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Addiction Case Conceptualization Template Client Name: James Presenting Concern : Why did the client come to counseling? James “Jim” is seeking counseling after his wife of 10 years threatened to leave him with the kids due to his drinking problems if he did not seek help. Case Conceptualization : Note: Include specific information about client symptoms and presenting concerns. Include demographic information. Review biopsychosocial factors and considerations including: biology, family, culture, environment, and other relevant systemic considerations; assess how the addiction impacts all major life areas. James “Jim” is a 33-year-old heterosexual, Caucasian male. Jim has been married for 10 years and has two biological children, aged 4 and 6. He reports that he is a practicing Catholic, and his faith is important to him. Jim is employed full time at a biotechnology research and development firm and is in an upper management position. His wife recently stated to Jim that if he didn’t seek help for his drinking problems, she would “take the kids and leave.” Jim states he doesn’t believe he has a drinking problem. Jim’s first exposure to alcohol was at age 9 and at age 14, he began consuming beer on the weekends with his friends. During his first year at college, Jim’s drinking patterns increased, and he was unable to manage school and his drinking behaviors, so he reduced his drinking to one or two nights per week instead of four nights per week. About 5 years ago, Jim states he began drinking whiskey with his coworkers to “unwind and socialize” and he also states that drinking was an expectation when he was on business trips. Over the past 6 months, Jim states he has had 3 episodes where he was intoxicated to the point of a blackout while he was drinking alone on a weekend night. Jim has missed 3 days of work in the past month due to not feeling well after a drinking episode, which is starting to impact his relationship with leadership at his firm. Assessment : Identify and describe 1–2 assessment tools to be used with this client and the rationale for selecting the assessment tool. As the counselor for Jim, I would utilize the Alcohol Use Inventory (AUI) to assess concerns related to alcohol abuse (Capuzzi & Stauffer, 2020). The AUI “assesses clients’ perceived benefits, styles, consequences, and concerns related to alcohol use” (Capuzzi & Stauffer, 2020, p. 130). The AUI has 17 primary scales that range from perceived benefits of drinking to consequences of drinking (Capuzzi & Stauffer, 2020). This assessment would be useful for Jim due to his statements of not thinking he has a drinking problem. This assessment could help the counselor and Jim be on the same page about the presence of any drinking problem. Diagnostic Impressions : Note: Include the provisional diagnosis for the client and any rule-out or alternative considerations noted. The provisional diagnosis for Jim is Mild Alcohol Use Disorder (F10.10) (American Psychiatric Association, 2022). The provisional diagnosis is a severity of mild due to the presence of 2-3 diagnostic criteria from initial intake information. After assessments, the severity could be changed to moderate (F10.20) or severe (F10.20). COUN 6730 Addiction Case Conceptualization Template Page 1 of 3

Client Name: James Rationale for Diagnostic Impressions : Note: Use the DSM-5 to explain how the client’s symptoms are reflected in the diagnostic criteria for each diagnosis that you render. Jim meets 3 diagnostic criteria for Mild Alcohol Use Disorder (APA, 2022). Due to Jim missing work multiple times in the last month, he meets the criteria of failure to fulfill major role obligations at work (APA, 2022). Since Jim’s wife has said she would leave if he does not stop drinking, Jim meets the criteria of continued alcohol use despite interpersonal or social problems (APA, 2022). Jim’s continued drinking to the point of blackout and after having to call out of work show that he meets the criteria of continued use despite physical problems caused by alcohol (APA, 2022). Therapeutic Approach : Identify the chosen therapeutic approach to be used with this client and the rationale for your selection. The therapeutic approach I would use with Jim would be functional analysis (Capuzzi & Stauffer, 2020). Functional analysis will assist the counselor and Jim in determining the triggers and consequences of Jim’s alcohol use (Capuzzi & Stauffer, 2020). Once consequences and triggers are discovered, the counselor will assist the client in making connections between the two (Capuzzi & Stauffer, 2020). Determining connections will assist with making treatment goals and a treatment plan for the client (Capuzzi & Stauffer, 2020). Treatment Goals : Identify three initial treatment goals you are considering in working with this client and note how you will measure/know when goals are attained. Note: Significant issues will need treatment goals. One treatment goal for Jim at the start of counseling will be to abstain from drinking alcohol 3 out of 7 days a week for 1 month. After 1 month, if Jim has met the goal of abstaining from drinking for 3 days a week, the goal can be updated to more days of abstaining. A second treatment goal will be for Jim to decrease the amount of alcohol he consumes when he drinks. The goal can be to drink a maximum of 3 drinks on days that he drinks as it coincides with the initial goal of abstaining for 1 month. When this goal is met, Jim can work towards a new goal of drinking 2 drinks instead of 3 to decrease the behavior. A third treatment goal for Jim can be to use a replacement behavior instead of drinking 3 out of 7 days a week to decrease stress from work. A replacement behavior can be decided by the counselor and Jim, but can be something related to journaling, exercising, or any other hobbies that Jim would be interested in doing. After Jim utilizes the replacement behaviors on the days that he is abstaining from drinking according to the first goal for one month, the number of days for the replacement behavior can be increased as the days to abstain drinking increases. Relapse Prevention and Continuum of Care : Describe relapse prevention needs and challenges for the client. Discuss the continuum of care plan and recommendations for the client. To encourage relapse prevention, Jim should continue participating in counseling throughout treatment to continue editing goals as needed. It is recommended that Jim utilize replacement behaviors for drinking alcohol to decrease the craving or desire for alcohol. The counselor and Jim can collaborate on the replacement behaviors to encourage continued relapse prevention. Ethical Considerations : Note any ethical considerations or challenges associated with this case. An ethical consideration that could be associated with this case would be informed consent. It is important that Jim understands he has the ability to stop the counseling relationship at any time (American Counseling Association, 2014). Another ethical consideration that the counselors should keep in mind is for referring to other services (ACA, 2014). The counselor should refer Jim to other providers if Jim’s needs are outside of their scope of practice (ACA, 2014). As with any counseling relationship, it is important for confidentiality to be withheld and that Jim understands when confidentiality would have to be broken (ACA, 2014). COUN 6730 Addiction Case Conceptualization Template Page 2 of 3

Client Name: James Reference List: American Counseling Association (ACA). (2014). ACA code of ethics. Retrieved from https://www.counseling.org/knowledge-center/ethics American Psychiatric Association (APA). (2022). Diagnostic and statistical manual of mental disorders. (5 th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu? url=https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x16_Substan ce_Related_Disorders Capuzzi, D., & Stauffer, M. D. (2020). Foundations of addictions counseling (4 th ed.). Boston, MA: Pearson. COUN 6730 Addiction Case Conceptualization Template Page 3 of 3

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