Clinical Case Formulation Key Assignment
Format
It is recommended to use the given directions as a template to formulate your paper. You can use sections 1-5 as headings such as Background with Demographics, Assessment of the Client, Theoretical Orientation, etc. Under each heading, you can use subheadings like MSE, DSM-5-TR Diagnosis, Risk, etc. APA headings and subheadings help guide the reader through the document, provide a general idea of what to expect from the paper, and lead the flow of discussion. These elements divide and define each section of the paper. Your paper should have 8 to 10 pages of content, along with a cover page and reference page. You must use a minimum of 4 scholarly references, in addition to your textbooks. Scholarly references can include peer-reviewed articles, journals, government websites, and included supplemental resources. You must cite all information from the required resources/textbook plus the four additional scholarly references using APA style. The format is not a DO A CLIENT MAP, and the paper does not use bullets. This assignment will be graded using the Clinical Case Formulation Rubric. The assignment is worth 60 points. You can use the information in the rubric as a guide towards completing the module assignment.
Clinical Case Formulation
SWK 660 Psychopathology
1) Each student willselect the following:
• A DSM-5-TR mental health disorder (specifically a Traumaand Stressor-Related Disorder or other Trauma-Linked
Disorder).
• Individual demographics (cultural, racial, and ethnic factors, as well as
gender inclusivity, are critical to this assignment). In order to increase
knowledge, skills, and awareness, it is essential to choose a disorder and
demographic variables that differ from your own. Examples: A 35-yearold African American female with depression; A 17-year-old White, gay
male raised in a strict Catholic family; A 65-year-old Asian American
female who uses a wheelchair and practices Buddhism.
• Four scholarly references must be cited and discussed. Please refer to the
rubric and instructions below for additional information. Scholarly
references can include peer-reviewed articles, journals, government
websites, and included supplemental resources.
2) Paper Outline/Template:
Section 1 – Background with Demographics (Competencies 2.1, 9.4)
Redacted identifying information will include a summary:
• Presenting problem & history of problem
• Describe the individual’s unique demographics: Identify cultural, racial, and ethnic
factors, as well as gender inclusivity. 2.1
• Social and Family Relationships
• Prior Mental Health and Substance Abuse Treatment
• Medications
• Historical, Intergenerational, and Current Trauma 9.4
• Strengths and Coping Skills 9.4
Section 2 – Assessment of the Client (Competencies 2.2, 7.2, 7.3, 8.3)
• Write a Mental Status Exam (Identify each MSE domain/component) 7.3
Page 2 of 3
• Discussthe client’srisk assessment: trauma identification (signs of mental trauma)
and the individual’s identified protective factors. 7.3
• Cite and discuss at least two scholarly references addressing the cultural
implicationsspecific to the individual and their diagnosis. (e.g., Prevalence
of PTSD in Imprisoned White Men or Characteristics of Korean Females
with Schizophrenia). 8.3
• Discuss the link/bridge between assessment and diagnosis within a cultural context and
through client participation. 8.3
• Provide one Trauma and Stressor-Related Disorder or other TraumaLinked Disorder principal DSM-5-TR Diagnosis (include the code, a
brief rationale for each applicable criterion, and the criteria set for the
diagnosis) 7.2.
• Identify and discuss two Differential Diagnoses.7.2
• Briefly discuss diagnostic bias and strategiesto manage biases when working with
diverse populations. 2.2
Section 3 – Theoretical Orientation (Competencies 7.1, 8.2, 8.4)
• Discuss how theory informs assessment, diagnosis, intervention, and goals for treatment. 7.1
• Discuss the proposed intervention strategy, diagnosis, and trauma-informed care
intervention for the individual in sufficient detail. 8.2
• Discuss briefly how the intervention is tailored toward the individual’s needs and trauma
responses.7.1
• Discuss and document two empirically supported journal articles that support evidence-based
trauma-informed care interventions related to the individual’s specific diagnosis. 8.4
Section 4 – Developing a Comprehensive Treatment Plan (Competency 6.1)
• Collaboratively formulate three treatment goalsinformed by the individual’s
diagnosis and cultural context.
