case conceptualization of client

Treatment Professional/Counselor would write it. In clinical
terms.
here vignett:
The Story of Sam
When Sam was a youngster, he was quiet and somewhat withdrawn. He grew up with his mother and stepfather. Sam’s stepfather was a big, husky guy with a booming voice who often intimidated Sam and his mother. The stepfather also would drink heavily and, at those times, became physically and verbally abusive to both Sam and his mother. Sometimes, when the stepfather would return from a bar, he would wake Sam up and beat him for some perceived transgression even if it were not so. Sam’s mother, also afraid of the stepfather, did not protect Sam.
Sam grew into a teenager who had very few friends. His schoolwork was poorly done as he remained so anxious and frightened at home. He did not tell anyone about the situation because he was ashamed. At times, he thought about suicide, even as a young teenager. At one point, at age 14, Sam tried to hang himself in the garage. His mother found him and released him, comforting and chastising him at the same time. They decided to keep this another secret from Sam’s stepfather.
Sam barely finished high school. His teachers noticed a change in him and sent him to the school guidance counselor. Sam was clearly very depressed; he remained, for a brief period, in counseling and then quit, feeling it didn’t help. He took up drinking and found that, then, his terribly overwhelming sad thoughts went away for a while. He snuck drinks at home and also began smoking marijuana. He liked the euphoria that this drug gave him.
After he left school, Sam continued to drink and smoke marijuana. When he was not using, he felt his depression overtake him. He tried to work at several part-time jobs — at Wendy’s, warehouse work, Lowe’s, and a supermarket — but these jobs did not last. Sam simply could not keep up with the work, and he was let go. These rejections caused him to drink more, and the vicious cycle continued. Each time, he stopped using, he became so depressed that he thought of killing himself.
One day at age 23, Sam became so depressed that he cut his wrists severely. His mother found him and, this time, called an ambulance. For the first time, Sam was hospitalized, and offered treatment.
Screening and assessment are central to identifying and treating clients with cooccurring disorders (CODs) in a manner that is timely, effective, and tailored to all of their needs. The assessment process helps fulfill a critical need, as most people with CODs receive either treatment for only one disorder or no treatment at all.
Most counseling professionals can initiate the screening process. Understanding why, whom, and when to screen and which validated tools to use are the keys to success.
The assessment process is a multifactor, biopsychosocial approach to determining which symptoms and diagnoses might be present and how-to tailor decisions about treatment and follow-up care based on assessment results.
The 12 steps of assessment are designed to foster a thorough investigation of pertinent biopsychosocial factors contributing to, exacerbating, and mitigating the client’s current symptomology and functional status. At its core is the client’s chronological history of past symptoms of substance use disorders (SUDs) or mental illness, as well as diagnosis, treatment, and impairment related to these issues.
Counselors should get a detailed description of current strengths, supports, limitations, skill deficits, and cultural barriers. Identification of a client’s stage of change and readiness to engage in services will inform treatment planning and optimize adherence and outcomes.
TWELVE STEPS IN THE ASSESSMENT PROCESS
Step 1: Engage the client.
Step 2: Identify and contact collateral (family, friends, other providers) to gather additional information.
Step 3: Screen for and detect CODs.
Step 4: Determine quadrant and locus of responsibility.
Step 5: Determine level of care.
Step 6: Determine diagnosis. Identify differential Dx and assign Provisional
Step 7: Determine disability and functional impairment.
Step 8: Identify strengths and supports.
Step 9: Identify cultural and linguistic needs and supports.
Step 10: Identify problem domains.
Step 11: Determine stage of change.
STOP HERE…..
Step 12: Plan treatment.
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