You are a counselor working in a community mental health agency that serves low- income individuals through Medicaid and Indigent Care. You are assigned a walk-in client who came in a few minutes prior, asking to see someone. You walk into the waiting room to greet your new client, Josh. Josh is a fifty-three-year-old male with graying hair, a slight build, and a friendly demeanor. As you shake Josh's hand, he cracks a joke about your being his savior.

You take Josh back to your office to begin the intake session so you can gather more information and identify Josh's needs. After discussing confidentiality, the process of counseling, and other relevant information, and after getting Josh's informed consent, you ask Josh to talk about what brought him to your office today. It is evident that Josh likes to talk, and he begins to tell story after story about people he has met on the street that seemingly have no relevance to why he might be there, seeking your services. Respectfully, you cut in and tell Josh that, while listening to him talk about other people he has met is interesting, you are wondering how that relates to what brought him in today.

Josh gives you a lopsided grin and says, "Yeah, I guess I'm a bit nervous. It's always easier to talk about someone else rather than myself. I'm just concerned that you might judge me. I'm still not real sure I should have come here."

You reassure Josh that you are here to help, not to judge: "It's okay, Josh, we have all lived different lives. Why don't you start by telling me a little about yours?"

"Well, that is the part I'm a little afraid of," he says, and looks down at the floor. "I've been in prison for the past thirty years. I just got out about a month ago. It's been real hard to adjust to living on the outside. I'm feeling kind of lost, and I'm afraid I'm going to get caught using again and end up back inside. I don't want to go back. I want to have a life." Josh looks into your eyes. He looks firm and determined, yet scared.

"So, you're afraid of what I might think about you because you're an ex-con and a recovering substance abuser? It must have taken a lot of courage to come here today

with those thoughts of potential rejection. I'm really glad those thoughts didn't stop you." You smile at Josh encouragingly.

Josh quickly looks up at you, meeting your eyes. The anxiety on Josh's face dissipates. "Yeah, me too. This is tough, but it's better than I thought it was going to be."

Josh then launches into his life's story. He was thirteen when he first began using drugs. His parents were overly involved in their own lives, and as long as Josh did his chores, he was free to roam. His family lived in a very small town in New Mexico, and Josh's parents had naively thought that the town was a safe haven in which to raise kids. While Josh was close to his four other siblings, he had been drawn to the wild boys of the neighborhood. Those boys were interesting and had helped stave off the boredom that a small town can bring. It was those boys who first introduced Josh to alcohol, marijuana, and later, methamphetamine.

Josh talked about how he and the boys began to hang out with an older man in a nearby town who cooked his own crystal. Josh and his friends began to work for this man, first selling crystal, and then stealing and chopping cars. At age seventeen, Josh was busted for possession with intent to sell and grand theft auto. On his first day in prison, two inmates jumped him and raped him. He was the new fresh meat.

Josh looks up just then to see your reaction. You meet his eyes honestly, empathically, without judgment.

"I can't even begin to imagine what that must have felt like, Josh, to be so young, so alone, so vulnerable. That must have been terrifying. They hurt you."

Tears form in Josh's eyes as he tells the rest of his story. His family disowned him. His father was a respected man in their little community, and having a son in prison was a disgrace. It had been over twenty-five years since Josh had had contact with any of his family.

The same two men in prison had repeatedly raped Josh for months after his arrival until Josh killed one of his abusers, defending himself against yet another attack. Josh was then sentenced to thirty years in prison for aggravated murder. Eventually, Josh teamed up with several other inmates in a gang and was able to keep himself from being abused further. Josh was released from his thirty-year sentence about five years ago, but was re-arrested several times for possession of a controlled substance, and was finally released one month ago. Josh is currently living in a halfway house with ten other parolees.

"Josh, how long has it been since you last used? From what you've told me, you've been in prison a long time."

"Drugs are very easy to get in prison. I used the whole time I was in. I also wasn't in prison for a solid thirty years straight. I was paroled early on the murder for good

behavior. But once out, I just couldn't cope. I'd been locked up for too long. I don't know how to act, what to do; gosh, once I even got into trouble for staring at a girl. Since I got out for the murder, I've been busted three more times for use and possession. It's the only way I know how to cope. But I'm fifty-three years old, and since the age of seventeen, I haven't known much of anything except for the inside of a prison. I don't want to die not knowing how to live. I know that if I don't get help, I'll die in prison. I just know it. Please help me. I just don't know where to start." Josh continues to talk about his post-prison use and his efforts to make changes.

You ask Josh a few more assessment questions regarding his intent to change his current behavior and to assess his level of motivation. From all that Josh has told you, you assess that he is in the preparation stage of change. Josh knows he has a problem and needs to do something about it, but he doesn't know what to do about it. Josh has tried to deal with his addiction problem on his own, but he has been unsuccessful in abstinence and is feeling discouraged.

"I've tried, I really have, but I just can't seem to stay away from it," he says.

You view Josh's attempts a little differently. You note to Josh that, while he may not have been able to abstain, he has engaged successfully in harm reduction. Josh has independently switched from crystal to marijuana and alcohol, which has reduced his potential for negative consequences. Josh has also moderated his use to just weekends, and he purchases minimal amounts of pot for single consumption, rather than buying his usual ounce. These positive actions made by Josh have reduced his harm and are important steps toward his goal of abstinence. You point out the gains Josh has made in his goals all on his own and empathize how hard it must be for him to curtail something that has brought him comfort in his life.

"Wow, I feel like you understand me," he says. I hadn't realized I was doing good. I thought I was just failing. I feel like there is hope I can make the changes I need to make."

The rest of the session is spent further clarifying Josh's goals, examining antecedents to Josh's use (e.g., when does he have the most desire to use; what is going on for him emotionally inside, or in his environment, during this time; when has it been easiest for Josh to abstain from use; and what is going on during that time). By the end of the session, Josh is feeling confident and is eager to return for another session. You send Josh home with a homework assignment to write down the times when he is feeling the need to use. Josh is to write down what is going on around him, who is present, what events just took place, what he is thinking and feeling in the moment, and to also write these same things down during the times he successfully abstains from using. Josh firmly shakes your hand and grins at you. "I am really glad I came today," he says.

"I am too, Josh. See you next week," you reply. "You bet you will."

please answer:

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 your differential diagnostic process of other disorders (i.e., what other disorders did you consider to rule out and why)
5. An identified theory with 1-2 theoretical interventions for working with this client and a brief description of how that theory conceptualizes mental health, functioning, and diagnoses.
6. A detailed, culturally relevant, evidence-based treatment plan that consists of 2-3 goals for the client and specific referrals that you would offer (i.e., family counseling, substance abuse counseling, etc.)