• List and discusstwo measurable objectivesto achieve each goal.
• Discuss how protective factors may interrupt the risk to pathology and foster resilience.
Section 5 – Recommendations and Prognosis (Competency 6.2)
• List two additional adjunct community-based treatment
recommendations or wrap-around services – individual and/or family,
including referrals to other providers/prescribers/agencies to support
the client further.
• Demonstrate engagement at all levels of treatment decisions(Individual
engagement and positive therapeutic engagement).
• Discuss outcome (prognosis) within the context of environmental and personal factors.
3) Format:
• The best way to formulate/construct the paper is to use the directions as a
template. For example, use sections 1-5 as headings (e.g., Background with
Demographics, Assessment of the Client, Theoretical Orientation, etc.)
Page 3 of 3
• Under each heading, use subheadings (e.g., MSE, DSM-5-TR
Diagnosis, Risk, etc.). The use of APA headings and subheadings helps
guide the reader through the document, gives the reader a general idea
of what to expect from the paper, and leads the flow of discussion.
These elements divide and define each section of the paper.
• The paper should include 8 to 10 pages of content, plus a cover page and
reference page.
• Use a minimum of 4 additional scholarly references in addition to your
textbooks. Scholarly references can include peer-reviewed articles, journals,
government websites, and included supplemental resources.
• Cite all information from the required resources/textbook plus the
four additional scholarly references using APA style.
• The format is not a DO A CLIENT MAP, and bullets are not used in the paper.
4) Grading:
• This assignment will be graded using the Clinical Case Formulation Rubric.
• The assignment is worth 60 points.
• Use the information in the rubric as a guide toward successfully completing
the module assignment
YOUTUBE VIDEO:
Clinical Case Formulation Key Assignment Rubric Module 8
A few tips for your final paper:
1. The best way to formulate/construct your paper is to use the directions as a template. For example, use the direction sections I-IV as headers (e.g. Background with Demographics, Assessment of the Client, Theoretical Orientation, Developing a Comprehensive Treatment Plan etc.). Under each header use subheadings (e.g. DSM-5 Diagnosis, MMSE, Presenting Problem, Three Treatment Goals, etc.).
Use APA headings and subheadings formatting. The use of headings and subheadings give the reader a general idea of what to expect from the paper and leads the flow of discussion. These elements divide and define each section of the paper.
Additionally, cross reference your directions with the rubric to ensure you are covering the content correctly.
2; The paper should be a minimum of 8 pages and maximum of 10. This does not include your title page nor reference pages.
Clinical Case Formulation Rubric
SWK 660 Psychopathology
5 points 4.5 4 points 3.5 3 points 2.5 2 points 1.5 1 point
8.4
Critically select
and implement
trauma-informed
evidence-based
interventions to
address the
adverse
consequences of
trauma.
Student demonstrated
an exceptional
understanding and
thoroughly explained the
relationship between
diagnosis and traumainformed care
intervention. Student
was clear
with overview and
provided two empirically
supported articles.
Student was able to
provide both discussion
and documentation
supporting the choice of
intervention.
Exceeds
4, but
does not
meet all
criteria
for a 5
Student demonstrated a
sufficient understanding
and explanation of the
relationship between
diagnosis and traumainformed care
intervention. Student was
clear with overview and
provided one empirically
supported article. Student
was able to provide both
discussion and
documentation supporting
the choice of intervention.
Exceeds
3, but
does not
meet all
criteria
for a 4
Student demonstrated an
adequate understanding and
modest explanation of the
relationship between
diagnosis and traumainformed care intervention.
Student was mostly clear
with overview. Student was
able to provide both
discussion and
documentation supporting
the choice of intervention
however; the support for
intervention was not
evidence-based.
