Substance Abuse Clinical Assessment; Treatment Plan Essay

Name of Client: David J.
General Information:
18yo male. presently seeking therapy @ community mental wellness centre following a traumatic accident that ended any possibility for a football calling.

Medical / Physical Health Status:
household Dr. stated David perchance has depression as a consequence of the accident ; still retrieving from hurt.
Employment/Work History and Financial jobs and Support Status: HS bead out ; parent’s divorces. lives with female parent. received support from siblings up to 2 months after accident
Drug/Alcohol Use and Treatment History:
Pain Master of Educations for hurt ; takes more than prescribed ; tested positive THC meth & A ; opioids ; presuming this was the clients first visit to the healer.
Family History of Alcohol/Drug Use ( 2 coevalss ) :
none.
Legal Problems / Legal Status:
Illegal drug usage.
Family History:
Parent’s divorced ; Father is African American. Mother is Hipic. no indicant of household mental wellness issues or substance maltreatment
Family / Social and Interpersonal Relationss:
Mother’s favourite kid. Seems to hold a difficult clip pass oning with male parent. male parent is loud and angry. client is more unfastened when male parent is non about. siblings were supportive undermentioned accident. nevertheless for the last 5 hebdomads they have been unsupportive. Merely child populating a place. He has a friend that comes over 2 -3 times per hebdomad.
Use of Recreational Time:
He used to bask seeing seeing school friends and playing video games. but now reports holding no energy for much else. Complains of missing energy to see people.
Psychiatric/Mental Health Status and Intra-personal View:
He reports “I might every bit good be dead. I can’t do anything now and ne’er will” Self destructive behaviour. evading to loss of hope/giving up.
Spirituality/Role of Religion:
unknown.
Diagnostic Impression
AXIS I: Substance maltreatment related upsets. Mood upset. Adjustment upset. Possible Eating upset.
Description: hurting med maltreatment and proving positive via uranalysis for THC. opioids. & A ; Methedrines. Mood swings – one minute he is excited and chatty & A ; in a few hours or following twenty-four hours he will kick of non holding any energy or involvements. Adjustment – he felt that the accident was the terminal of any chance for a professional calling. experiencing hopeless. deficiency of enthusiasm for acquiring healthy. ( Possible weight loss )
AXIS II: N/A.
Description: N/A.
AXIS III: Leg injury-compound break left leg above articulatio genus 10 months ago *Referred by primary attention physician.
AXIS IV: Primary support group. educational jobs. Problems related to societal environment. other psychosocial and environmental jobs.
AXIS V: GAF: 47.
Crisis direction and intercession schemes:
drug usage – reference it. speak about it ; suggest rehabilitation for drug usage self-destructive ideation- reference issue with client.
Treatment Plan:
A. Description of theoretical theoretical accounts used:
1. Short term ends:
I. Relief of symptoms of depression.
II. Restore relationships with old friends.
III. Find at least one new activates that evoke positive feelings.
IV. Develop no ego injury contract.
V. David will describe no self-destructive ideation for 4 back-to-back hebdomads.
VI. Learn get bying accomplishments to work on adjust and adapt to injury.
VII. Learn to place maladaptive. negative ideas and how to replce them with more positive adaptive ideas which will be measured by showing these accomplishments during therapy.
Sessionss and by prep assignments for 4 back-to-back hebdomads.
2. Long term ends:
I. Explore instruction options.
II. Research consistent single therapy.
III. Substance maltreatment Recovery. Group therapy.
IV. Improve sense of ego and assurance.
V. Stable support system.
VI. Reduce symptons of depression.
B. Model of single therapy: ( motivational interviewing. group therapy. fam therapy. etc )
1. Individual therapy twice a hebdomad for 4 hebdomads the one time a hebdomad for 6 hebdomads until symptoms have approved pending other demands and or restrictions ( insurance. interventions installation demands. etc. ).
*Counselor and client will systematically find the future class of the Sessionss.
2. Person Centered/Humanistic attack ( he opened up with female healers easy ).
C. Adjunctive referrals:
Therapist will mention client to 12 measure plan ( Narcotics anon. . crystal meth anon. . marijuana anon. ) and/or detox installation.
D. Specific intercessions for specific showing issues:
1. Medication management-Reevaluate prescription medicines with medical physician.
2. Individual therapy-explore. procedure. . & A ; decide depressive emotions and get bying accomplishments.
3. Family therapy-explore & A ; assist household to understand kineticss. negative forms & A ; jobs in the household construction. Promote household to larn & amp ; utilize communicating and struggle declaration accomplishments.
4. Physical therapy as a hurting decrease to cut down hurting Master of Educations 5. No self-harm contract.
5. Increase parent’s and sibling’s ability to back up & amp.