Online Class Assignment

PSYC-FPX4300 Assessment 3: I’ve Got You Pegged (Treatment Plan)

Assessment and Treatment Recommendations Worksheet


Client Name: Max
Assessment Date: October 3, 2022

Substance Use History: Drug

First Use: Yes or No

Xanax No

Follow-on question:

Pattern of use over time?

4 to 5 per day

Frequency of use in past month? Everyday

Date/Amount of most recent use?
4 to 5 per day

Have these drugs ever been used in combination?

Michael has not used these drugs in combination with any other drugs, to my knowledge, from the information provided in the case study.


Physical Consequences (Describe the physical consequences the client has experienced from substance use)
Michael has not shown any physical consequences of the usage, except that he feels that he is good to go once he takes the four to five pills for the day. He has not said why he feels the need to take Xanax (Case Study, 2022).

Psychological Consequences (Describe the psychological consequences the client has experienced from substance use)
Psychologically Michael feels the need to hide his use from his parents and school for fear of getting into trouble. Michael comes off as a bit defiant against his parents and resentful that they don’t notice him due to their divorce. He is also being affected in some way because they don’t know that he is gay. However, he doesn’t seem to have a problem with them knowing but makes it seems like they could possibly have an issue with this fact due to the fact that they are very religious.

Medical Concerns (Describe any medical concerns that might relate to substance use) Michael’s mother has been seeing a therapist since the divorce. He says it is due to depression or anxiety; however, he is not completely sure. He has no other medical history or concerns related to the use of Xanax.

Past Treatment History (Describe any past treatment history for substance use, mental health concerns, or other related issues)
Michael has not had any past treatment for any substance use, health concerns, or any other related issues. Michael specifically stated that he is able to receive the Xanax by lying to his doctor (Case Study). Michael noted that his parents have a history of drinking, but not in a bad way.

Environmental Factors

Residential (Describe their living situation)
Michael lives with his mother due to the divorce. He has visitation with his father every other weekend.

Social support system (Describe their social support system including: family, friends, social groups)
Michael’s mother and father are focused on the divorce, so they don’t pay attention to him and his brother very much. His brother was suspended from high school due to smoking weed. Michael’s current friends all use Xanax as he does, and they often share between themselves or offer to sell their Xanax.

Family and Family History

Family History of Use (Describe if family members use or have a history of using substances)

Both of Michael’s parents drink alcohol, but he stated it was a normal amount. Michael’s older brother smokes weed. There are no other known family members with a history of substance use.

Family Mental Health History (Describe if family members have a current or past history of mental health problems and/or treatment)

Michael’s mother is currently being seen by a therapist for issues related to the divorce, possibly anxiety or depression related. There are no other known family history-related illnesses.

Current Additional Status To Consider

Educational (Describe client’s educational level and if they are currently in school)
Michael is currently in his final year of middle school. He will be attending high school next year.

Financial (Describe client’s employment and financial situation)
There is no known information about financial or work situation. Due to Michael being a minor, he likely too young to work.

Legal (Describe if client has current or past legal problems) There are no known legal problems that Michael has faced.

Motivation for Treatment (Describe if the client thinks they have a problem, if they plan to stop or reduce their use of substances, and why they are seeking treatment)

Michael is not currently seeking treatment for his use. He is likely seeing a doctor due to his parent’s divorce. Michael has not mentioned that he feels he has a problem with substance use, but he has mentioned that he has problems.

Recommended assessment measures (what additional assessments or tests would you recommend)
In my opinion, I would likely assess his reasoning for using Xanax, in order to dig a little deeper into the root of the issue. I feel there are some deeper feelings and emotions at play in regards to his usage.