Exceeds
2, but
does not
meet all
criteria
for a 3
Student demonstrated a
minimal understanding and
explanation of the
relationship between
diagnosis and traumainformed care intervention.
Student was not clear with
overview and did not
provide discussion or
documentation supporting
the choice of intervention.
Exceeds
1, but
does not
meet all
criteria
for a 2
Student did not provide
discussion and/or
documentation
supporting traumainformed care
intervention.
Student did not
demonstrate an
understanding of
diagnosis or traumainformed care
intervention.
7.3 Design and
conduct traumainformed
assessment and
planning
strategies that
include risk and
protective factors
that empower
service
recipients.
Student demonstrated
exceptional assessment
skills documenting
client’s social and
historical information. All
MSE domains, types of
trauma, risk
assessment and
supportive protective
factors were identified
and discussed.
Exceeds
4, but
does not
meet all
criteria
for a 5
Student demonstrated
thorough assessment
skills documenting client’s
social and historical
information. Most MSE
domains, trauma
identification, risk
assessment, and
supportive protective
factors were addressed
and discussed.
Exceeds
3, but
does not
meet all
criteria
for a 4
Student included an
adequate demonstration of
assessment skills
documenting client’s social
and historical information.
Limited MSE domains,
trauma identification, risk
assessment, and supportive
factors were addressed and
discussed.
Exceeds
2, but
does not
meet all
criteria
for a 3
Student included a minimal
demonstration of
assessment skills
documenting client’s social
and historical information.
Neither the MSE domains,
trauma identification, nor
risk assessment were
addressed and discussed.
Exceeds
1, but
does not
meet all
criteria
for a 2
Student did not include
demonstration of
assessment skills.
Page 2 of 5
2.1
Demonstrate
culturally
centered
practice that
recognizes the
diversity factors, to
include trauma
experiences and
responses at the
micro, mezzo and
macro levels.
Student illustrates
a sophisticated
understanding of client’s
unique demographics,
background of diversity
and trauma.
Demonstrates the
intersectionality of
multiple factors
including age, class,
color, culture, disability,
ethnicity, gender,
gender identity and
expression, immigration
status, political ideology,
race, religion, sex, and
sexual orientation.
Exceeds
4, but
does not
meet all
criteria
for a 5
Student illustrates
numerous key diversity
and trauma issues, unique
demographics and
background information of
client as a consequence of
difference, including
oppression, poverty,
marginalization, and
alienation as well as
privilege, power, and
acclaim. Clear description
of trauma and diversity’s
effect on identities,
assessment and
intervention strategies.
Exceeds
3, but
does not
meet all
criteria
for a 4
Student identifies at least
one salient trauma and
diversity issue that exists
with client. The paper
demonstrates diverse
demographics and
background information of
client that might affect
assessment and intervention
strategies.
Exceeds
2, but
does not
meet all
criteria
for a 3
The student misidentifies
salient trauma and diversity
issues. Vague and often
unclear description of
diversity, demographics
and client background
information effect of on
identities, assessment and
intervention strategies.
Exceeds
1, but
does not
meet all
criteria
for a 2
The student fails to
identify key trauma and
diversity issues,
demographics and
background
information of client.
2.2
Apply selfawareness to
manage the
influence of
personal biases
and values in
working with
diverse
individuals,
families, groups,
organizations,
communities and
constituencies.
The student has
masterfully gained selfawareness to eliminate
the influence of
diagnostic biases
working with diverse
groups. Recognizes and
communicates an
understanding of the
importance of difference
in shaping life
experiences and
outcome.
Exceeds
4, but
does not
meet all
criteria
for a 5
Student proficiently
manages and recognizes
the extent to which their
cultural structure and
values may oppress,
marginalize, alienate,
create or enhance the
therapeutic relationship.
