Chemical Dependency #2

Diagnoses and Client Case Presentation

• Example case:

  • Client: Mary

  • Age: 33

  • Demographic: Caucasian female

  • Reason for seeking treatment: Addiction treatment due to probation for OBI (Operating a Boat Intoxicated)

  • Date incurred: December

  • Treatment: Court-ordered

Living Situation Assessment

• Importance of understanding living conditions:

  • Temporary housing details such as sober living or renting space

  • Current status: Hospitalized, foster care, homeless, jail or prison

• Categories of homelessness:

  • Couch surfing

  • Living in shelters or completely without residents

• Contextual significance of housing situations:

  • Stability implications: Living with friends vs. living in unsafe environments

• Request for household information:

  • Member names, relationships, and quality of relationships

  • Examples of family dynamics:

  • Living with jobs or partners, noting relationship quality (e.g., rocky, healthy)

Marital Status and Support System

• Assessing marital status:

  • Options include married, divorced, widowed, single, long-term relationship

• Evaluating support system quality:

  • Healthy, toxic, abused, or strained relationships

  • Single and feelings of loneliness

Family History Analysis

• Inquiry into family relationships and historical context:

  • Presence of unhealthy relationships, boundary issues, and communication problems

  • History of mental health or addiction issues within the family

Personal Strengths and Limitations

• Identifying client strengths and positives contributing to success

• Recognizing limitations:

  • Issues related to transportation, housing, finances, food security

Community and Social Support

• Examining friendship, care, and community support:

  • Presence of sponsors, support meetings, friendship groups

  • Feeling isolated or surrounded by substance users

Meaningful Activities and Coping Skills

• Assessing enjoyable activities or coping mechanisms:

  • Identifying healthy activities

  • Exploring the decline in engagement in these activities

  • Strategy to correlate activity decline with substance use impact on relationships

Spiritual or Religious Beliefs

• Assessment of spiritual/religious connections:

  • Inquiry into trauma related to forced or unhealthy religious upbringing

  • Addressing potential benefits of spiritual practice for recovery

  • Professional boundaries: Counselors should not impose beliefs but validate client feelings

Cultural and Ethnic Considerations

• Understanding cultural identity and its significance:

  • Inquiry into cultural practices and experiences of bias or trauma

Dependence and Family Structure

• Inquiry regarding children:

  • Number of children, their gender, and living arrangements

  • Understanding familial structures and parental access or rights

Educational and Employment Background

• Educational history:

  • Highest grade completed, special circumstances like learning disabilities

  • Prenatal exposure: substance-use exposure impacting development

• Employment history details:

  • Employment status, reasons for unemployment, constraints affecting job search

  • Identification of skills or interests related to job possibilities

• Military history:

  • Branch served, discharge status, relevance to treatment needs relating to substance use

Substance Use and Mental Health Treatment History

• Collecting information on past treatments:

  • Outpatient and inpatient services, psychiatric hospitalizations

  • Diagnosis history: major depressive disorder, PTSD, etc.

• Specific substance use data collection:

  • Identify substances used, age of first use, last use

  • Pattern of use: frequency and amount of substances

  • Method of use verification

  • Symptom endorsement for substance use diagnoses:

  • Number of symptoms identified across 11 criteria

  • Severity classification based on symptom count

Medication Information

• Documenting medication purpose and efficacy:

  • Prescribing rationale and compliance inquiry

• Additional medical history:

  • Allergies, surgeries, and need for case management referrals

Sexual History and Concerns

• Inquiring into sexual orientation and sexual health concerns:

  • Relevant historical context related to sexual health

Abuse and Violence History

• Assessing past abuse:

  • Types: physical, verbal, sexual, financial, history and impact

Legal History and Current Status

• Overview of legal status:

  • Probation status, pending charges, history of substance-related charges

Mental Status Evaluation

• Key areas to assess:

  • Lethality risk: suicidal ideation, self-harm history

  • General observations: appearance, build, behavior

  • Communication skills through motor activity and speech assessment

  • Cognitive function: client's knowledge of self, time, and place

  • Mood and affect evaluation: assessment of emotional expression

Summary of Health and Treatment Needs

• Comprehensive interpretation summarizing all findings:

  • Presenting problems and emotional context

  • Diagnosis codes and narrative description of disorders

Compliance with Ohio Administrative Code

• Understanding state standards for assessment information:

  • Critical components necessary to be included

  • Importance of compliance for agency operation and reimbursement

Conclusion and Future Steps

• Future classes and directions on assessment and treatment plan assignments

• Main takeaway: effort and engagement in assignments are valued over perfection