Psychological and Social History

Psychological and Social History

SUBS 606

Case Study Instructions and Template

This is a comprehensive project divided into 2 Case Study sections. The expectation is that you will be able to show a working understanding of the course material thus far (Case Study 1: Chapters 1–5; Case Study 2: Chapters 6–7, 9). Case Study 1 will include all parts of the assessment, except the final 2 sections of treatment recommendations and recovery recommendations, which will be the requirements of Case Study 2. The chapter readings and additional materials available each week will enhance your ability to excel in this project. Review the “How to Approach a Case Study” document prior to composing your assignment.

For each case study, you are to read the provided Case Study Vignette and complete a thorough assessment based upon the information presented within the Case Study using the Case Study Template below. Both Case Studies will use the same Case Study Vignette. Case Study 1 will include the section headings Reason for Assessment through Spirituality. Case Study 2 will include the final 3 section headings: Diagnostic Impression, Treatment Plan, and Aftercare Recommendations.

Current APA format is required for all components of the paper (title page, citations, reference list). This case study needs to be strongly supported by the literature (a minimum of 5 sources for Case Study 1 and a minimum of 5 additional sources for Case Study 2) and, if done properly, will render 15–20 pages. This project is designed for you to show a working understanding of the course materials; therefore, it is truly a comprehensive project.


Each Case Study is due by 11:59 p.m. (ET) on Sunday of the assigned module/week.



Case Study Template


Page one is the title page formatted in current APA style (running head, page number, title page information).

Case Study 1 or 2 [Title should correspond with assignment]

Begin line 1 of page 2 with a current APA formatted title (matching the title page). Be sure to format page 2 and forth in current APA style (running head, page number, headings, and citations).

Reason for Assessment

Briefly describe why you are completing a substance abuse assessment for the individual in the Case Study Vignette. This information is provided in the vignette. Summarize the information into your own words. Quotes must be limited to statements made by the client and these must be minimal.

Sources of Information

In paragraph format, list the sources from which you obtained the information used in your report. Examples include the client, treatment center, medical records, diagnostic interview, family members, case workers with agencies, completed inventories, etc. Keep in mind not to add or make-up information; only use what is available to you in the vignette. The examples will give you an idea of possible sources of information in an assessment should you be completing an actual assessment on the individual in the case study.

Biopsychosocial History

The purpose of this section of the assessment is to provide an overview of the client’s biological, psychological, sociological, and developmental history. If available, spiritual information can be included in this section, as well.

Use the information provided in the corresponding Case Study Vignette to complete the psychosocial section. Review the How to Approach a Case Study document, as some of the available information may be limited.

This section needs to include sources (citations and references) to support findings, including course materials.

Biological, Psychological and Social History. Begin your discussion on this line since this is a Level 3 current APA heading.

Each topic (biological, psychological and social) will need a new paragraph. Keep in mind to interpret the Case Study Vignette. You will need to explore the information provided and take a close look at the individual to thoroughly assess these 3 factors. Interpretation and assessment requires the counselor to understand addictions, particularly the biological aspects, in order to thoroughly develop a treatment plan for the individual. The individual may not specifically state they are experiencing symptoms of addiction, and they may not be aware of their signs and symptoms. Hence, you must be able to evaluate, decipher, and determine the individual’s history based on the information provided. Ideally, you would be able to ask further questions directly. For the case study assignments, you may include these questions in formal statements. For example, “As a counselor, I’d like to investigate the client’s background as it relates to friendships and relationships during his or her developmental years.” This might include use of drugs and alcohol, influences, early sexual experiences, etc.

Developmental. Childhood developmental history can influence an individual’s use of substance as an adult. Was the individual exposed to substances at an early age directly or indirectly? Did the individual meet all developmental milestones? Was he exposed to ridicule, bullying, or learning difficulties in school? What were the expectations of the individual? When was the individual exposed to sexuality?

As we explore an individual’s developmental background, we gain a better assessment of his or her lifespan and possible influences that may contribute to his or her use and abuse of substances.

Family. We know family can impact addiction through exposure, behaviors, instability within the family unit, and more. Perhaps there was death, loss, or trauma experienced during youth. It may be that the individual had a strong, stable family unit until he engaged in relationships as an adult. In this section, you will present the individual’s family history, focusing on significant factors.

This can be a difficult topic for clients to address and it may be one they have repressed or denied. It may be that they blame their adult choices on events from their childhood. The purpose of assessment is to evaluate and explore in order to identify client needs and impacts on treatment and recovery.

Current Status

In this section of the assessment, address the client’s current levels of functioning. You will need to interpret the information available in the Case Study Vignette and utilize the information from the textbook to help you do so. What is the client experiencing currently that presents a need for treatment? This section needs to include sources (citations and references) to support findings, including course materials.

