Her most severe symptoms of anger, fear, and shame are leading her to self harming behaviors such as suicide, burning, and overdosing on prescription medication and alcohol. I believe that treating these symptoms to include fear of abandonment, rejection, and being alone would minimize her self-harming behavior. These symptoms are complex due to her early sexual abuse and rape. She has been diagnosed with BPD, PTSD, and Alcohol Use Disorder. Furthermore, she has many symptoms under the criteria of PTSD such as: Intrusive memories; dissociative reactions; recurrent distressing dreams; avoidance of external reminders; inability to remember parts of the traumatic event; persistent negative emotional state (depression, anger, and anxiety); feeling detached; self destructive behaviors; problems with concentration; sleep difficulties; significant distress and impairment in relationships (American Psychiatric Association, 2013). Secondly, Rosa’s symptoms associated with BPD are: instable relationships; impulsivity; frantic efforts to avoid abandonment; unstable and intense interpersonal relationships; unstable sense of self; self harming behaviors (over spending, burning, suicide, sex, substance use, and binge eating); chronic feelings of emptiness; transient, stress-related paranoid ideation; and affective instability (panic, anger, and despair) (American Psychiatric Association,
Jake Levy is a 31 years of age Caucasian male, who is married to Sheri a 28 years of age Caucasian female they have two sons, Myles is a 10 years of age Caucasian male and Levi who is an 8years of age Caucasian male. Jake is an Iraq War veteran and employed as a human resources assistance for the military. Seri teaches special education at a local elementary school. It was mention within this case study that Jake, as well as, Sheri used marijuana and the past, but now they are both social drinkers. It also stated within this case study that Jake and Sheri are both Jewish decadence. The couple has some friends, however due to Jake’s behaviors, they have slowly isolated themselves. The reason why Jake seeking therapy because his wife Sheri
Peterson currently lives with her 54-year-old father, she stated they have a good relationship, and that he has always been supportive of her. Ms. Peterson’s daughter previously lived in the home with her and her father before she lost custody. Ms. Peterson has a new group of friends that she socializes with than she previously did five-years-ago when she was sober; she stated that all of her new friends abuse alcohol and drugs. She does not have any relatives, peer groups, community affiliations outside of her father, daughter, ex-husband, and current friends. Although Ms. Peterson does have an addiction to alcohol and opiates she believes completing a program will effectively assist with the effort of taking care of herself and her daughter. Ms. Peterson is currently unemployed, and receives no other income, she stated she relies on her father and her ex-husband financially. She has the goal of obtaining employment so she can buy a home for herself and her daughter to live in. Ms. Peterson currently lives in a four bedroom, 2 and a half bathroom home, in a rural-suburban neighborhood. The significant issues surrounding her current situation is substance abuse, loss of custody of her child, and unemployment.
SC placed call to Pa and spoke with Bill Pa’s spouse who reported that doing ok. But she has come combative lately and verbal abusive. Bill spoke at length about her behavior and the impact it has on him. Bill is offended when Pa makes disparaging remarks about him and calls him out of his name. Bill reported that he believes Pa needs a medication review and a change in meds. Because the medication that supposed to help with her outbursts and combative behavior is not as effective anymore. He reported that Pa fell on 11/11/15 but did not need medical treatment because she did not sustain any injuries (just soreness). The SC inquired about Bill handle his frustration and when Pa becomes abuse or combative and he state he just deals with it because he loves her “and no matter what that’s his wife and he’s going to do right by her” so he talks to
Pt is 43 years old AA female who decided to return to OMHC after the program that she attended, Universal Counseling, was closed down. Initial admission to OMHC was around 2012. Pt has been diagnosed with PTSD, Bipolar, and Anxiety Disorder in the past. Her depressive episodes started at the age of 13 and after she was sexually assaulted by distant uncle. She later developed aggressive behavior around late teen and was involved in numerous arrests, starting the age of 18. Pt grew up in violence environment. "I used to watch my father beating up my mother." In 2003, pt was involved with a man, who later became her husband. The relationship was abusive. "He was verbally and emotionally abusive." The instability in the relationship has also led to numerous arrests for both pt and ex-husband. "He got arrested but he always got away with it. I was the one who would usually stay in jail." At times, her husband would change the stories of their verbal and physical altercation, leading to pt being arrested.
