Phase II OP Treatment: A Case Study

Client successfully completed IOP and OP treatment this date. Client is recommended to abstain from alcohol and all other mood-altering substance(s). Client is recommended to attend at a minimum of two self-help support meeting to aid long-term sobriety.

PO was on time and moderately participated in the group activity. PO engaged in the group discussion, and shared personal experience and insights related to the topic appropriately and honestly. PO completed the weekly treatment progress report, which indicated having attended 2 support meetings this past week. Documentation was provided. PO has a positive response to treatment, and gained a better understanding of the negative effects of substance use.

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.

Client is attended 10 out of 13 groups and missed 3 of them during the month of March, 2017. UA collected on 03/06 was positive for alcohol use. Client admitted 03/18/17 as his last day of alcohol use. Client appears to struggle to maintain his sobriety. Relapse prevention and ways to comply with treatment and court mendates were discussed. Client reported that he started taking Disulfiram 250 mg (Medication for alcoholism) on a daily basis to manage his cravings. Client also reported that he will try to attend self-help meeting daily. Client may benefit from a brief inpatient placement due to continued alcohol use.

PROGRESS: Client working on following the right path in order to avoid the use of alcohol and marijuana.

My client who had been diagnosed with a life threatening dis-ease (for the second time) arrived for a Therapy session.

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

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.

No signs or symptoms of intoxication or withdrawal are present upon admitting to the Intensive Outpatient treatment. Client reported Methamphetamine, Marijuana, and alcohol as his drug of choices. Client provided random UA on 04/16/18, 04/23/18, and 05/07/18, results were positive for Methamphetamine. Last attended treatment on 05/07/2018.

Writer and client met to discuss client's treatment goals. Client stated that he wanted his goals to be graduating from high school and furthering his education, respecting his mother, and having a successful completion from Giant Steps. Client stated he wanted these as his treatment goals because he needs to have a better attitude when it comes to his mother, would like to have a successful completion to make not only himself happy, but his parents as well, and that he would like to do well in school because he would like to go to trade school after graduating from high school. Client and writer will meet weekly to discuss progress of treatment

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.

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.

important for counselors to keep in mind that not all client’s get better. More specifically, some

Pt. is currently in Phase 0 of the treatment program. Pt. received his treatment plan 11/24 /16 treatment plan update. Patient’s current TX goals address opiate dependency, maintain financial obligations and improve his social support system. Pt. has some minor problems sharing his personal issues during therapy sessions as indicated by his low self-esteem and resistant to opening up about his serious relationship issues. Pt. made some gain in achieving his goal of avoiding opiate and maintain his AMS account balance in a good standing. Pt. has been able to stop using heroin, but he continued to smoke marijuana few times per week and cocaine occasionally. Pt. remains at 55 mg. of Methadone and he reported that current dose is working well.

The interviewees came to the interview with positive thoughts of getting treatment. They expressed hope in treatment, striving towards recovery with positive experiences with an empathetic staff.