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➢ Final Exam Due: May 9, 2018, 11:00 PM– Total 100 points
The Final Project is a comprehensive assignment whereby the student will demonstrate
understanding in the concepts that were covered during this semester. The project consists
of the student reading the case presentation and completing the tasks that follow. The
student will complete the following activities based upon this client:
Instructions: Read the case history and then complete the diagnosis, assessment and treatment
plan sections that follow based upon this client as described at the end of the case history.
Client Sally, a 28-year-old married Hispanic female, came to our center for an assessment due to
a court mandate after an arrest for child neglect. Sally is involved with DCFS and has
temporarily lost custody of her three children due to the arrest.
Sally has three children, ages 3, 5 and 7. She is married for seven years now. Her children are
from the same father who she dated for three years before they married. Sally is unemployed and
works at home by taking care of her children. She receives funding through the states LINK
system, which provides for adequate food. Her husband works as a laborer and their income is
just slightly above the poverty level. Sally states that overall, she is happy but the stress of the
handling her children can get to her. Sally states that she dropped out of high school and never
got a GED. She is not interested at this time to return to school or getting employment outside of
the home as she cannot afford child care to allow for her absence from the home. In addition, her
spouse does not want her to work outside the home.
Sally reports that she has been using alcohol and other drugs on a regular basis since she was 15
years old. We took an alcohol history. She reports drinking beer about three times a week,
consuming about 4-6 12 oz cans per time. She drinks with her husband, friends or alone, usually
when feeling bored or frustrated. She states that drinking helps her relax and deal with the stress
of parenting. She does not feel that she has a problem with alcohol. She denies any withdrawal
history or any previous treatment for substance use. She states she is in total control of her
drinking. However, after some questioning, she did admit that she drinks on occasion in front of
her kids and even got drunk a couple of times in front of her children. She states she still was
able to address their needs and does not feel that her drinking had any adverse effects on her
Sally also reports using other drugs as well. She regularly smokes marijuana and used
prescription opioids from time to time ever since she was prescribed them two years ago after a
fall that injured her neck. She states that she has ongoing neck problems and admits that at times
she uses substances to help deal with the pain. She states that she smokes marijuana almost every
day, at least one joint a day, but sometimes will have four or five, depending upon the situation.
Marijuana helps her feel more relaxed and helps her to forget things that upset her. She is not
concerned about her marijuana use because she feels that everybody is doing it and doesn’t think
it is addicting. Her friends all use substances as well.
Sally has been under psychiatric care for seven years now. She has been diagnosed with
generalized anxiety disorder (GAD), and has been taking Lexapro, 10mg per day for the last five
years, but had stopped taking it about one month ago as she does not like taking the medication
and cannot afford to buy it. Prior to the past five years, she was on medication off and on, but
never stuck with it. She reports that while taking the medication she would often have difficulty
sleeping, and headaches. She also has had thoughts about suicide in the past but has not made
any attempts. She says the thoughts come and go and sometimes can be overbearing, although
she does not feel depressed.
Sally states that she first started feeling anxious when she was 21. She was hospitalized two
years later after reporting suicidal thoughts and not feeling like she could stop herself from
acting out on them. She denies any suicide ideation at this time. She states her anxiousness tends
to fluctuate but most of the time she is more unmotivated and more tired than anxious.
Sally states her physical health is good except for her neck pain although she has not seen had a
physical exam for over two years now. She smokes cigarettes, about one pack per day and does
not engage in any regular exercise. She reports having had an affair after a night out with her
friends where she drank too much, and she engaged in unsafe sex. She reports no history of STIs
as far as she knows.
Sally states that she has little family support. Her mom and her talk from time to time and she
relies on her for additional financial aid, but she does not feel close to her. She states her mom
was mean to her as a child and she was physically disciplined often, at times for no apparent
reason. Her father is deceased for eight years now after being murdered during an attempted
robbery where he refused to give the robbers his cash. Sally states she was not close to her dad
and has no real feelings about what happened to him.
Besides getting high, Sally spends her time with her kids and watching TV. She used to have
several hobbies such as walking, reading, and bike riding, before she started getting high, but
stopped doing this because it was difficult for to concentrate when reading and she lost
motivation to exercise. She would like to return to taking better care of herself but feels little
energy to do so at this time. Her eating habits are poor, and she seldom eats three nutritious
meals a deal, usually snacking and catching a meal when she thinks about it. She is about 20
pounds underweight.