D: Client was on time for intake appointment. Together, discussed the assessment recommendation and barriers to successful treatment outcomes. Client reviewed and signed of all treatment admission paperwork, including treatment agreement, ROIs, THS treatment policies, THS alcohol drug Services patient rights, THS patient responsibilities, THS health and safety information, THS counselor disclosure information, patient grievance procedures, THS HIV/AIDS information, THS notice of privacy practices, referral to Quit smoking, and marijuana policy. Treatment plan was developed, which was focused on Dim 4, 5, and 6; focusing on developing readiness to change, identifying relapse potential, and building a strong family and social support system.
Ms. Lewis had completed 1 year of a 10-year sentence in prison for the distribution of an illegal substance. She reported that 3 years ago she had served 1 year for possession, but denied responsibility for the sentence. She disclosed getting into a fight between 1 and 2 years ago, but did not provide details about the fight. She endorsed a significant history of physical abuse throughout her childhood, and during her romantic relationships. Military, immigration, and custody status was not assessed.
Karta is a 12 year old African American girl, who has experienced a long history of trauma. She was referred to me by her school social worker Ms. Johnson who reports that she has academic problems, severe inattention, hyperactivity, physical violent tantrums and is disrespectful to her peers and teachers.
Mrs. Jones is a 67 year old female who presented to the ED via LEO under IVC through DayMark Recovery Services. Per documentation Mrs. Jones has been non compliant with medications and has been experiencing symptoms of psychosis. At the time of the assessment Mrs. Jones appears calm and cooperative. She does present with tangential speech and vaguely answers questions. She recently was discharged from Novant health 1/3/17 and followed up with DayMark 1/11/17 with new changes in medications. Per documentation she has not been taking medications, answering the phone when called, not eating, and bathing. Mrs. Jones has a history of non compliance. Mrs. Jones reports denies suicidal ideation, homicidal ideation, and symptoms of psychosis. She reports
Ms. DeMarzo is a 43-old individual, who was born and raised in Staten Island, NY. She graduated from Tottenville High School in 1990. Following her graduation she attended the College of Staten Island but did not graduate, she went to work. Ms. DeMarzo reported that she currently works as a paraprofessional for the NYC board of education.
She Moved in after serving in the army as an automotive mechanic 2 years ago. She was divorced prior to finishing her service in which she notes that her husband no longer helps with their daughter. She for the past 2 years’ work as a administrative assistant at the chaplain department at Veteran affairs. She described work as being stressful because she is her inability to perform well, concentrate, Tardiness, and recent altercation. Many of this she notes may be influenced by her insomnia and depressed mood. During her service in the army she vividly describes several specific instance that caused her psychological and physical trauma, namely a head injury. As noted above since then she has experienced nightmares, flashbacks and hypersensitive state. She notes that her worries and anxiety is temporally alleviated when she is engaged with her daughter. She denies alcohol abuse but admits to two to three drinks a week. She denies drug usage and sexual
The case of Jennifer McAllister is about a 16 year old bi-racial European American and Hispanic teen who has been showing signs of substance use with marijuana, alcohol, cocaine, and methamphetamine. At the age of 12 when she was in the seventh grade was when Jennifer started her drug use. After speaking in a confidentially disclosed interview Jennifer confessed that she would drink alcohol with her friends. The drinking was also something that followed the sexual abuse that was going on between her and her father. The initial interaction was when her father began to tell her to stay home more often. Following that he would enter her room and fondle her, next kissing and caressing her. Jennifer said that these action made her feel “confused,
Assessment completed to document the extent of substance use and criminal history to include completed assessments of alcohol consumption, substance use and trauma history, to be used to determine Donna “Patty” Cunningham’s current treatment needs. Also, an assessment of strengths and needs, current living situation, relationship with her significant other, current substance use, social support, financial needs, recovery goals and basic needs. Patty has never received any past counseling or drug treatment.
The assessment that I would use for this client would be the Drug Use Screening Inventory-Revised. This assessment consists of true and false that address the client’s substance abuse, physical health, mental illnesses, family relationships, other relationships, education, vocational status, social skills, hobbies, or negative behaviors (Brooks & McHenry, 2015, p. 89). By completing this assessment, the therapist can obtain more information about Sara’s history, relationships, mental health, and behaviors.
Before we implemented our opioid addiction and rehabilitation service, it was important for us to examine what obstacles we might face and need to overcome as well as what we might be able use in our favor to help with our service. We performed a SWOT analysis to help identify the external opportunities and threats that were present as well as our internal strengths and weaknesses so that we might more efficiently jumpstart our service.