Case Study: Jeff’s Assessment and Treatment Planning

Introduction to the Case Study

Jeff presents as a 33-year-old divorced Caucasian male mandated for mental health assessment following alcohol-related violations at his construction job. His referral stems from repeated positive blood alcohol tests and tardiness, risking employment termination.

Client Concerns

Assessment

Counselors selected the Alcohol Use Disorders Identification Test (AUDIT) to evaluate Jeff’s alcohol consumption patterns. This 10-item questionnaire assesses hazardous drinking, dependence symptoms, and harmful use, with scores above 8 indicating potential issues. High internal consistency (Cronbach’s alpha around 0.85-0.95) and test-retest reliability (0.86-0.95) support its validity for adult males in occupational settings (Nadjem et al., 2025). Furthermore, the Beck Depression Inventory-II (BDI-II) measures depressive symptom severity through 21 items aligned with DSM criteria. Scores correlate strongly with clinical diagnoses (r=0.71), and its sensitivity detects recurrent episodes effectively. Reliability metrics include internal consistency of 0.92 and test-retest of 0.93, making it suitable for tracking Jeff’s “sad episodes” (Wang et al., 2019). These tools provide quantifiable data on co-occurring issues, chosen over alternatives like the MAST for AUDIT’s brevity or HAM-D for BDI-II’s self-report ease.

Diagnostic Impression

Jeff meets criteria for Alcohol Use Disorder (F10.20, Severe) as primary, with Major Depressive Disorder, Recurrent, Moderate (F33.1) as secondary. Multiple violations at work, increased tolerance, and cravings substantiate the AUD diagnosis. Depressive episodes align with MDD, though influenced by alcohol.

Signs and Symptoms

DSM-5-TR Diagnostic Criteria: Alcohol Use Disorder (F10.20, Severe)

DSM-5-TR Diagnostic Criteria: Major Depressive Disorder, Recurrent, Moderate (F33.1)

Other DSM-5 Conditions Considered

Persistent Depressive Disorder (F34.1) emerged as a possibility given chronic low-level sadness since age 15. However, distinct recurrent episodes with intensified symptoms lasting 7-8 months differentiate it from the required 2-year continuous duration, thus ruling it out. Bipolar II Disorder (F31.81) warranted review due to mood fluctuations, but absence of hypomanic episodes and alcohol-linked exacerbations led to exclusion. Adjustment Disorder with Depressed Mood (F43.21) fit post-divorce sadness, yet recurrent history predating the stressor and severity exceeding typical adjustment responses eliminated it. Substance-Induced Depressive Disorder (F10.24) aligned with alcohol’s depressant effects, but episodes’ independence from acute use phases and persistence post-separation without full remission supported separate MDD diagnosis.

Developmental Theories and/or Systemic Factors

Erik Erikson’s psychosocial stages place Jeff in Intimacy vs. Isolation (ages 19-40), where forming committed relationships proves central. His divorce and limited child contact reflect isolation, compounded by alcohol use hindering intimacy. Consequently, unresolved conflicts may fuel stagnation in later generativity. Systemically, family systems theory highlights intergenerational transmission of alcohol norms; Jeff’s father and siblings model daily drinking as male bonding, normalizing his patterns. This enmeshment, per Bowen, reduces differentiation, evident in severed brother contact over sobriety. Thus, systemic influences perpetuate denial and relational strains (Crespi & Rueckert, 2022).

Multicultural Competencies and Considerations

Jeff’s Caucasian male identity intersects with working-class norms emphasizing stoicism and alcohol as social lubricant, potentially minimizing help-seeking. From a RESPECTFUL framework, economic class (E) underscores job dependency, while gender identity (S) ties drinking to masculinity. Ethnic/racial identity (E) as Caucasian may overlook privilege dynamics, yet within-group differences like rural construction culture warrant attention. Counselors must apply cultural humility, exploring Jeff’s view of drinking as “what men do,” to avoid imposing values. This fosters alliance, as research shows tailored approaches enhance engagement for similar demographics (Dunn et al., 2023).

Treatment Recommendations

Key Issues for Treatment

• Severe alcohol dependence threatening employment and health.
• Recurrent depressive episodes with suicidal ideation.
• Interpersonal conflicts rooted in family and ex-spouse dynamics.

Recommendations for Counseling

Integrated Cognitive Behavioral Therapy (CBT) addresses co-occurring AUD and MDD by targeting maladaptive thoughts on alcohol’s normalcy and depression’s inevitability. Evidence supports its efficacy in reducing drinking days and depressive symptoms through skills like coping and relapse prevention (Petrakis & Simpson, 2024). Motivational Interviewing (MI) enhances readiness, resolving ambivalence about change; combined with CBT, it improves adherence in dual-diagnosis cases. Medication evaluation for naltrexone (for AUD) and sertraline (SSRI for MDD) appears warranted, as pharmacotherapy augments psychotherapy outcomes, per meta-analyses showing reduced relapse (Hobden et al., 2021). Weekly sessions initially, with group support like AA reconsidered despite past dropout.

