Case History When Conducting An Evaluation It Is Also Import
Case Historywhen Conducting An Evaluation It Is Also Important To Con
When conducting an evaluation, it is also important to consider the client’s demography as a possible contributing factor. Use the module readings and the Argosy University online library resources to research methods of recording case histories. Create a case history for a person with an addiction that clearly traces contributing factors. Do not include identifying information. At this point, do not include details of any mental illness that would constitute a dual diagnosis.
Be sure to cover the following components in your case history: Demographics – including age, gender, ethnicity, socioeconomic status, marital status, number and ages of children, living arrangements, and religion if applicable. Family background. Education. Employment. History of chemical use. Description of the current problem (include history of previous treatment, if any).
After completing the case history, consider ethical standards in relation to this client. What potential ethical issues exist or may come into play with this client? Be sure to include at least one ethical issue. Explore multiculturalism, duty to report/warn, and confidentiality. For example, if the client has children, explain how duty to report may come into play when working with this client.
Write a 3–4-page report in Word format. Apply APA standards to citation of sources.
Paper For Above instruction
In this paper, I will develop a comprehensive case history for an individual struggling with addiction, emphasizing the contributing factors derived from demographic, social, and personal history. Additionally, I will discuss pertinent ethical considerations that professionals must be aware of when working with such clients.
Construction of the Case History
The hypothetical client is a 35-year-old male of Hispanic ethnicity, identifying as Christian, residing in an urban area. He belongs to a middle socioeconomic status, with a steady employment history in construction. He is divorced, with two children aged 7 and 10, who live with their mother. The client currently lives alone in an apartment.
His family background reveals a history of substance use among relatives, including an uncle with alcohol dependence, which might have influenced his early exposure to substance use. He completed high school but did not pursue higher education. His employment history is characterized by intermittent work, influenced by economic instability and physical injuries sustained on the job, which contributed to initial prescription of opioids.
History of Chemical Use and Current Issues
The client reports that he began using alcohol socially in his teenage years, with escalation during his late twenties when his work-related injuries and subsequent chronic pain led to the prescription of opioids. Over time, he developed a dependency on prescription medications, which transitioned into illicit drug use, including methamphetamine, as a means to cope with emotional stress and physical pain. His current problem involves a pattern of compulsive drug use that has impaired his occupational functioning and strained familial relationships.
Previous Treatment and Contributing Factors
He has been briefly involved in outpatient substance abuse treatment twice but discontinued due to transportation issues and feelings of shame. The contributing factors identified include his familial history of substance use, socioeconomic hardships that limited access to consistent healthcare, physical injuries leading to medication dependence, and emotional factors such as loneliness and stress related to divorce.
Ethical Considerations
When working with this client, several ethical issues emerge, particularly pertaining to confidentiality, the duty to report, and multicultural considerations. Confidentiality is crucial; however, if the client reports neglect or harm to his children, the clinician’s duty to report may necessitate breach of confidentiality. Understanding the duty to report is especially pertinent if the clinician learns that the client’s substance use might endanger his children or others.
Multicultural sensitivity is essential, considering the client’s Hispanic background, which may influence his perceptions of mental health and substance use, as well as his willingness to seek help. Respecting cultural values and avoiding bias helps foster trust and engagement.
Conclusion
Developing a detailed case history allows clinicians to better understand the multifaceted contributors to addiction. Ethical awareness ensures that the clinician navigates complex situations responsibly, particularly when balancing confidentiality with the duty to protect clients and others. Recognizing cultural influences further enhances the effectiveness and sensitivity of treatment efforts.
References
- American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.).
- Berman, A. T., & Sperry, L. (2011). Ethical decision making for counseling professionals. Routledge.
- Corey, G., Corey, M. S., & Callanan, P. (2015). Issues and ethics in the helping professions (9th ed.). Brooks Cole.
- Halter, M. J. (2020). Introduction to social work & social welfare: Critical thinking perspectives. Oxford University Press.
- Knight, H. (2018). Substance use and addiction: Ethical considerations and clinical approaches. Journal of Ethics in Mental Health, 12(2), 45-53.
- National Institute on Drug Abuse. (2022). Principles of drug addiction treatment: A research-based guide (Third edition). NIH.
- Sommers-Flanagan, J., & Sommers-Flanagan, R. (2018). Ethical practice in action: Cases in context. Wiley.
- Watson, A. C., & Byrne, R. (2010). A systematic review of qualitative studies on perceptions of mental illness among ethnic minorities. International Journal of Social Psychiatry, 56(4), 390-403.
- Walsh, F. (2016). Family resilience: A framework for clinical practice. Family Process, 55(1), 1-14.
- York, E. (2019). Ethical and legal issues in substance abuse treatment. Journal of Substance Abuse Treatment, 97, 43-50.