ISP In Dim: A Case Study

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.

Although the main goal of the assessment is to refer clients to treatment, many clients refuse treatment. However, they are willing to accept referrals to non-addiction agencies to resolve problems that have either been caused by addiction or that led to the problems. This assessment may be an intervention that the client needs. You will want to use the appropriate research-based screening tools that may be applicable to the client’s individual circumstances.

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

I don’t know what to do. No matter what I am doing never satisfied her.” Client reported participating in self-help meeting regularly and will continue to do so. Verification of self-help meeting attendance was provided. No other problem was identified. Reviewed initial ISP dated on 03/19/2018, to identify new ideas about addiction and learn to practice coping skills, reported still working on completing the ISP. Reviewed ISP dated on 03/26/2018, to maintain sober and not to use drugs and alcohol. Reported that he has not started working on it yet. Both ISPs were extended for 04/25/2018. ISPs are continued to be monitored. No new ISP was developed at this time. Discussed relationship issues, and assisted client to understand the importance to have health boundaries with oneself and others. Discussed the reasons to complete ISP on time and to abstain from alcohol and drug with client. Discussed personal

Mr. Charles’ ability to maintain sobriety and learn a healthy lifestyle of recovery, taking into account that his drug dependence will only continue and possibly increase if untreated. Mr. Charles would benefit from an outpatient treatment program in order to become educated regarding the dangers of substance use/abuse. Mr. Charles will also be able to process his patterns of drug use and learn to recognize triggers that lead to his substance abuse. Mr. Charles will also be able to learn the effects and consequences of substance abuse and how to remain abstinent from drugs. While in group therapy, Mr. Charles will learn appropriate techniques to resist peer pressure to drug use as well as assist him in developing a supportive network to encourage him to maintain abstinence. The intervention would assist to minimize the possibility of Mr. Charles’ drug use from progressing into the late stages of chemical dependency.

will schedule an appointment to discuss and create a budget plan. Patient is currently free from all illicit drugs, which has helped her Adderall medication to be more beneficial. Primary Counselor will encourage Pt. to follow through with all mental health appointments. Counselor will prompt Pt. to develop a positive self-image. Pt. has denied having any auditory or visual hallucinations during the last quarter as evidenced by group and individual session notes. Pt. has had some setback in achieving her goals of decreasing her family conflicts and resolving intimate relationship issues. Counselor will encourage Pt. to attend the AMS parenting group and share her expectations regarding having a more functional family unit. During the next quarter therapy sessions, Counselor will utilize role-playing, role reversal, modeling, and behavioral rehearsal to assist Pt. in order to develop positive ways to resolve conflict with ex-husband. Pt.’s current treatment plan goals focus on opiate use disorder, financial, mental health services and parent-child relational problems. During the upcoming quarter, current goals will continue to be

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.

Client was considered to be in semi-compliance with treatment during this reporting period. Client attended two secheduled groups with two absences. UA were negative for all tested substances. Client reported participating in self-help meeting regularly; verification was provided. Treatment attendance needs to be improved in 30 days.

This in-person interview was made final April 7, 2011 with the interviewee, Mae Parnell, who is employed as a case manager at Haymarket Center, located as 120 So. Sangamon St., Chicago, IL. Mae Parnell’s primary job description at Haymarket Center is to coordinator the approach to the delivery of substances abuse and social and health services. She will also provide each client with connections to seek the appropriate organizations that will be able to assist and devote to the care of his or hers unique circumstances and to help him or her attain goals for him or

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

Problem # 5 Illicit opiate use Goal(s): to be free from illicit drugs. Status: Active Objectives/Progress: Pt. has struggled with continued use of illicit drugs (marijuana, opiates and amphetamines) and his last quarter UDS reflect a pattern of heavy substance use. Pt. was encouraged to work with the medical staff to achieve a stable dosing level. Pt. is regularly taking his medication as prescribed by AMS Doctor and he stated his current prescribed methadone 90 mg is working "well". During the last quarter, Pt. made progress on developing a therapeutic relationship with his new AMS counselor for the upcoming quarter. Also, Counselor focused therapy session on establishing rapport and building trust with him. Pt. is currently in the contemplation stage of change because he more open to receiving information about his negative habits and willing to use educational interventions which he agreed with this assessment. Pt. was reinforced for any statement that reflected acceptance of his chemical dependence and acknowledgment of the negative consequences that opiates has had on his life. During the upcoming quarter, Counselor will assist Pt. to discuss and weigh the pros and cons of continuing his addictive

Met with PO for an individual session to discuss treatment progress and concerns. PO was on time with a delightful attitude. PO has a positive response to treatment, and is in compliance with treatment expectations. Reported no alcohol or substance use, clean and sober date as 11-03-2015. Indicated that he "got a driver license", the first driver license in his life, and plans to buy a car and insurance next week. PO stated that he keeps himself busy as boredom is one of his major relapse triggers. New ISP was established in Dim. 5 to develop a balanced life style without substance use.

Client was invited to introduce herself to the other members of the group, and she did so with genuine enthusiasm. She had just been released the day prior from BCP, after completing her mandatory 5-day sentence and adamantly declared that she will not be doing anything that would jeopardize her freedom again. Also, she explained how her mother, father, and daughter are supportive of her recovery, including that her mom would make her leave if she “slipped.” She was fast and thorough with the assignment in which she elaborated on her three top relapse signs which included working too much, thinking about the past, and avoiding talking about her problems in recovery for which she had solutions for: “slow myself down”, “call somebody to talk to” (in recovery), and talk to people at AA meetings respectively. Client was warned about over excursion and seemingly was open to the feedback