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Clinical Assessment of Patient for Drug Abuse, Assessment Example

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Assessment

Case Specifics

Name of Patient:                                    Carrie Marianne Perez

Age:                                                               25

Case Diagnosis:                                       Substance Abuse

Substance Concentration:                 Alcohol

Time Span of Abuse or Addiction:  4 to 5 Years

Source of Referral:                                 8-year-old daughter of patient

Interested Organizations:                   Family Social Services; Child Protective Services

1.     Case Brief

The patient has been reported for her addiction by her 8-year-old daughter who she was living with for the past six years. The daughter was two years old when her grandparents died and she was returned to her mother’s care.  The daughter claims that when she was about four, she noticed Ms. Perez began drinking more; it is unclear if the problem began then, or if the child only became aware enough to notice the problem at that time.  The mother cannot get a job that pays enough to support them.   Family Social Services in conjunction with Child Protective Services is considering taking custody of the daughter away from the mother.

It is believed that depression and frustration became specific factors that contributed to the development of the mother’s addiction. The abrupt responsibility for her child with no parental support while still a teenager has placed the patient in a situation she cannot control.  Her ability to handle challenges, such as getting a job without getting good education first, adds to the chaos of the situation. Along with this, at her age, she is expected to “act like an adult” while having little understanding of what that means.  She believes she should be focusing on herself first, yet she does not want to give up custody of her child.

1.  Larger System

  • Have you ever tried to stop drinking before? If so, what programs did you use to stop?
    • What worked for you in those programs?
    • What wasn’t so successful for you in them?

Patient states that has made no previous determined effort to stop drinking.  Occasionally has stopped for brief periods but not with “intention” to stop using alcohol.

  • It was probably a surprise for you to be referred to this program by your daughter. What do you think about that?

Patient states that she was not really surprised by daughter’s action because drinking has become a source of contention between them for some time.  She is, however, disappointed.

  • You were very young when you had total responsibility for a 2-year-old toddler. What was the hardest part of that experience?   Patient said having her boyfriend dump her once he knew she was pregnant was the worst.  She felt abandoned by everyone.
  • Do you think your drinking affects your ability to be a good parent? Patient asserts she’s a good parent whether she’s drinking or not.
  • CRAFFT Assessment (Cook et al., 2005). Note that two or more YES responses define a clinically relevant substance abuse problem.
Question Yes/No
In the past year, have you ridden in a car driven by someone (including yourself) who has been drinking ?    NO (doesn’t own car)
Do you use alcohol to relax, feel better about yourself, or fit in?   YES
Do you use alcohol when you are by yourself?   NO—child always there
Do you forget things you did while you are using alcohol? SOMETIMES
Do your family or friends tell you to reduce your drinking? YES
Have you gotten into trouble while using alcohol? YES—a couple bar fights, nothing more

2.  Culture

  • Do you belong to any organizations or groups that give you support?

Patient says no, she’s not a joiner.

  • Family? No real family left.  A brother is in prison, parents dead.
  • Friends? Yes, have one very close friend Rosa.  Rosa has two little girls.
  • Church? Doesn’t go to church.
  • School? Doesn’t attend school.
  • Work? Couple co-workers have lunch with occasionally and sometimes go for a drink after work with.  Not particularly close to them, however.
  • Who do you think cares about you? Rosa maybe?  Daughter?  Maybe Max her boyfriend?
  • Do you have roots or family from someplace else? Where? Family from here as far as patient knows. Not a close family. Originally from Mexico, but no known family there.
  • Do you have any particular opinions about counseling and treatment for addiction? It’s for losers.
  • You had to leave school very young. Have you ever thought about going back to school to get more education?  If so, what would you like to learn?  Patient says she hated school couldn’t wait to get away.  Now, she wishes she’d stayed to learn more.  She’d like to be a beautician, someday—she’s good with fixing up hair and makeup.

 

 

2.     Family Background (from McGoldrick, 2003).

 

Horizontal Stressor Specific Description When did it start? How long did it last?
Birth?

Death?

Divorce?

Separation?

Moves?

Stage changes?

Pregnancy scare 2 years ago, came to nothing

 

Series of boyfriends leaving.

About 2 years ago

 

 

Pretty regularly over the years

About 2 months.

 

 

Most lasted less than 1 year; current live-in only about 4 months

Unpredictable events

Untimely death?

Major illness?

Handicaps?

Traumas?

None to speak of.    
Family’s general “luck” in life Lousy. Family never had a chance to succeed.  
Rapid succession of stressors? After parents death when had to take on child. 6 years ago 6 years.

