Substance Abuse Clinical Assessment & Treatment Plan

Name of Client: David J

General Information:
18yo male, currently seeking therapy @ community mental health center following a traumatic accident that ended any possibility for a football career

Medical / Physical Health Status:
family Dr. stated David possibly has depression as a result of the accident; still recovering from injury

Employment/Work History and Financial problems and Support Status: HS drop out; parent’s divorces, lives with mother, received support from siblings up to 2 months after accident

Drug/Alcohol Use and Treatment History:
Pain meds for injury; takes more than prescribed; tested positive THC meth & opioids; assuming this was the clients first visit to the therapist

Family History of Alcohol/Drug Use (2 generations):
none

Legal Problems / Legal Status:
Illegal drug use

Family History:
Parent’s divorced; Father is African American, Mother is Hispanic, no indication of family mental health issues or substance abuse

Family / Social and Interpersonal Relations:
Mother’s favorite child. Seems to have a hard time communicating with father, father is loud and angry, client is more open when father is not around, siblings were supportive following accident, however for the last 5 weeks they have been unsupportive. Only child living a home. He has a friend that comes over 2 -3 times per week.

Use of Recreational Time:
He used to enjoy seeing seeing school friends and playing video games, but now reports having no energy for much else. Complains of lacking energy to see people.

Psychiatric/Mental Health Status and Intra-personal View:
He reports “I might as well be dead, I can’t do anything now and never will” Self destructive behavior, eluding to loss of hope/giving up

Spirituality/Role of Religion:
unknown

Diagnostic Impression
AXIS I: Substance abuse related disorders. Mood disorder. Adjustment disorder. Possible Eating disorder

Description: pain med abuse and testing positive via urinalysis for THC, opioids, & meth. Mood swings – one moment he is excited and talkative & in a few hours or next day he will complain of not having any energy or interests. Adjustment – he felt that the accident was the end of any opportunity for a professional career, feeling hopeless, lack of enthusiasm for getting healthy. (Possible weight loss)

AXIS II: N/A

Description: N/A

AXIS III: Leg injury-compound fracture left leg above knee 10 months ago *Referred by primary care doctor

AXIS IV: Primary support group, educational problems. Problems related to social environment, other psychosocial and environmental problems

AXIS V: GAF: 47

Crisis management and intervention strategies:
drug use – address it, talk about it; suggest rehabilitation for drug use suicidal ideation- address issue with client

Treatment Plan:

A. Description of theoretical models used:
1. Short term goals:
i. Relief of symptoms of depression
ii. Restore relationships with previous friends
iii. Find at least one new activates that evoke positive feelings iv. Develop no self harm contract
v. David will report no suicidal ideation for 4 consecutive weeks vi. Learn coping skills to work on adjust and adapt to injury vii. Learn to identify maladaptive, negative thoughts and how to replce them with more positive adaptive thoughts which will be measured by demonstrating these skills during therapy sessions and by homework assignments for 4 consecutive weeks

2. Long term goals:
i. Explore education options
ii. Explore consistent individual therapy
iii. Substance abuse Recovery, Group therapy
iv. Improve sense of self and confidence
v. Stable support system
vi. Reduce symptons of depression

B. Model of individual therapy: (motivational interviewing, group therapy, fam therapy, etc) 1. Individual therapy twice a week for 4 weeks the once a week for 6 weeks until symptoms have approved pending other requirements and or limitations (insurance, treatments facility requirements, etc.) *Counselor and client will consistently determine the future course of the sessions. 2. Person Centered/Humanistic approach (he opened up with female therapists easily)

C. Adjunctive referrals:
1. Therapist will refer client to 12 step program (Narcotics anonymous, crystal meth anonymous, marijuana anonymous) and/or detox facility

D. Specific interventions for specific presenting issues:
1. Medication management-Reevaluate prescription medications with medical doctor 2. Individual therapy-explore, process,, & resolve depressive emotions and coping skills. 3. Family therapy-explore & help family to understand dynamics, negative patterns & problems in the family structure. Encourage family to learn & use communication and conflict resolution skills. 4. Physical therapy as a pain reduction to reduce pain meds 5. No self-harm contract

5. Increase parent’s and sibling’s ability to support & encourage