Lasa 2 Case Study Diagnosis And Treatment Recommendations

Lasa 2 Case Study Diagnosis And Treatment Recommendationsthis Assign

Lasa 2: Case study: Diagnosis and Treatment Recommendations This assignment is designed to help you synthesize the course material and apply the material in creating an assessment, and generating a diagnosis, as well as treatment recommendations. Read the case study provided and write a clinical report which includes: A summary of the major issues facing the client needing to be addressed. A working diagnosis for the client (with diagnostic summary and rationale) utilizing the following information from the CAGE screening tool and case history information. A Mental Status Exam which applies the information from the case history. Detailed treatment recommendations determining which modality (family, individual, group, or couples) is most appropriate for this client. Be sure to provide the rational for your choice by integrating information from the case summary. Recommendations on whether individual is a good candidate for treatment placement (inpatient, residential, or outpatient) and an analysis of the pros and cons for your selection based on a summary of the issues. Your paper should be at least 4 pages long. Remember to include a cover page and reference page, and to support your arguments with information drawn from the online content, the textbook, and other credible, scholarly sources to substantiate the points you are making. Apply APA standards for writing and citations to your work.

Paper For Above instruction

Introduction

The case study presents complex mental health and substance use issues requiring a comprehensive assessment and tailored treatment plan. Understanding the core problems faced by the client, establishing a precise diagnosis, and recommending the most suitable therapeutic modality are crucial steps in facilitating effective intervention. This paper synthesizes the information provided—including the case history, CAGE screening outcomes, and mental status examination—culminating in specific treatment recommendations. The overall goal is to align clinical judgments with evidence-based practices for optimal client outcomes.

Summary of Major Issues Facing the Client

The client exhibits signs indicative of substance dependence coupled with underlying psychological distress. According to initial case information, the client reports frequent alcohol misuse, confirmed by CAGE screening results that reveal significant concern for alcohol-related problems. The client's psychological profile indicates symptoms of potential depression and anxiety, which may be exacerbated by substance use behaviors. Social factors, such as strained familial relationships and occupational difficulties, further compound the issues. These multifaceted challenges suggest the necessity of an integrated treatment approach addressing both substance dependence and co-occurring mental health issues.

Working Diagnosis with Rationale

Based on the case history and screening tools, the provisional diagnosis includes Alcohol Use Disorder (AUD), moderate to severe, according to DSM-5 criteria. The CAGE screening tool results support this diagnosis, indicating frequent alcohol use despite adverse consequences, with at least two positive responses requiring clinical attention. Additionally, considering reported symptoms, a comorbid diagnosis of Major Depressive Disorder (MDD) is plausible, supported by mood disturbances and anhedonia noted during the mental status exam. The rationale for this dual diagnosis stems from the client's history of alcohol misuse impairing functioning and the presence of mood symptoms, which may serve as both a cause and consequence of substance dependence, necessitating an integrated treatment approach.

Mental Status Exam

The mental status examination conducted reveals a moderately disorganized thought process, blunted affect, and impaired judgment. The client reports feelings of hopelessness, low energy, and difficulty concentrating—symptoms consistent with depression. Orientations to time and place are intact; however, insight into the substance use issues appears limited. The client demonstrates some level of impulse control but reports cravings and withdrawal symptoms. Memory appears to be preserved, although concentration is impaired. These findings substantiate the diagnosis of comorbid substance use disorder and depression, underscoring the need for a multidimensional intervention.

Detailed Treatment Recommendations and Modalities

Considering the client’s multifaceted issues, an integrated treatment modality combining individual therapy, group support, and family involvement offers the most comprehensive approach. Cognitive-Behavioral Therapy (CBT) tailored for substance use and depression has demonstrated efficacy in similar cases by addressing maladaptive thoughts and behaviors. Additionally, Motivational Enhancement Therapy (MET) can foster engagement and readiness for change. Group therapy, such as 12-step programs, provides peer support vital for sustaining sobriety. Family therapy might address relational dynamics, enhance communication, and strengthen support systems. The choice of modality is grounded in the client's specific needs, including the severity of substance dependence, mental health symptoms, and social context.

Placement Recommendations: Inpatient, Residential, or Outpatient

The decision regarding placement depends on the severity of substance dependence, mental health stability, and social support. Given the client's significant impairment, outpatient treatment may initially be appropriate if they demonstrate some stability and motivation. However, if psychiatric symptoms worsen or relapse occurs, inpatient or residential treatment may be warranted to provide a controlled environment for detoxification and intensive therapy. The advantages of outpatient include greater flexibility, easier integration into daily life, and reduced stigma, while inpatient treatment offers intensive supervision, 24-hour care, and immediate intervention for crises. A thorough assessment suggests starting with outpatient services, shifting to inpatient if necessary, to balance treatment intensity with client autonomy.

Conclusion

The case underscores the importance of a tailored, multi-modal treatment plan that addresses both substance use and co-occurring mental health issues. An integrated approach utilizing individual, group, and family therapies is recommended, with placement decisions made based on ongoing assessment of the client's stability and response to treatment. By aligning clinical interventions with the client's specific needs and circumstances, the likelihood of successful recovery and improved functioning is maximized.

References

• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
• Moos, R. H., & Moos, B. S. (2007). Rates and predictors of relapse after natural and treated remission from alcohol use disorder. Addiction, 102(8), 1310–1318.
• Vanderplasschen, W., Rapp, R. C., & Monserud, M. A. (2020). Family involvement in substance use disorder treatment: A review and future directions. Addictive Behaviors, 102, 106273.
• Substance Abuse and Mental Health Services Administration. (2020). Treatment Improvement Protocol (TIP) Series No. 45: Substance Use Disorders and Co-occurring Mental Disorders. HHS Publication.