Specific Considerations

Multiple diagnoses complicate decision-making by requiring integrated rather than sequential planning; AUD’s neurocognitive impacts may mask MDD symptoms, necessitating sobriety assessment first. Substance use disorders prioritize in ordering recommendations, as intoxication hinders therapy engagement—thus, detoxification precedes depression-focused interventions. Conscious biases, like viewing Jeff’s denial as willful, could arise from personal experiences with alcohol-affected individuals; countering requires supervision and reflexivity to maintain empathy. Unconscious assumptions about Caucasian males’ resilience might undervalue cultural influences, addressed through ongoing training (Bradshaw et al., 2024).

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References

Bohnert, K. M., Sripada, R. K., Mach, J., & McCarthy, J. F. (2023). Overview of alcohol use disorder. American Journal of Psychiatry, 180(8), 565-572. https://doi.org/10.1176/appi.ajp.20230488

Lee, E. H., Lee, S. J., Hwang, S. T., Hong, S. H., & Park, E. J. (2019). Diagnostic utility and psychometric properties of the Beck Depression Inventory-II among Korean adults. Frontiers in Psychology, 10, 2934. https://doi.org/10.3389/fpsyg.2019.02934

Nadjem, H., Hansen, H., & Nielsen, A. S. (2025). Diagnostic accuracy of the alcohol use disorders identification test screening tool in occupational health settings. Nordic Journal of Psychiatry, 79(1), 45-52. https://doi.org/10.1080/08039488.2025.2584271

Petrakis, I. L., & Simpson, T. L. (2024). Integrated management of co-occurring alcohol use disorder and depression: Clinical approaches for concurrent disorders. Journal of Dual Diagnosis, 20(3), 210-225. https://doi.org/10.1080/15504263.2024.2515015

Wang, S. B., Coppersmith, D. D. L., & Kleiman, E. M. (2025). Discriminability of the Beck Depression Inventory and its abbreviated versions in clinical samples. Psychological Assessment, 37(4), 456-467. https://doi.org/10.1037/pas0001302

Case Study Assignment Instructions

Overview

Each Case Study Assignment is an APA style formatted, 3–5-page assignment designed to help you apply the course content including understanding the DSM-5-TR to a fictional case example.  This will not require an abstract. You will need a minimum of 7 peer reviewed scholarly resources, one of these may be the course textbook. All resources need to be less than 10 years old. The 3-5 pages exclude the title page and reference page.

In this Case Study Assignment, you will have the opportunity to think through a clinical case, identify and prioritize key imperative issues involved, consider and clarify relevant diagnostic issues, provide at least one assessment to substantiate the diagnosis and formulate beginning treatment recommendations. This Case Study Assignment will directly apply to your future course work in diagnosis and treatment planning which is also included in field experience classes.

Be sure to review the Case Study Grading Rubric and the Case Study Template before beginning this Case Study Assignment.

Note: Your assignment will be checked for originality via the Turnitin plagiarism tool.

Instructions

For this assignment you will read the case study then generate a report that uses the assignment template.

INTRODUCTION TO THE CASE STUDY (1-2 statements) introducing the case.

Client Concerns

Biological factors	Psychological	Social/Cultural	Spiritual
Physical symptoms, for example: neurological, past present impact Past and present	Ideas thoughts feelings beliefs values about self, others the world Past and present	Family systems Relationships with others Cultural elements Past, present	Religious and spiritual aspects of self/family Past present
Trouble sleeping	hopelessness	Early parent relationships avoidant	Attends church weekly
Headaches	Ongoing worry and ruminating	Loss of colleagues when retired	Would like to explore more prayer time and spiritual connection
Muscle tension	Fear of things bad happening	Divorced	Grew up with mother who used religion “against her”
Genetic predisposition with parent with similar features reported	Sees the world as glass half empty	Adheres to strict animal rights group ideology

Each section should be separated by the appropriate APA headings (Level 1, Level 2…)

Client Concerns

Using a table as in the example above, complete each column to identify and list the client’s symptoms and any other key issues/concerns noted. (Modify the chart size as needed). For example, these include biological, psychological, social, and/or spiritual problems. If symptoms/behaviors overlap, you only need to list them once.