The student demonstrates
sufficient self- awareness
and keen insight to
managing diagnostic
biases.
Exceeds
3, but
does not
meet all
criteria
for a 4
Student has an adequate
understanding of diagnostic
biases and how they affect
the therapeutic relationship.
Adequate recognition and
insight are demonstrated
throughout the paper.
Exceeds
2, but
does not
meet all
criteria
for a 3
Student fails to recognize
the extent to which their
diagnostic biases may
oppress, marginalize,
alienate, or create/ enhance
privilege and power in the
therapeutic relationship.
The student demonstrates
limited self-awareness to
minimize the influence of
biases working with clients.
Exceeds
1, but
does not
meet all
criteria
for a 2
Student is devoid of selfawareness, recognition of
diagnostic biases working
with diverse individuals,
families, groups,
organizations,
communities and
constituencies.
7.1
Articulates and
demonstrates the
influence theory
has on
assessment
process.
Student thoroughly
articulated how theory
informs assessment,
diagnosis, intervention
and treatment goals.
Exemplary traumainformed assessment
skills were
demonstrated and
discussed linking the
proposed treatment
theory, diagnosis and
trauma-informed
intervention.
Assessment process
collaboratively tailored
toward the client’s
needs and trauma
responses.
Exceeds
4, but
does not
meet all
criteria
for a 5
Student proficiently
articulates theoretical
influences upon the
clinical assessment,
diagnosis, intervention
and treatment goals.
Effectively articulates the
link between theory and
assessment.
Demonstrates how
theory facilitates
appropriate selection of
trauma-informed
intervention strategies
and treatment planning
tailored toward the client’s
needs and trauma
responses.
Exceeds
3, but
does not
meet all
criteria
for a 4
Student demonstrates a
general understanding of
theoretical influence upon
assessment process.
Briefly demonstrating how
theory facilitates
appropriate selection of
intervention strategies and
treatment planning.
Exceeds
2, but
does not
meet all
criteria
for a 3
Student demonstrates
emerging knowledge on
the influence of theoretical
influences on the
assessment process.
Difficulty articulating a link
between theory,
assessment, diagnosis and
intervention strategies.
Exceeds
1, but
does not
meet all
criteria
for a 2
Student does not
articulate nor
demonstrate use of
theory’s influence on
assessment.
Page 3 of 5
7.2
Apply an
assessment
strategy to
assess
individuals,
families, groups,
organizations,
and communities
within a
complimentary
theoretical model.
Student formulated a
trauma-informed
assessment
demonstrating
exemplary clinical
skills; Correctly
documents a traumaand stressor-related
principal diagnosis,
code and criteria set.
Illustrates the rationale
for each criterion
(indicated by either a
subjective account or
observation) based
upon the client’s
presentation; Identified
and discussed two
differential diagnoses.
Exceeds
4, but
does not
meet all
criteria
for a 5
Student formulated a
trauma-informed
assessment
demonstrating proficient
clinical skills; Documents
a trauma- and stressorrelated principal
diagnosis, code and
criteria set. Illustrates a
rationale for most criterion
(indicated by either a
subjective account or
observation) based upon
the client’s presentation;
Identified and discussed
one differential diagnoses.
Exceeds
3, but
does not
meet all
criteria
for a 4
Student formulated a
general mental health
assessment demonstrating
developing traumainformed clinical skills;
Documents a principal
diagnosis, code and criteria
set. The diagnosis is not
trauma-and stressorrelated. Brief rationale for
each criterion (indicated by
either a subjective account
or observation) based upon
the client’s presentation;
Identified and discussed
one differential diagnoses.
Exceeds
2, but
does not
meet all
criteria
for a 3
Student formulated a
general assessment
demonstrating emerging
clinical skills; Traumainformed assessment
strategies are not
identified; The principal
diagnosis is not traumaand stressor-related and
missing a diagnostic code
and criteria set. Does not
illustrate a rationale for
each criterion (indicated by
either a subjective account
or observation) based
upon the client’s
presentation; Did not
identify differential
diagnoses.
