Born and raised in Wisconsin, Tyler found himself at 26, living in South Florida and a job waiting tables at a local restaurant. He had the benefits of a loving family back home, good looks, and a friendly disposition. Like many young drug addicts, Tyler presented himself as an average post-college millennial attempting to navigate his way forward.

Having once again completed detox for his heroin addiction, Tyler contacted the agency about recovery coaching at the recommendation of a rehab center he once attended. Tyler had been to multiple treatment centers over the last ten years; an even worse relapse followed every attempt at sobriety.

The agency received a panicked text followed by Tyler's equally frantic telephone call saying he had tested positive for drugs and was immediately being removed from the sober house he had been staying at. The agency was surprised because he had contacted them earlier to say he went to a NA meeting and everything was going well. Tyler stated that he was feeling "down" and was having suicidal thoughts.

It was discovered that Tyler never went to the meeting and instead bought heroin. Having to leave the sober house on the spot, he went to his girlfriend's house for the night.

Directions

The clinical case formulation assignment is designed as an exercise in differential diagnosis to develop the student's skill in assessing an actual clinical case. Each student will be assigned a case vignette that provides clinical data from which a diagnostic formulation can be developed. The task is to present a comprehensive diagnostic formulation that integrates etiology, theory, and research as they apply to the case. In addition, the student should identify the process of ruling-out other disorders as possible diagnoses, as they rule in the final diagnosis. Finally, the student will develop a culturally appropriate, evidence-based treatment plan, including additional assessment, case management, etc. The case formulation should include a brief description of the following:

1. The external or environmental factors that might be relevant in the etiology and maintenance of the client's presenting problems.
2. The internal factors (biological, affective, cognitive) that might be relevant in the etiology and maintenance of the client's problems.
3. Provide the DSM-5-TR diagnosis, including code, for each particular case.
4. Identify the process of ruling out other disorders.
5. A detailed, culturally relevant, evidence-based treatment plan, inclusive of referrals.