Clinical Assessment (Describe the client’s diagnosis, if any. Support with evidence from client’s history and from scholarly literature—this should be one to two pages)

Michael has been shown to be abusing the drug Xanax by using it every day in increments of 4 to 5 pills at a time. He shows a dependence on the drug based on the amount that he uses and the frequency of usage. Although he does not state why he feels the need to take Xanax, he feels that he is good after taking the 4 to 5 pills. Michael has gained a tolerance to the drug by showing he needs more than necessary in order to get by. Michael is diagnosed by the DSM-5 with substance abuse, and the ICD-10 code is F19 for anxiolytic drugs. According to the DSM-5, tolerance is when an increased dose is used to receive the desired effect (DSM- 5, 2022). Unfortunately, Michael has given little information on his drug history use of Xanax and how it affects him physically or mentally.

There is currently estimated to be 0.3% of 13–17-year-olds affected by the use of anxiolytics (DSM-5, 2022). Anxiolytic substances include benzodiazepines, carbamates, barbiturates, and barbiturate-like hypnotics, which also have sedative-like effects. Prescription sleeping medications and nearly all prescription anti-anxiety medications are among this class of drugs, including Xanax. Symptoms of the abuse of this type of drug include poor performance in school or work, missed work or school days, or suspension or expulsion from work or school. Another symptom of the use of these drugs includes neglect of children or the household by parents.

Features supporting the diagnosis of substance abuse would be Michael’s level of tolerance to the drug and his daily usage. Other supporting factors could be related to the environment, such as his parent’s divorce. Even though he does not mention specifically that he was affected by it, he does show some agitation with being left alone or ignored. Being that the drug is also very easily attainable from friends in or out of school to him, it is a normal type of thing to do because all of his friends are doing it.

Treatment Recommendations (Provide treatment recommendations for this client. Be sure to consider: financial/insurance resources, willingness to change, culture and diversity, and severity of use. Support recommendations with evidence from scholarly sources. This should be one or two pages)

Michael is currently a teenager, and therefore, it is up to his parents to seek out help for him. It is my opinion that, with their attention, he would be willing to seek help. I believe that he is currently feeling more ignored due to his parent’s divorce. Michael has not mentioned a reluctance to get help for his substance abuse, so I believe that if his parents noticed an issue and brought it up, he would likely be interested in treatment.

There are currently four phases of care when it comes to the treatment of substance abuse, palliative care, stabilization, rehabilitation, and maintenance (Miller, et al, 2019). Palliative care is the first step in treatment, which involves initially seeking out help for the problem. During this phase, a doctor or family may encourage seeking further treatment. Stabilization can generally be used to prepare for the third stage; this can involve managing the withdrawal symptoms. Rehabilitation is what most people think of when using the term treatment for drug abuse. During rehabilitation, each person’s individual needs and goals are addressed in order to change the habit and issues with the initial abuse. During the maintenance stage, each person is focused on staying off of the drug in whichever way they have planned in stage three.

Michael would benefit from therapy and rehabilitation treatment in order to reduce or stop his drug abuse completely. Therapy would greatly benefit him due to his parent’s divorce and being a teenager entering high school. At his age, entering high school is a very stressful experience, and the anxiety of keeping up can affect his drug abuse. A clinical therapist can get to the root of the problem and offer some coping techniques in order to get through his problems without feeling the need to take Xanax.

Ethical Considerations (Describe any ethical considerations relevant to this case. Include: Client confidentiality, multiple relationships, etc.)

Ethical considerations to take into account would be that he is a minor; however, when seeing a therapist or any doctor, they still have the right to abide by the code of conduct and not release his information, even to his parents. Therapists are prohibited from releasing clients’ information due to client confidentiality unless they offer their written consent to do so. Being that he is a child, his parents will likely want to know his diagnosis and treatment, but there are rules that they will have to discuss.


Case Study (2022) Capella University, Michael.

DSM-5 (2022). Diagnostic And Statistical Manual Of Mental Disorders, Fifth Edition https://doi-

Miller, W. R., Forcehimes, A. A., & Zweben, A. (2019). Treating Addiction (2nd ed.). Guilford Publications, Inc.

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