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1 Case Study Brittany M. Hill Walden University COUN 6730: Counseling Addictive Disorders Dr. Startasha Dillard July 9, 2023

2 Case Study Assessments and clinical interviews are important in making any kind of mental health diagnosis. This paper will provide a conceptualization of a client, Ella, who was referred to counseling for substance use. This paper will outline some questions to ask during a clinical interview as well as standardized assessments to utilize with the client. In conclusion, a preliminary diagnosis will be made with the information provided in the case study. Selected Case Study Ella, a 19-year-old bisexual female has been referred to counseling by her college advisor due to struggling academically and weight loss. Ella is of Asian American heritage and was raised in a middle- class neighborhood by both parents. Ella explains that she had little freedom growing up and is expected to be successful and not misrepresent the family. She explains that her parents are unaware of her sexual identity being bisexual. Ella explains that she uses methamphetamine occasionally as it helps her stay awake when studying or when she is working at her part-time job. She also explains that methamphetamine decreases her appetite, so it has helped her lose approximately fifteen pounds since the start of the school year. Ella explains that she is hoping to pledge to a sorority by the end of the year so she can fit in with the “pretty, thin, rich girls,” as she is currently struggling with connecting with others. Clinical Interview Questions While standardized assessments are important with identifying and diagnosis a substance use disorder, it is also important for the counselor to ask appropriate questions to determine if a standardized assessment is warranted (Capuzzi & Stauffer, 2020). As Ella’s counselor, one question that I would ask during the clinical interview is for the client to describe the history of substance use and explain any changes in the substance use patterns over time. This question would be important in getting a better picture of how long Ella has been struggling with substance use. Getting more information about

3 the duration and patterns of substance use can assist the counselor with the diagnostic criteria for substance use disorders to provide a proper diagnosis (Capuzzi & Stauffer, 2020). A second question that I would ask as the counselor is if the client has ever tried to quit or cut back on using the substances they are using. This question can help counselors identify the client’s motivation to stop using substances. If the client has previously attempted to quit, this question can also tell the counselor what methods did not work for this client so they can collaborate on another method (Capuzzi & Stauffer, 2020). A third question I would ask as a counselor would be if the client has experienced any negative consequences in their life related to their substance use. For example, Ella explains that she uses methamphetamine to stay awake to study, so this question can help open the conversation to see if Ella struggles with sleep even if she is not using it. It will be important for the counselor to know the impact the substances have on the client’s life to assist with prevention strategies (Capuzzi & Stauffer, 2020). A fourth question I would ask Ella in the clinical interview is if there are any specific triggers or factors that cause her to continue using. If a counselor knows the triggers of substance use, they can assist the client with other coping strategies to use when those triggers come up. This question can also help determine if there is a co-occurring mental health or physical illness that could be contributing to substance use (Capuzzi & Stauffer, 2020). Assessment Instruments In addition to questions during the clinical interview, it is also important to conduct standardized assessments to provide accurate diagnoses of substance use disorders (Capuzzi & Stauffer, 2020). For Ella, one assessment that I would use as her counselor would be the Substance Abuse Subtle Screening Inventory-3 (SASSI-3) (Capuzzi & Stauffer, 2020). The SASSI-3 measures various aspects of substance use disorders, like causes and consequences (Capuzzi & Stauffer, 2020). Addictions counselors view the SASSI-3 as the most important screening for substance use disorders (Capuzzi & Stauffer, 2020).

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4 A second standardized assessment I would use with Ella is the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) (Capuzzi & Stauffer, 2020). The specific screen within this assessment that I would focus on is the Addiction Acknowledgement Scale (AAS) (Capuzzi & Stauffer, 2020). This screen will measure if Ella acknowledges her substance use and can determine the communication about her substance abuse status (Capuzzi & Stauffer, 2020). Preliminary Diagnosis The preliminary diagnosis of Ella would be Mild Stimulant Use Disorder of Amphetamine-type Substances (F15.10) (American Psychiatric Association, 2022). This diagnosis is the preliminary diagnosis because Ella does meet 2 of the criteria listed, which is the minimum number of criteria needing to be met for a diagnosis (APA, 2022). Some areas that would need to be explored more in depth with Ella to give a complete diagnosis would include tolerance, the impact the substance has on her life (i.e., at work), and craving for the substance (APA, 2022). Additional Information Needed To provide a complete diagnosis for Ella, I will need more information like if the substance impacts other areas of her life. If the substance use impacts her social life or major duties at work, the diagnosis could be more solidified. It would also be important to know if Ella has ever attempted to stop using the substance, which would lead to another diagnostic criteria for Stimulant Use Disorder being met (APA, 2022). Since the referral was made by the school counselor due to Ella’s dropping grades, it can be implied that the substance use is impacting Ella’s life in other areas; however, it would be useful to obtain collateral information from any other providers that Ella sees to determine any underlying symptoms or triggers of the substance use. Conclusion Ella is a 19-year-old bisexual female who was referred to counseling for substance use. A preliminary diagnosis was made for Ella of Mild Stimulant Use Disorder of Amphetamine-type

5 Substances (F15.10) (APA, 2022). More questions and assessments would be helpful in obtaining more information in Ella’s case to solidify a proper diagnosis to collaborate on treatment options.

6 References American Psychiatric Association. (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.

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