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    As part of your responsibilities with the Department of Community Health and Corrections, you spend some time each week seeing outpatient clients at a community health clinic. You have already met with Gary R. on a couple of occasions. Gary has exhibited psychotic symptoms, as he appears to hear voices and has said things about people being in the room, when there are not other people present. Gary often seems restless, rubbing his arms and getting to his feet and then sitting back down during interviews. Gary seems to have substance abuse issues, and has smelled of liquor during his interviews, while also mentioning using amphetamines and cocaine. His use of different substances has made it more difficult to arrive at a diagnosis for him. Today, during your session with Gary, he made several statements about teaching "Mary" a lesson and finally says that he has a knife and that he's going to show Mary not to mess with him. You know that he has a sister named Mary. After Gary leaves, you try to decide what to do next for his case.

    · Although confidentiality applies to the therapist-client relationship, there is also a "duty to warn." When does the "duty to warn" apply and what steps would you want to take to follow up on this in Gary's case?

    · How can substance use/abuse affect the ability to make a psychiatric diagnosis? In particular, for Gary's case, how might his psychotic symptoms be difficult to separate from his use of alcohol and amphetamines for the purposes of diagnosis?

    · What does it mean to be "dual diagnosis?"

    · What other steps, in terms of treatment or otherwise, would you recommend in following up in Gary's case?

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    Solution Summary

    Psychiatric diagnosis.