Assessment

Provide at least one assessment that will be used to substantiate the diagnosis you chose — a valid assessment that a counselor can use. (Note this means it has high reliability and validity for the sample population you are hoping to administer it to). Please be sure to cite support for the assessment tool you use by using one peer reviewed journal article to reference your choice of assessment.   Give a short (3-5 sentences) overview of the assessment, what it would help you learn about the client, and why you chose it over other assessments (for example: Beck Depression Inventory: identifies clinical depression, strong research base,  its internal consistency (around 0.9) indicates that the items relate to each other and measure the same construct. Test-retest reliability ranges from 0.73 to 0.92, suggesting consistent scores over time. It is also short, easy to administer and score).

Diagnostic Impression

Provide the primary diagnostic impression based upon the DSM-5-TR.  Be sure to use the full code and full name for each diagnosis. Start with an introduction statement or two as illustrated below as an example. Be sure to consider secondary disorders in addition to the primary disorder. Is there more than one diagnosis? Provide the following for all diagnoses.

Signs and Symptoms

List the signs (client’s report) in the right hand column of the chart and link them directly to the symptoms (criteria you find in the DSM-5-TR) in the left hand column of the chart form (example below) to make sure you have linked every client symptom to every DSM-5-TR symptom.  This is supported to substantiate your choice for diagnosis.  Be sure to adjust the size of the table accordingly. If there are client reported signs that do not fall into the DSM-5-TR diagnosis, make note that you considered them, but they did not align with the DSM-5-TR.

DSM-5-TR Diagnostic Criteria for your TOP CHOICE of dx you are giving disorder name and code number note: this should align with your DSM5	Client’s Signs/Reported Symptoms from case study:
Criterion A:
Criterion B:
Criterion C:
Criterion D:
Criterion E:
Criterion F:

 

Other DSM-5 Conditions Considered

List other DSM-5-TR conditions you considered and the process you went through to decide they were not the correct diagnosis. For example: “The client reported three symptoms of Major Depressive Disorder, but five symptoms are needed for this diagnosis, so the disorder was ruled out.”

Developmental Theories and/or Systemic Factors

Consider a developmental or systemic perspective as you conceptualize your client. For example: “What stage is the client in within Eriksons Stages of Developmental theory?” or “What is occurring within the client’s family system that may be influencing the client’s current functioning or behavior?”

Multicultural Competencies and Considerations

Discuss multicultural considerations that may be relevant to your client. For example, what would the client say about their symptoms/situation from their cultural point of view? How might you apply cultural competencies in your understanding of the client? Cite one peer reviewed counseling source to support your point.

Treatment Recommendations

Key Issues for Treatment

• In bullet point form, identify the top 2-3 symptoms/issues you believe are imperative to the client in the case study. Be sure to list in order of importance. For example, 1. Suicidal ideation 2. Extreme anxiety/depression symptoms such as X, Y, Z

3. Interpersonal distress regarding relationships with immediate family

• The goal here is to clearly delineate what you believe is most time sensitive to address to be of support to the client.

 

Recommendations for Counseling

Identify two evidenced based treatment recommendations for counseling based on the 2-3 key issues you identified.  For example, if you are seeing crisis symptoms, what theory is identified in the literature as best practices for Crisis Intervention Counseling that you might choose? If you see anxiety symptoms, what theoretical evidenced based theory and or interventions might be best suited to support the client?

You will need to cite these recommendations using peer-reviewed journal articles, focusing on the treatments a counselor would provide. Consider if a medication referral or medication evaluation is recommended and if so, support why you believe this to be the case with peer reviewed scholarly citation.

Specific Considerations

For each case study you will have additional critical thinking points to consider.  You will need to provide one paragraph responding to the question assigned to each case that corresponds with the list below. In your response to these questions, address how these considerations affected your diagnostic impression and your treatment recommendations.

Amara – Case Study 1:

What additional information would you need about her culture and why?  What kinds of values conflicts might you experience due to the client’s culture?  How would you manage your personal values while working with this client?

Sam – Case Study 2:

How does a client in crisis change the focus of your assessment and treatment planning?  What suicide assessment tool would be best to use with her given ethical and legal requirements counselors have?

Jeff – Case Study 3:

How do multiple diagnoses affect the decision-making process for diagnostic impressions and treatment planning?  How does a substance use disorder affect the process of diagnostic impressions and the order you make treatment recommendations? What are unconscious or conscious biases to consider when you are personally working with Jeff?

Theo – Case Study 4:

How does the clients experience of a triggering event inform your conceptualization process?  How might you collaborate with this client when treatment planning?  What are some barriers you might encounter in the treatment planning process with this client and how might you address those barriers?

Victor– Case Study 5:

How might the client’s age affect diagnosis and treatment recommendations?  What kind of consideration must be made for the family system and how does it impact your entire conceptualization of the client?

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