Exceeds
1, but
does not
meet all
criteria
for a 2
Student did not formulate
a trauma-informed
assessment; Missing a
principal diagnosis, code
and criteria set. Does not
illustrate the rationale for
each criterion (indicated
by either a subjective
account or observation)
based upon the client’s
presentation; Did not
identify differential
diagnoses.
6.1 Establish a
relationally
based process
that encourages
individuals,
families, groups,
organizations
and communities
to be equal
participants in
the
establishment of
expected
outcomes.
Student discussed and
demonstrated an
excellent ability to
involve client throughout
treatment planning.
Three goals and two
objectives were
formulated
collaboratively with the
client. Student
successfully attended to
protective factors by
focusing on the client’s
strengths as a means of
fostering resilience.
Exceeds
4, but
does not
meet all
criteria
for a 5
Student skillfully
demonstrated client
engagement and
involvement throughout
treatment planning.
Student appropriately
utilized the client’s
strengths, enhancing the
importance of resilience.
Two goals and 1 objective
were formulated
collaboratively with the
client.
Exceeds
3, but
does not
meet all
criteria
for a 4
Student adequately
demonstrated client
engagement and
involvement throughout
treatment planning. Student
marginally engaged and
mobilized the strengths of
the client. One goal and
objective were formulated
collaboratively with the
client.
Exceeds
2, but
does not
meet all
criteria
for a 3
Student minimally utilized
the client’s strengths in
treatment planning. Student
failed to engage client
throughout paper. Student
did not apply client’s
strengths to foster
resilience.
Goals and objectives were
not formulated.
Exceeds
1, but
does not
meet all
criteria
for a 2
Student did not engage
or mobilize client’s
strengths.
Student did not attend to
factors to build and
enhance individual
resilience.
8.2
Implement
effective
intervention
strategies to work
with individuals,
families, groups,
organizations, and
communities
within a particular
theoretical model.
The student’s choice of
an intervention strategy
is clearly evidencebased, specifically
related to the diagnosis,
interventionand treatment
goal. The intervention
strategy is detailed and
tailored toward the
client’s stated needs
and addresses traumarelated disorders.
Exceeds
4, but
does not
meet all
criteria
for a 5
The student’s choice of an
intervention strategy is
appropriate and evidencebased. The clinical
technique adequately
supports goal
achievement and relevant
to a trauma-related
diagnosis.
Exceeds
3, but
does not
meet all
criteria
for a 4
The student’s choice of an
intervention strategy is not
evidence- based; however,
the intervention is tailored
toward stated goals and
diagnosis. Trauma-informed
care intervention strategies
are vaguely mentioned and
discussed.
Exceeds
2, but
does not
meet all
criteria
for a 3
The student’s choice of an
intervention strategy is
neither appropriate for the
client nor appropriate for
the diagnosis and
treatment goal. The
technique is a poor fit for
the client’s needs. Traumainformed care intervention
strategies are not
mentioned.
Exceeds
1, but
does not
meet all
criteria
for a 2
Student does not
articulate nor
demonstrates use of
trauma-informed care
intervention strategies.
Page 4 of 5
8.3 Implement the
strategies that
empower
individuals,
families, groups,
organizations, and
communities in
various contexts of
practice.
Student demonstrated
an exceptional
understanding and
thoroughly discussed
the client’s diagnosis,
and how to link
assessment and
diagnosis within a
cultural context through
client participation.
Student provided two
empirically supported
articles and was able to
provide both discussion
and documentation
supporting the
diagnosis.
Exceeds
4, but
does not
meet all
criteria
for a 5
Student demonstrated a
sufficient understanding
and explanation of culture
and diagnosis.
