt, and a diminished ability to think or concentrate. After a careful assessment of her symptom timeline, it was concluded that her MDD was not substance-induced, as her symptoms preceded the onset of her relapse to substance use. The assessment of legal issues indicated that she is not on probation with the court system and entered treatment voluntarily. Alaina evidenced difficulty in identifying strengths, but with some additional probing she was able to acknowledge potential support from her aunt, as well as the importance of her spirituality. She reported that her Narcotics Anonymous (NA) sponsor was a source of support but moved away from the area about 6 months ago. She would like to begin attending NA meetings and looking for a new sponsor. It was determined that a functional analysis to identify the antecedents and consequences of her substance use and depression would provide the most useful information for treatment planning. First, following the loss of her job at a local hair salon, she reported that she had a lot of free time and got bored easily. She felt hopeless that she couldn’t find a new job and often ruminated over the guilt she felt about her choices in life and her inability to provide for her daughter. She contacted her old friends, which was soon followed by cocaine and alcohol use. She also reported feeling lonely, guilty, and worthless when she realized she could not adequately support her daughter financially, so drug use helped her “bury” these feelings, although they would always resurface when she was sober, leading to a cycle of negative reinforcement. Finally, she reported intensifying feelings of sadness and shame that she had used crack/cocaine and alcohol again given how much progress she had made in the past few years. She felt that she had let her daughter and aunt down. Taken together, it appeared that a lack of substance-free environmental reinforcements following the loss of her job was strongly associated with her relapse to substance use. This was soon thereafter compounded by the negative thoughts and feelings surrounding her parenting skills, resulting in repeated substance use and the cycle of negative reinforcement.

Summary: Substance use problems are complex, and a comprehensive understanding requires knowledge of biological, genetic, neural, behavioral, and cognitive factors. This chapter provides an overview of current practices and cutting-edge advancements for understanding and assessing substance use disorders. Although much work is still needed, great progress has been made in understanding the etiology of substance use, with greatest promise evident in approaches that consider the interactive influence of multiple factors. Additionally, clear advances have been made in both initial and ongoing assessments using self-report, interview, behavioral, and biological methods. Also of great promise is the greater attention to neurobiological, genetic, sex and gender, and diversity issues when considering vulnerabilities to developing substance use disorders, as well as barriers to assessment and proper treatment. In summary, although the challenges of understanding and assessing substance use disorders remain, it is clear that the field has seen important advancements aimed at addressing these challenges.

College of Social Sciences

Master of Science in Counseling

Biopsychosocial Assessment

NAME(S):

DATE OF BIRTH:

PRIMARY LANGUAGE:

REFERRED BY:

INTAKE DATE:

EVALUATED BY:

DESCRIPTION OF CLIENT(S):

Write what you observe about the client—age, sex, ethnicity, appearance, behaviors, and impressions.

PRESENTING PROBLEM:

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.

MENTAL STATUS:

Activity:

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.

SOCIAL HISTORY:

Describe the client’s present living situation:

Family:

School:

Health:

Occupational/Work:

Spiritual/Religious:

Legal:

Social History (include history of abuse/trauma):

HEALTH & WELLNESS HISTORY:

Substance use
(including alcohol, drugs, tobacco and caffeine intake)
:

Sleep habits:

Exercise habits:

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.

STRENGTHS:

Describe assets that will facilitate progress and change, such as motivation, intelligence, self-discipline, and willingness to utilize resources.

CHALLENGES

Describe aspects’ of the client’s life circumstance that may impede progress/change, such as homelessness, major psychiatric disorder, financial hardship, etc.

DIAGNOSIS:

Using the information gathered thus far, make a diagnosis using DSM 5.

DISCUSSION/CLINICAL FORMULATION:

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.

_________________________________________________ __________________

Student/Counselor in Training Date

_________________________________________________ __________________

Supervisor Date

College of Social Sciences

Master of Science in Counseling

Treatment Plan

Client Name:

Date:      

Clinical Placement Student:      

Type of service (check one): FORMCHECKBOX
Individual FORMCHECKBOX
Family FORMCHECKBOX
Child FORMCHECKBOX
Couple

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. Target Problem      

Specific/Short Term Goals:

Objectives:

Strategies/Interventions to Achieve Goals:

2. Target Problem

Specific/Short Term Goals:
Objectives:
Strategies/Interventions to Achieve Goals:

Monthly Review date: ___________________________________      

Client Signature: _______________________________________ Date:      

Counseling Student Signature: ____________________________ Date:      

Supervisor Signature: ___________________________________ Date:      

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