Case Study In Semi-liance

Client comes to treatment because she has been mandated by the court to receive services for her drug and alcohol usage. Client self-reports an extensive history of drug and alcohol usage, as well as, issues with controlling and maintaining her anger. Client is more concerned with her anger issues then her drug and alcohol usage. Client feels that if she can control her anger then she will not have to turn to drugs and alcohol. Client appears to be self-medicating with drugs and alcohol.

Ms. Bynum is a self-referral who agreed to participate in the TPAPN monitoring program. On 11/24/16, Ms. Bynum tested positive for alcohol (ETG - 2510 ng/ml, ETS - 77 ng/ml) and renewed her program with TPAPN. On 2/26/16, Ms. Bynum tested positive for alcohol (ETG - 7980 ng/ml, ETS - 1580 ng/ml). On 4/7/16, Dr. John Lehman conducted an assessment on Ms. Bynum and recommended 90-day inpatient treatment program that Ms. Bynum refused. Additionally, Dr. Lehman stated on assessment that Ms. Bynum is not fit to practice and has a high-risk for relapse.

Attended all treatment group as scheduled and actively participated in the group discussion and provided supportive feedback to others group members. Client is in compliance with treatment and all his legal mandates, and appears to be in the action stage of change. Overall, client is making steady progress in treatment.

Ms. Client is a twenty-two-year-old, Caucasian female was referred for a psychological evaluation by Dr. B., Clinical Psychiatrist and her therapist for her excessive use of cocaine, Xanax and other substances. Dr. B. stated Ms. Client has been experiencing loss of interest, feeling like a failure and frequently crying. Additionally, she complains that her struggle with substance abuse has impacted her social, emotional and behavioral functioning. Ms. Client was admitted to the facility following a relapse. This is her sixth substance abuse treatment program. The purpose of the current evaluation is to (1) assess present level of functioning, (2) determine diagnostic impressions, (3) to identify relevant treatment and service needs.

The participant is a 49 year old African American male who began using substances at the age of 13. He was diagnosed with severe alcohol, cocaine, and opioid use. The participant has been incarcerated over the past 32 years. He was recently paroled after completing eight years of a sixteen year sentence in the Illinois Department of Corrections for burglary and theft. The participant is on medications to treat HIV/AIDS and has been diagnosed with Major Depressive Disorder. He was referred to Healthcare Alternative Systems residential program through TASC as a condition of his probation.

The counselor met with the patient for her scheduled Addiction Severity Index assessment. The patient is a 54 year old black male. The patient states he is single with no children. He report currently lives with sister in law of his decease brother. The patient reports having a 14 years of education however no degree. The patient report receiving disability for mental health disorder. The patient reports he is currently not on probation. The patient reports he last use Cannabis 7/17/15 and started using at the age of 13 and smokes 3 to 4 times a week at least 2 joints. He also report using Alcohol 7/20/15 a 40oz beer and usually drank a couple a day. The patient denies any issues with HI/SI. Patient also reports he is taking his medication as prescribed. The patient appear to be in the pre-contemplation stage of change. The patient next scheduled individual session with the counselor is on Monday, July 27, 2015 at 02:30p

The client met with his counselor on 05/06/2017 for his one on one session to discuss his treatment plan goals. the client has been on track with his goals and is working on his second step. the client discuss one of the things that his currently working on and that is acceptance. the client explained that he is having a hard time acceptance certain situations and things that happen in his life, and most of the time it result in him resulting to using drugs. the client as well talked about being disappointed in himself for relapsing after two years of being sober. the client reported that he didn't use the tools that were given to him from his last his was in the program, getting a sponsor and learning coping skills. the client reported that

Xavier then reported, the applicant recovery is up and down and the reason the patient was transferred and admitted to the Norwich location was due to an altercation as the Hartford Dispensary has zero tolerance for physical violence. Since May of of this year, the applicant's UDS results are negative. Last positive result was in April for cocaine, according to the counselor. Please note, during the applicant intake, he was asked about other illicit drugs and only confirmed for use of heroin and THC, not the cocaine. The applicant's current dose at the Hartford Dispensary is 105mgs as he is being detoxed daily. His highest dose was at 145 mgs before his detoxification. The physical altercation was the applicant's first behavioral incident at the clinic. He was also on a 90 Probation for his illicit use and it would have expired in August, but due to the recent incident, he was removed from the clinic, not discharged, but transferred as mentioned before. Counselor Xavier only concern of the applicant is maintaining his

Progress: Ms. Bensalih is assigned UA color code Orange at HCMC building. The UA's result was positive for methadone only on 1/24/17. Ms. Bensalih is receiving methadone services at Specialized Treatment Services to help with withdrawal symptoms. Also, Ms. Bensalih completed a random UA's at Tubman

Objectives/Progress: As the Pt. has participated in the AMS program since 8/24/16 and he has been able to maintain abstinence from all illicit drugs for 6 months straight t. Pt.'s UDS has shown no evidence of drug use or lapse/relapse. Pt. is currently in the action stage of change as indicated by reminding himself of how much progress he has made and ability to change his behavior and achieve goals during the past quarter. He has currently obtained a full-time job as a shelving installer. Patient reports as scheduled to receive maintenance medication services as instructed by AMS Doctor and attends all mandatory one therapy session once a month. He continues to share his understanding of being powerless and unmanageable over his addiction. During the next quarter sessions, Counselor will support a realistic view of change through small steps.

Problem #5 Illicit opiate use Goal(s): To become drug free Status: Active Objectives/Progress: Pt. has not done well in achieving his goal of maintaining abstinence from all illicit substance use over the last quarter as evidenced by his positive UDS. Patient’s last urine screen results indicate that opiates have been used. Pt. reported that he was able to be clean from more than 30 days but he used drugs while walking through his neighborhood. Counselor expressed concern and disappointment about his recent relapse on heroin. During last month session, Pt. recognized the danger of the situation and how he will avoid the acquaintance that offered him drug. Pt. has failed to move to Phase 1 of the AMS of DE TX program due to his four positive UDS since entering the program on 7/6/16.Counselor will meet with Pt. to examine pt.'s motivation to stay clean, how to deal with triggers in order to achieve continued abstinence, to help him recover from his recent relapse and reenter the change process.

Pt. has been in the AMS program for 2 years. Pt. has had no positive UDS results for two years. Pt. is on a dose of 150 of methadone and he is responding as expected to his prescribed medication. Pt. demonstrated responsible attitude by attending monthly AMS groups faithfully. Pt. has discontinued all illicit drugs use and now he has used financial income in a more self-sustaining manner. Pt is effectively addressing this area by making regular payments as scheduled. Demonstrates treatment maturity and appropriately participating in medical treatment services. Pt. was taught calming strategies, such as relaxation and breathing techniques as indicated by previous counselor documentation. Pt. was assigned to this writer caseload and counselor

Objectives/Progress: Pt. developed and shared personal plans to avoid triggers, to break the cycle of procrastination and stay on his successful path of recovery. Pt. has made excellent progress on maintaining his commitment to abstinence as indicated by his clean UDS results since his admission and always attending scheduled AMS therapy groups. Pt. indicated that he is responding as expected to his prescribed 8 mg of subutex medication.

Substance Use History: The patient denies any drug or substance use except for Alcohol and Marijuana; started using in high school and everyday use.

PATIENT ASSESSMENT The case study patient is a 41 year old female, originally from Nebraska, where her family still resides. She currently works part-time and just recently started going back to college part-time for drug counseling. The patient’s interest in drug counseling is from past recreational drug and tobacco use for over 25