Relapse: A Case Study

D: Met with client for an individual session and treatment plan review. Client presented a good attitude and outlook, response to treatment appears positive. Reported no use of alcohol or other substances. Reported taking medications for anxiety, stress, and chronic physical pains as prescribed. Reported taking Antabuse for alcohol use disorder as court ordered. Client indicated main area of concern is attending self-help meeting. Client demonstrated variable compliance with treatment expectations, such as treatment group attendance, UA result was negative for alcohol and other substances. Client showed improvement on relapse prevention and problem solving skills, and is working on establishing and maintaining meaningful, intimate interpersonal relationship.

SOCIAL HISTORY: Patient admits alcohol ingestion nightly and on weekends. Denies tobacco use and illicit drug us. He is married.

In relation to drug abuse, relapse is resuming the use of a chemical substance or drug after a period of abstinence. The term can be said to be a landmark feature of a combination of substance abuse and substance independence. The propensity for dependency, repeated use, and tendencies that take the form of the substance being used, are some of the issues that drug users’ experience. Substances that enhance most severe tendencies in users and pose high pharmacological efficacy, are those that are cleared quickly from the body, in addition to those that bring out the highest tolerance. There can be increased substance tolerance with the increasing dependency in relation to drug in question,

The patient is a 34 year old black male. The patient reports he is single with 3 daughter ages 3, 11, and 13. The 3 year old live with him. He reports currently live with his mother and brother. The patient reports he has 14 years of education however has not received his degree. The patient reports being on probation for Injury to a child for the next two years. The patient is scheduled to be complete his probation in September 2016. The patient reports Cannabis is primary substances and his last use July 20, 2015. He stated on that day he smoked about 5 joint. The patient also report that he tried Xanax . 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 Thursday, July 30, 2015 at

In addition, if John’s condition gets worse he may need to be released into inpatient care at the VA hospital or Outreach Center until his condition improves or he may have an extended release date because of his current mental state which is not stable. Furthermore, John is currently on the prescription Gabapentin to help with cocaine cravings and to reduce stress and sertraline to help with his depression and if he stops taking these medications once released it could cause more problems so it is important that John does see a doctor which is another immediate need and does take his medications as

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.

PO was on time and participated in the group activities. PO stated “I am in the maintenance stage of change because I am in treatment. My clean date was 12-14-2015”. It appears that PO is making a steady change while in recovery as evidenced by staying clean and sober, and attending treatment and going to self-help meetings on a regular basis to maintain his sobriety. PO had a positive response to treatment.

PO had no service plan open in this dimension due to participating only one week in treatment. PO reported that he is living with his fiancé and her children at this time. PO reported he is not working due to working increased a level of stress and anxiety into his daily life. PO reported attending AA meeting and communicating with his sponsor regularly. PO will benefit from building and utilizing positive

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

Client has no know history of previous treatments. Client desires treatment due to unhappiness with current life style. Client states that his longest abstinence from alcohol is 4 days, nicotine an hour, and marijuana and cocaine 1-2 years over the last 5 years. Client recognizes several triggers for drinking episodes (social anxiety, loneliness, fear, feelings of inadequacy, and guilt). Client is not experiencing any cravings for chemicals at this time (currently using nicotine). Client states he has current problems with family resentments and anger, self-esteem, and anxiety that are unresolved. At this time, potential for relapse is moderate to severe. Client a limited support network and no relapse prevention plan.

He has a history of using alcohol to self-medicate, drinks 3-4 times a week and uses chewing tobacco.

Mr. Goins is a 52 year old male who presented to the ED via LEO following a 4 day binge on alcohol and requesting help with his dependence. Mr. Goins reports he moved to Asheboro recently and found work, however recently lost his job. He reported a history of alcohol use and depression. Dr. Keith requested an assessment on Mr. Goins.At the time of the assessment Mr. Goins denies suicidal ideation, homicidal ideation, and symptoms of psychosis. He reports 5 days ago he became unemployed. Mr. Goins reports his fiance who is his primary support system left town to go to a doctor appointment in their home state of Georgia. He reports binge drinking for the past 4 days attempting to cope with his recent stressor. Mr. Goins reports calling his fiance last night an expressed to her he need help. He states, "I told her I felt at the time no reason to live." Further Mr. Goins stated, "I just had too much in me last night, I had about 14 of them airplane bottles." Mr. Goins denies a history of self harm. He does report a prior hospitalization for depression in Georgia. He also reports a history of attending substance abuse treatment, which was a positive experience for him.

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.

Met with client for ISP review and to discuss treatment progress. Client appeared to be stable and engaged in the conversation. Client reported that she completed the FAFSA and is planning to go to Everette Community College in the summer. Client reported no use of substances. Client reported coping with temptation by walking away from the situations. Client was reminded that her relapse potential was moderate to high at this time and that she thus would be cautioned to avoid any unintended consequences; with help and support from treatment and her family, client would make his treatment a success. Reviewed ISP in Dim.5 dated 11/29/17, reported completion on approach C, but was unable to identify which peer pressure could be positive (approach

CPI arrived at the family residence located at 149 S Calhoun Avenue, Eatonville, FL 32751. CPI completed a joint visit with Taina L. Ramos FIS Counselor. Taina completed a BHC screen with Mr. Clayborne. Mr. Clayborne admitted to have a history of alcohol misuse and impulsive and aggressive behavior while under the influence. He began drinking while in his 20’s and drinks 1 to 2 times weekly. Mr. Clayborne drink preference is beer, but sometimes drinks vodka. He usually drinks when is stressed out. He has been to Alcoholics Anonymous meetings in Springfield, MA. The last meetings he attended was about 2 years ago. While in prison was seen by a psychiatric five times a day for 3 months, but is it not diagnosed with a mental health condition.