Indicators of Abuse and Dependency

In this section, you will use the Case Study Vignette to present any indicators of abuse and dependency on behalf of the individual. Much of his or her history was addressed above, and now the focus is on his or her current functioning as it relates to abuse and dependency. Keep in mind that some of his or her history may need to be included in this section, as it may continue to have repercussions or influences on the factors indicating abuse and dependency. For example, an individual may have criminogenic attitude and behaviors leading to his or her substance use presently and in the past. In the past, it may have resulted in legal problems for which he is presently on probation.

Keep in mind you are conducting a comprehensive assessment of the individual. This requires an evaluation of his or her overall functioning as it relates to indicating a presence or risk of abuse and dependency. In addition to the obvious information in the Case Study Vignette, keep in mind to include what you can determine based on the textbook and videos from the course related to the individual’s characteristics below. Include citations for anything not directly stated in the Case Study Vignette but garnered from the assessment and course materials.

Address each of the following headings thoroughly, yet concisely and succinctly (avoid wordiness and excess).

Attitude and Behavior

Social Functioning

Occupational Functioning

Financial Aspects

Familial Relationships



Note: For this section, keep in mind this is not limited to medical diagnoses. Include biological factors from the course material, nutrition, overall well-being, mental health, physical activity, etc. Some findings can be positive or negative depending on the identified problem. For example, a conscientious diet of healthy foods and exercise can be positive; however, if the individual demonstrates indicators of negatively impacted daily functioning because of obsessing about dietary intake, or exercises compulsively, these may be indicators of addictive behaviors and disorders.


Again, this is an area that can be positive or negative. Spirituality and religion can be used to enhance one’s life and foster balance, well-being, and humility. They can also be used to abuse others, justify actions (including substance use), and to impede one’s level of daily functioning. Think of the arguments for marijuana because God made it and its natural (He made poison ivy too), or wine is in the Bible (even though Daniel advised against drinking it). Sane discretion of spirituality is very different from using religion to justify our choices of the flesh and sin.



· Case Study 1 must have 10–15 pages of content.

· Case Study 2 must add an additional 3–5 pages of content.


Case Study 2

Begin Case Study 2 with the following section (be sure to change the title of your paper to correspond with the assignment). You may add it to Case Study 1 at this point in the document. The Diagnostic Impression heading will immediately begin after your last paragraph for the Spiritual Level 2 heading above. This will provide a complete assessment from beginning to end.

Diagnostic Impression

Using the information provided in the Case Study and in your assessment of the individual, give a diagnostic impression by ascertaining if this person is in the use, abuse, or an addictive cycle and if there are any co-occurring/additional issues. Utilize the information obtained in this assessment to formulate your diagnosis. The diagnosis must be justified with citations from textbook readings, presentations, etc.

Treatment Plan

Next, formulate a comprehensive referral(s) and treatment recommendations based on your determination of the individual’s current needs. This will require a thorough examination and evaluation of the client’s current status, treatment needs, and treatment goals. Explain your referrals and recommendations and support them with scholarly sources. You are expected to incorporate your readings and presentations. Use the learning materials to support your assessment, referral, and treatment recommendations. This assessment needs to be strongly supported by the literature.

Aftercare Recommendations

For this section, we will hypothetically find that the individual in the Case Study Vignette has successfully completed his or her proposed treatment plan. In this section, discuss aftercare recommendations for the individual to aid in maintaining sobriety and recovery. Note for future reference, this may be referred to as an Aftercare Plan or Discharge Plan, depending upon the treatment environment. Aftercare planning is required for any treatment environment, whether it be a counseling practice, a substance abuse treatment facility, or a behavioral health/psychiatric facility. In this section, explain and justify your aftercare recommendations and support them with scholarly sources.



Type Signature Date



The reference page begins on a new page and must be in current APA format. Be sure to include the textbook, DSM-V, course materials, and presentations as sources in your paper. You may also include additional scholarly sources. A minimum of 5 sources are needed for Case Study 1 and 5 additional sources for Case Study 2 (Sections: Diagnosis, Treatment Plan, and Aftercare Recommendations). The reference page must match the citations used in the body of the paper. If you are unsure how to format a reference, consult Chapter 7 of the APA Manual or Purdue OWL reference list resources beginning at


Final note: You have officially completed an assessment report based on your evaluation of the individual in the Case Study Vignette. You should have a good idea of how to assess and evaluate an individual presenting with substance related disorders and determine the appropriate course of treatment based on the gathered data related to the biopsychosocial history, current level of functioning, and indicators of abuse and dependency. You also know how to format and compose a formal evaluation report for a client based on your assessment findings. Congratulations!

Page 1 of 9

"Is this question part of your assignment? We can help"