Sally states that she has a poor work history. As mentioned, she is not currently working, but has
had past jobs as a waitress. Her last job was two years ago as a waitress. She lost this job after
coming in late repeatedly, usually after getting high or feeling unmotivated. Currently she feels
stuck, and wishes her life was different. She would like to get out more often but she has no good
day care options and has no car.
Sally denies any other legal troubles or history outside of the recent arrest for child neglect. The
current arrest happened after she had left her kids alone in the car while buying marijuana. A
neighbor spotted the friend the kids alone and contacted the police. When Sally returned, she was
arrested and her children were put in temporary custody while DCFS assesses the situation. Sally
was very upset about this and states she will do anything she has to in order to get full custody
returned to her.
Sally identifies the following problems in her life: lack of interest, relationship problems, anxiety
worsening, and increase marijuana use. She denies any problems due to use other than the
current arrest. She does not want to stop using marijuana or alcohol, and feels that she needs to
take prescription opioid pain killers occasionally for her neck pain as nothing else seems to help
her. She does not have a valid prescription for the opioids anymore and gets them from a friend.
Sally states that her kids are in good health and are developing fine. Her husband is supportive
but is not around a lot as he works long hours to support the family.
Sally identified the following strengths: sense of humor, easy to get a long, and a hard worker
when she is motivated. Sally states that others tell her she is very funny and easy to get along
with. This has helped her in her past employment.
Sally is willing to listen to recommendations for counseling in order to satisfactory complete
treatment and comply with the DCFS mandate for treatment so that she can get her kids returned
to her.
Complete all work on the forms provided below.
Student Name:
1) Payoff Matrix – Complete the Payoff Matrix below based upon the client’s case study.
Instructions: Instructions for completing each quadrant appear below. For all quadrants, please
be as specific as possible about the consequences.
Advantages of Using Substances – 4 points
Advantages of Not Using Substances – 4
Disadvantages of Using Substances – 4
Disadvantages of Not Using Substances – 4
2) Indicate the DSM V Diagnosis for this client – both the substance abuse diagnosis as well
as the mental health diagnosis (2 points):
Substance Use Diagnosis (Provide the code and the description):
Severity Level:
Mental Health Diagnosis (Provide the code and the description):
Severity Level:
3) Provide your rationale for these diagnoses and their severity level (2 points):
1) Provide a summary of the Client’s problem areas or needs (if any) in each of the following
ASAM Dimensions:
1. Acute Intoxication/Withdrawal – (2 points):
2. Biomedical Conditions – (2 points):
3. Emotional/Behavioral Conditions – (2 points):
4. Treatment Resistance/Acceptance – (2 points):
5. Relapse/Continued Use Potential – (2 points):
6. Environmental Support – (2 points):
2) Summarize the client’s strengths – (2 points):
3) Summarize any barriers that need to be addressed in order to enhance treatment
effectiveness – (2 points):
4) Summarize the client’s preferences – (2 points):
5) As a result of the assessment of your client, indicate the 4 most important areas you would
address at the onset of treatment – (2 points each):
6) What stage of change do you think this client is in and what evidence supports your view?
– (2 points):
1) Stage-Wise Goals
Based upon the stage of change the client is at as indicated above, set one goal to enhance
their motivation ( 2 points):
Goal (The expected Outcome):
Intervention ( Specific steps to reach the goal, what will the client actually do?):
2) For each of the 4 areas above in the assessment, set one goal and two objectives to assist
the client in treatment. Remember, goals are expected outcomes, and objectives are the
specific steps to reach that outcome. Objectives must be specific and measureable, i.e;
what is the client to do, how often and when?
1. Goal – (2 points):
1. Objective – (2 points):
2. Objective – (2 points):
2. Goal – (2 points):
1. Objective – (2 points):
2. Objective – (2 points):
3. Goal – (2 points):
1. Objective – (2 points):
2. Objective – (2 points):
4. Goal – (2 points):
1. Objective – (2 points):
2. Objective – (2 points):
3) List any referrals you would make to community resources and why and how you would
locate these resources – (2 points):
4) How would you structure this client’s treatment to ensure that an integrated approach was
being used? Provide 5 examples – (2 points each):
5) How might you use the Motivational Interviewing technique to address the resistance this
client is experiencing? Provide three examples – (2 points each):
6) How might you use the Cognitive-Behavioral approach to address both the substance
abuse and mental illness symptoms this client is experiencing? Provide three examples (2 points each):
6) After several months of treatment, should you feel that you are not having much of an
effect on the client’s progress, discuss what steps you might take to address this – (2

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