Phase II OP Treatment: A Case Study

The client met with his counselor for his 1x1 session to completed his Exit plan. The client has completed and turned in his second step and has went over it with his counselor. the client seems to be interested staying clean and sober and appears to be seeking understand as to how to stay sober. The client has learned to let go of some of his resentment but needs to work in letting the resentment he has against himself. The client reported that he follow through with the King of Kings sober living stipulation as to having to attend three meeting a week there at there program to prove that he wants to go into their sober living program once an open becomes available. the client reported as well that he will be spending more time with his

A: Client showed progress in treatment and appears to be in the action stage of change at this time.

the client met with his counselor on 01/29/2017 for his weekly 1x1 session to discuss his recovery program and what progress has been made during his time in the program. the client has been in compliance with the program requirements . the client has been attending his group session and 1x1 session, he also has been attending family group with his mother and girlfriend that are currently supporting his recovery. the client has been attending all of his doctor appointments and taking his medication on a regular basis. the client has been attending outside meeting as well, and is now phased up in the program to go on weekend passes. The client appears to be taking his recovery seriously, he talking about attending an AA meeting close to his

No signs or symptoms of intoxication or withdrawalwas reported at time of discharged. Client reported no urges or cravings at time of discharge.

Counselor met with Pt. for an individual session. Counselor and Pt. discussed her progress in treatment and description of her medication compliance. Pt. reported wanting a higher dosage of methadone to side effects (cold). Pt. mentioned that she would like to switch to Vivitrol medication because she is going to move with her mother house in Lewes, DE and she cant come to the clinic everyday. Pt. requested, discussed and completed an AMS Modality Switch form. Counselor encouraged Pt. to talk about her current triggers and possible solutions she can plan ahead of time. Pt. stated, "I have no triggers." Counselor elicited the client’s perceptions on her several positive urine analysis. Pt. indicated that she use crack cocaine when she is depressed.

PROGRESS: Client is working on the right path in order to avoid drugs and alcohol

Client was considered to be in compliance with treatment during this reporting period. Client attended weekly group as scheduled. UA was negative for alcohol and other tested substance. Participation in a self help program was verified. Client continues to make positive changes in treatment. Client is transffered to a monthly group from weekly group; tentative treatment completion date is November 2017.

The client and counselor met for his 1x1 session to discuss what progress had been made in regards to his treatment plan. The reported that he needs to continue to work on his attitude & behavior , it not as bad as before the client reported from when first came to the program. The client reported that he learning about relapse prevention, ways of preventing himself from relapsing . the also talked about guilt and being stress out about his girlfriend her house being shot at, things he has no control over while being in the program. The client appears to struggling with things he has no control over. The counselor will meet with the client next week to go over the assignment that was given during his 1x1 session.

Objectives/Progress: Pt. has maintained Phase 7 take-home privileges. As the pt. has participated in a total recovery program, he has been able to maintain abstinence from mood-altering drug use as evidenced by submitting 19 clean UDS results since entering and reporting sustained abstinence. Pt. is compliant with all aspects of treatment, provides negative UDS, and attends required monthly counseling. Pt.'s program attendance is in a good standing but pt. needs to attend different AMS groups. He was advised to schedule different groups and the benefits of doing so. Pt. has achieved a lengthy period of sobriety and has good insight into personal recovery behaviors. Counselor will review this long-term goal with pt. during his therapy sessions.

Persistent Depressive disorder was also considered, but since the client meets the criteria for major depressive ruled out this

The client and his Counselor met for a l1x session to discuss what progress has been made regarding this treatment plan. The client and his counselor did an overview of his first step. The Client this time has admitted that drugs were a problem for him and , his had no control over his adiction. the Client has reported that he is much stronger in his recovery now, and that his feel like he can live a productive life without the use of any mind altering chemial's.

Objectives/Progress: Pt. continues to maintain total abstinence and Phase 7 status of the tx program. During the last quarter, Pt. denied any recovery issues or concerns and he is maintaining compliance with all tx criteria and obligations. Pt. has become more open during groups by acknowledging and accepting his chemical dependence; this openness was noted and reinforced. During the last quarter, Pt. provided input of ongoing activities that he is working on at this

The provider facilitated a session focused on Substance abuse skills. The staff educated Gary on how important is to maintain sobering. Gary informed the staff that he has not had alcohol for over few weeks now. The staff encouraged Gary to try to avoid getting closer to alcohol as possible. Gary informed the staff that he attended AA meeting the night before and he enjoyed. Therefore the staff encouraged him to continue to attend the AA meeting. The plan is to continue to train Gary to maintain his sobriety.

SUBJECTIVE: The client was seen in the office of assigned therapist. The client reported that he was pleased and encouraged by the progress he is making in the program. He denied any problems with staff or other clients. The client reviewed his past relapse and addressed why he thought he was in treatment and the future without addiction or alcohol. This therapist guided the client in taking responsibility for where he is, and to look at how his alcohol has affected everyone in his path. The client engaged in a discussion concerning his inability to stay sober. This therapist assisted the client in exploring the 12-step program of AA and Celebrate Recovery. Jim was recently involved with CR however he stopped attending meetings. He went to

PO was 15 minutes late for the group, stated "We had to finish the job". PO was minimally participated. PO was unable to complete the hangout due to language barriers. PO indicated that he is working and making money, and he is happy. PO reported no urges or cravings, and he is remained clean and sober. PO completed the weekly treatment progress, reported attended two self-help group, documentation was provided.