Student was clear with
overview and provided
one empirically supported
article. Student was able
to provide both discussion
and documentation
supporting the choice of
diagnosis and how to link
assessment and diagnosis
within a cultural context
through client
participation.
Exceeds
3, but
does not
meet all
criteria
for a 4
Student demonstrated an
adequate understanding and
modest explanation of
culture and diagnosis
through client participation.
Student was able to provide
both discussion and
documentation supporting
the choice of diagnosis
however; the support for the
diagnosis was neither
culturally relevant nor
evidence based.
Exceeds
2, but
does not
meet all
criteria
for a 3
Student demonstrated a
minimal understanding and
explanation of culture and
diagnosis. Student was not
clear with overview and did
not engage client
participation nor
documentation supporting
the choice of diagnosis
within a cultural context.
Exceeds
1, but
does not
meet all
criteria
for a 2
Student did not discuss
nor provide support for
the diagnosis and cultural
underpinnings.
6.2 Implement
appropriate
engagement
strategies to
engage
individuals,
families, groups,
organizations
and communities
within a
particular
theoretical
model.
Student demonstrated
an excellent ability to
engage and encourage
a collaborative
relationship. Student
saw client as expert,
allowed
them to determine
outcomes, and
encouraged active
participation of client.
Student utilized theory
successfully to
establish outcomes
and prognosis.
Exceeds
4, but
does not
meet all
criteria
for a 5
Student adequately
demonstrated
encouragement of
participant engagement
and determination of
outcomes. Student saw
client as expert.
Student led outcomes
discussion some of the
time. Student showed
demonstration of
theory and discussion of
prognosis.
Exceeds
3, but
does not
meet all
criteria
for a 4
Student demonstrated basic
engagement and
encouragement of
participation.
Student provided the
outcomes to client with
some client involvement.
Student used basic
information from theory to
establish discussion of
prognosis.
Exceeds
2, but
does not
meet all
criteria
for a 3
Student demonstrated
minimal engagement and
encouragement of client
participation in outcomes.
Student developed
outcomes without client
involvement. Student did
not use theory nor discuss
prognosis.
Exceeds
1, but
does not
meet all
criteria
for a 2
Student did not
establish outcomes or
discuss with client.
Student did not use
theory.
9.4
Systematically
use assessment
and evaluation to
include historical
and
intergenerational
trauma, current
trauma reactions
and risk and
resilience
factors.
Student illustrates
a sophisticated
understanding of
client’s historical and
intergenerational
trauma. Demonstrates
the intersectionality of
multiple factors
including age, class,
color, culture, disability,
ethnicity, gender,
gender identity and
expression, immigration
status, political
ideology, race, religion,
sex, and sexual
orientation.
Clearly identifies
client’s strengths and
coping skills.
Exceeds
4, but
does not
meet all
criteria
for a 5
Student illustrates
numerous
historical and
intergenerational trauma
demographics of client as
a consequence of
difference, including
oppression, poverty,
marginalization,
and alienation as
well as privilege, power,
and acclaim.
Clear description of
trauma’s effect on
identities, assessment and
intervention strategies.
Client’s coping skills and
strengths are highlighted.
Exceeds
3, but
does not
meet all
criteria
for a 4
Student identifies at least
one salient trauma issue
that exists with client
historically and/or
intergenerational. The
paper demonstrates diverse
demographics and
background information of
client that might affect
assessment and intervention
strategies. Vague mention of
client’s coping skills and
strengths.
Exceeds
2, but
does not
meet all
criteria
for a 3
The student misidentifies
salient historical and
intergenerational trauma
issues.
Vague and often unclear
description of
trauma, demographics
and client background
information’s effect of on
identities, assessment and
intervention strategies. No
mention of client’s strengths
nor coping skills.
Exceeds
1, but
does not
meet all
criteria
for a 2
The student fails to
identify key trauma
issues, demographics
and background
information of client.
Page 5 of 5
APA/ Grammar The assignment is
exceptionally written.
