Diagnosis for Substance Use Disorder with Co-occurring Disorder

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Diagnosis for Substance Use Disorder with Co-occurring Disorder
In your professional capacity as a substance abuse counselor, you are not permitted to give diagnoses for mental disorders other than those related to substance abuse. However, you will likely be exposed to clients with mental health disorders in the assessment or treatment process. The competent substance abuse evaluator will be able to identify clients who present mental health disorders and make the appropriate referrals. Providing appropriate referrals for clients is common in the substance abuse field.

In M1: Assignment 3, you developed a case history for a person with an addiction. In this assignment, you will develop a case history and include one mental disorder. The inclusion of a mental disorder in your case study will aid in the examination of co-occurring disorders. You will then present your diagnosis and referrals.

This assignment has two parts. Complete both parts.

Part I

Create a case history for a person with an addiction and a mental disorder. Do not include identifying information. Include the following elements in your case history:

Demographics—including age, gender, ethnicity, socioeconomic status, marital status, number and ages of children, living arrangements, and religion if applicable
Presenting problem
Previous psychiatric treatment of patient
Previous chemical treatment of patient
Chemical history
Medical history—including disabilities if applicable
Work and education history
Legal or financial concerns
Family background
Concerned person involvement
Referral source
Part II

Analyze the case history and present your diagnosis as related to substance use disorders. Include the following in your diagnosis:

Summarize key case study elements you would use to formulate a diagnosis and guide your treatment plan.
Identify at least two assessment tools that you would use to formulate a diagnosis. Justify why you have selected these tools.
State your diagnosis related to substance use disorders. Justify your reasons for your diagnosis.
Identify other concerns and offer recommendations and referral opportunities. Justify your reasons and explanations.
Write a 3–4-page report in Word format. Apply APA standards to citation of sources.

Case history

Sebastian Bardem, is a 45-year-old male sanitation employee in New York. Sebastian is a Latin American who was born and raised in America along with his siblings. Sebastian is a married to his wife Luciana Sanchez and they are blessed with two children Maria Jose and Mateo Bardem who are 3 years old and 9 years old respectively. Sebastian’s wife is non-employed and the burden of taking care of the family lies solely on him, his wife has made efforts to ensure she helps her husband so that their children can attend school like other children, but she has not been successful in finding a job. Sebastian’s burden overweighs him, his salary is barely enough to cater for his family’s needs and there are days he gets home without food or money thus causing constant arguments with his wife.

Sebastian was born in a family of six that is his father Maximiliano, his mother Mariana, his brothers Mateo and Lucas; and his sister Camila. Sebastian was born into a family in which education was not the key thing in achieving life success, but it was seen a lower priority. Maximiliano, Sebastian’s father did not have a chance to attend school since his parents were drug traffickers who ended up in prison while Mariana was born in a poor background and only managed to get to high school level. Out of Sebastian’s siblings Mateo and Camila were the only ones who decided to take their studies seriously and they got good professional positions.

Lucas and Sebastian never got to college as they dropped out due to peer pressure and frustration due to the kind of life they were living. The two brothers decided to seek employment to help their parents and their siblings, but it was not easy for them and they ended up engaging in illegal businesses, Lucas was imprisoned, and Sebastian was lucky, and he decided to look for a legal job in a sanitation company. Sebastian has worked in Clean City Sanitation Company for over ten years and he has become frustrated due to the low salary he gets, and he cannot quit and get a better job since he did not finish college like his other siblings. Camilo and Mateo have made efforts to find him a better job but due to competition in the job market their efforts have been futile. Due to frustration and the constant pressure Sebastian gets from his family and due to the illegal businesses, he carried out in the past, he has become a constant marijuana smoker and he drinks alcohol daily to ease his stress.

Sebastian begun smoking marijuana back in high school together with his peers though he did consistently drink alcohol. After dropping out from high school he spent most of his time in clubs with his brother Lucas drinking and smoking after a fruitless job search. Sebastian spent most of his time drinking alcohol and even after marriage he would go home late and continue drinking the next morning as he carried out his illegal businesses. Despite efforts by his wife to urge him to reduce his smoking and alcohol consumption he did not quit. After his brother was arrested, Sebastian stayed at home in fear of being arrested but it took him one month before he went back to his usual routine though this time he was employed as a sanitation worker. Going to work drunk almost cost him his job but he was lucky since the manager was aware that he had a family that he had to take care of. Sebastian cannot go a day without smoking and drinking a situation that causes conflicts between him and his wife a state that would lead to divorce since Sebastian spends most of his salary in clubs and the little remaining is hardly enough to cater for his family.

Sebastian’s work performance is poor, he has been given numerous work suspensions and finally his position was changed since despite the suspensions he did not improve. Sebastian’s wife has made efforts to make sure that her husband goes to work well dressed but he frustrates her every time as he prefers baggy shirts and trousers which to him align with his work position. Sebastian’s addiction has raised gutted debates between him and his parents who are not in support of the kind of life he is leads and are not happy with the way he neglects his family. Sebastian has been among the lucky alcoholics and marijuana smokers who have not had complicated health complications. Most if peers have been to rehabilitation centers, hospitals and others died, but this is not a reason to celebrate since Sebastian’s health is deteriorating as he rarely eats, and his body is becoming weaker per day and he will be forces to go to hospital for checkups.

What potential ethical issues exist or may come into play with this client?

Neglect of family is a major ethical issue that is present in the case of Sebastian. Sebastian did not mind the welfare of his family and he was irresponsible this is shown by the time he went home, he never got time to be with his family. He also misused the little money he earned in clubs rather than saving up for his family. Another ethical issue is his poor work performance, he went to work drunk and since he knew he would not lose his job he did not make any efforts to improve his work performance.

Explain how duty to report may come into play when working with this client?

Sebastian has two children; Maria Jose and Mateo Bardem. A physician taking care of Sebastian may use the two children to track Sebastian’s progress or to find out if he is taking his medication and transforming from his earlier way of life.


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