 

Vertical  Stressor Specific Description When did it start? How long did it last?
Generational issues In conflict with parents till they died, but they looked after daughter for her. From the time she was about 11 and puberty started Until their deaths 6 years ago, about 8 years.
Family attitudes? None to speak of    
Family taboos? Don’t let the authorities come after you As long as she can remember  
Family Expectations That she’ll come to no good end. As long as she can remember  
“Hot button” issues? None to speak of    
Situation within the family? No family remaining    
Family anxiety level? Within current home, very high, lots of conflict For several years, but worse since current boyfriend moved in Worsened about 4 months.

 

 

 

C. Perez

 

  • Do you get any help from your child’s father?   He went to prison and was stabbed. He’s dead.
    • Do you want help in locating him? Not applicable
    • Does he pay any child support? If not, do you want help in forcing him to help you financially?  Not applicable.
  • Is there any other family who can help you with your child? Who?  No family remaining.
  • What about friends? What child care assistance do you have available to help you?  Rosa and patient trade off looking after each other’s kids when we need to.

 

 

4.  Current Significant Relationships

  • Who are the most important people in your life?
Area People (list 1 to 3) Quality of Relationship (1=terrible; 10=terrific)
Work

 

George at work

Louise

3

5

School/Peers

 

Rosa

Max (boyfriend)

8

6

Family

 

Daughter 4

Relationships among these major players are complex.  Rosa, patient’s best friend, recently admitted having a one-night stand with Max.  This has caused conflict between patient and Max. Relationship with Rosa has not suffered nearly as much. It is likely that relationship with Max was in trouble before the Rosa incident.  Relationships with daughter are also complex.  Daughter gets along well with Rosa, but hates Max.  Furthermore, there is some possibility of abuse, but patient will not confirm. Rosa also is hostile toward Max.

5.  Symptoms

  • How much have you drunk in the past 7 days? Unknown, maybe a 6-pack and a couple shots of tequila each day?
  • How much do you typically drink in a day? About that—a 6-pack and a couple shots of tequila.
  • How often do you drink to the point where you feel drunk? Nearly every day.
  • How often do you pass out or forget what happens when you drink? Doesn’t happen often, maybe once a week.
  • Have you ever “lost time” as a result of using alcohol?
  • Do you drink more or less now than you did 1 month ago? One year ago?  About the same. Maybe a little more.
  • Do you feel that your alcohol use interferes with your ability to function daily?

6.  Resources, Strengths, Assets

  • Larger issues strength, resource, or asset? Patient has desire and believes she has ability to be a good parent.
  • Culture strength, resource, or asset? Very close friend in Rosa.
  • Family background strength, resource, or asset? Patient has demonstrated ability to rise to the occasion at the age of 19 and take on responsibility of raising a child.  Furthermore, the child his mature and capable.  Patient indicates great love for daughter, even though they are often at odds over her drinking and despite terrible relationship between daughter and live-in boyfriend.
  • Significant relationships strength, resource, or asset? Daughter clearly loves her mother and best friend Rosa also is a strength.
  • Symptom relationships strength, resource, or asset? When asked about her level of drinking, patient was surprised when she counted up how much she actually drinks each day. That surprise made her stop and think. She may be coming to the realization that she has an alcohol abuse problem.

7.  DSM-IV Multiaxial Summary

Axis I: Clinical or symptom disorders

Symptoms demonstrate clear signs of alcohol abuse.

Axis II:  Personality disorders or mental retardation

No distinguishing personality disorder or mental retardation shown.

Axis III: General medical conditions

Patient appears generally healthy with no known medical problems of note.

Axis IV:  Psychosocial stressors

Biggest stressor is conflict within home between daughter and live-in boyfriend. Further, there is evident worsening relationship between boyfriend and patient, in part due to boyfriend’s one-night stand with best friend  Rosa.  Unclear whether this relationship will last much longer, especially given patient’s history of very short-term romantic relationships.

Axis V:  Global assessment of functioning

Patient is reasonably high functioning, but her drinking is interfering with her ability to make responsible decisions about her life.  She aspires to be a good, loving parent and to someday become a beautician or cosmetologist.  However, she continually spends most of her free time abusing alcohol, leaving little time or energy (or money) for either parenting or for attending any type of training.  She has not accepted her addiction completely but is beginning to consider that she needs to make some changes in her life to improve it.

References

Cook, R. L., Chung, T., Kelly, T. M., Clark, D. B. (2005). Alcohol screening in young persons attending a sexually transmitted disease clinic comparison of AUDIT, CRAFFT and CAGE instruments. Journal of General Internal Medicine, 20(1), 1-6.

McDonell, M. G., Comtois, K. A., Voss, W. D., Morgan, A. H. Ries, R. K. (2009). Global appraisal of individual needs short screener (GSS): Psychometric properties and performance as a screening measure in adolescents. American Journal of Drug & Alcohol Abuse,  35 (3), 157-160.

McGoldrick, M. (2003). The family life cycle. In Normal Family Processes, Froma Walsh ed., New York, NY: The Guilford Press, Ch. 14.

Miller, W. R., Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change.  New York, NY: The Guilford Press.

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