It is written clearly and
concisely and guides
the reader smoothly
through the paper
using appropriate
transitions and linkages
with the content. There
are no APA,
grammatical or spelling
errors.
Information
from any resources was
used/cited appropriately.
No direct quotes were
used.
Exceeds
4, but
does not
meet all
criteria
for a 5
The assignment is well
written and organized in a
readable format with
specific headings and
subheadings to guide the
reader. All APA guidelines
were followed. There are
no typos or grammatical
errors. Writer followed all
mechanical guidelines
provided by instructor.
Exceeds
3, but
does not
meet all
criteria
for a 4
Minimal errors in relation to
APA, grammar, and spelling.
No major APA violations.
Some organizational
techniques/styles noted in
writing to guide the reader.
Exceeds
2, but
does not
meet all
criteria
for a 3
One-two major APA
violations and/or several
minor violations. General
direction in writing noted;
however, style appears
choppy or disconnected.
Headings are misused and
do no facilitate the
organization of the
assignment.
Exceeds
1, but
does not
meet all
criteria
for a 2
Numerous APA, spelling
and/or grammatical
errors. Difficult to follow
logic of ideas in the
paper. Failed to abide by
the majority of
mechanical guidelines
provided by the
instructor. Outside
resources were not used
appropriately.
3. The paper is not a client MAP and should not use bullets.
DIAGNOSIS IS: ACUTE STRESS DISORDER(F43.0)
SCENARIO FOR THIS ASSIGNMENT:
Katy Williams, a
20-year-old woman from Jacksonville, Florida, shared with a mental health
specialist that she experienced a car accident a week ago while heading home
from work. As the sole child raised by her parents, she discloses ongoing challenges
since the incident. Katy describes feelings of irritability, being on edge,
experiencing flashbacks, struggling with concentration, and facing sleep
disturbances due to nightmares.
Her apprehension extends
to driving, as she fears the possibility of another accident or even death.
This fear prompts her to avoid driving at night. Katy expresses guilt for
staying late at work, believing the accident could have been prevented if she had
left during a safer and brighter time. In response to her heightened anxiety,
she now prefers carpooling with a co-worker and opts for home delivery of
essential items rather than driving.
Returning to work three
days after the accident, Katy continues to grapple with symptoms of anxiousness
and sensations of breathlessness. These lingering effects underscore the
emotional toll the incident has taken on her well-being.
Sample Mental Status Exam1
The client is a 26 year old, white, and single male, who appears his stated
age. His employer referred him to services, after he reported to his boss that he
had a “problem” with Vicodin. He appears to be in excellent physical condition.
Dressed in a business suit and tie, he is well groomed. His facial expression
shows a tight, drawn smile. He states, “I’ve never talked to anyone like you, and
I’m a little nervous, but I’m okay.”
The client sits somewhat slouched in his chair. He has no unusual
movements or reactions to the environment. He readily makes eye contact
throughout the interview. He cooperates in answering questions, and he has a
positive relationship with the examiner.
The client’s speech is of normal rate and volume. He uses good grammar
and speaks intelligibly. His flow of thought is easy to follow, goal directed, and
organized. A few times during the interview, he loses his train of thought, but he
quickly regains it, saying that he feels anxious, never having been “in a place like
this.” There is no reason to suspect that he has a problem with flow of thought.
The client admits that he has a problem with pain killers, particularly with
Vicodin, and that he has “overused” them, resulting in what he calls symptoms of
withdrawal, severe enough to warrant asking his boss for help. He has never had
any kind of treatment for addiction, and when asked if he abuses alcohol, he
states that he drinks “a few beers” once a week but does not get drunk. He
reports no family history for alcohol or other drug abuse or dependence. He also
states that has never had any mental health counseling. Except for his problem
with Vicodin, he adamantly asserts that he has never used any illegal substances,
including marijuana.
YOUTUBE VIDEOS:
