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Fictional case study Essay

The purpose of this interview was to assess the patient’s need for addiction treatment by reviewing patient’s present and previous usage history, emotional and behavioral stability, and potential for relapse, environment, pertinent medical conditions, and willingness or desire for treatment. An interview and medical records gathered this data.

Name: Stan Jacobson Date: May 6, 2005

Age: 25 years old Gender: Male

Ethic background: Caucasian Birth date: February 3, 1980

Residence: 161 N. Ray St. Minneapolis, MN Referral: Court ordered

The client is being assessed today due to a conviction of driving under the influence. The ruling judge ordered the client to obtain professional help with addiction problems. This assessment will determine level of recommended treatment, if any treatment is needed.


Client’s usage history began when client was approximately 15 years old (usage is approximately 10 years). Client states the he is currently a ‘heavy’ drinker who frequently drinks until drunk. Client states that he uses alcohol 5-7 days a week, with consumption ranging from 6-24 beers per occasion. Client also has a history of heavy drug use. Client states that alcohol is the present drug of choice, but admits to occasional marijuana and cocaine use. Marijuana usage is approximately once a month, cocaine use is approximately 3-4 times a year, and amounts used are unknown.

Client is a 2 pack a day tobacco smoker. Because of client’s alcohol use, client was recently convicted of driving under the influence of alcohol and ordered to seek help. Client was placed in a youth detention center in high school for theft and ultimately was expelled from regular school, finishing his education at a continuation high school. Client reports significant social and relationship difficulties. Client presents with no history of alcohol, marijuana, or cocaine withdrawal symptoms and does not appear to be experiencing symptoms currently. Client states that he is not currently experiencing nicotine withdrawal, however there is potential for nicotine withdrawal

Risk level: Due to lack of significant and harmful withdrawal symptoms, risk level is 0.


Client states he has a history of impotence (medically untreated). Client does not have any known medical conditions that would prevent recovery. Client has no known allergies, no currently prescribed medications, and smokes tobacco daily.

Risk level: Due to lack of interfering medical conditions, risk level is 0.


Client states that there is no known history of previous diagnosis or treatment for psychological problems, nor any current or previous use of psychiatric medications. Presently, there has been no known psychological testing or psychological consultations. Client complains of depression, anxiety, thoughts of suicide, low self-esteem/ self-concept, and anger. Client states that he attempted suicide a couple of years ago. Client states history of anxiety is cause of impotence. Client presents to be anxious, calm, well groomed, and orientated. Client’s speech is normal and thought processes appear to be scattered.

Risk level: Due to history of suicide attempts and thoughts of suicide, risk level is 2.


Client states he has a desire to change and to stop alcohol consumption. Client remains unsure if he is addicted to alcohol and does not feel he is addicted to marijuana or cocaine. Client admits to nicotine addiction; however, at this time client is not motivated to cease nicotine usage. Client is open to individual therapy, outpatient alcohol treatment, and self-help groups. Client feels that these options will aide in his recovery. Client states he is willing to follow the recommendations of current assessment.

Risk level: Client is motivated to change alcohol consumption and emotional issues, but does not view marijuana and cocaine usage as a concern. Client does not desire to change nicotine consumption. Risk level is a 1, as client shows a willingness to change.


Client has no know history of previous treatments. Client desires treatment due to unhappiness with current life style. Client states that his longest abstinence from alcohol is 4 days, nicotine an hour, and marijuana and cocaine 1-2 years over the last 5 years. Client recognizes several triggers for drinking episodes (social anxiety, loneliness, fear, feelings of inadequacy, and guilt). Client is not experiencing any cravings for chemicals at this time (currently using nicotine). Client states he has current problems with family resentments and anger, self-esteem, and anxiety that are unresolved. At this time, potential for relapse is moderate to severe. Client a limited support network and no relapse prevention plan.

Risk level: Due to short length of sobriety, lack of support network and relapse prevention plan, and current emotional issues, risk level is 3.


Client lives alone. Client works full time in constructions and studies psychology part time at a local college. Client states he does not have any social friends and he is a ‘loner’. Client has poor family relationships. Client is divorced and has a history of volatile relationships. Client has no prior involvement with self-help groups or strong support systems.

Risk level: Due to lack of a supportive social network, some criminal activity, and lack of counseling services risk level is 2.


Client recognizes his chemical usage as a problem and is motivated to change. Client is open to therapy, and willing to work on past and present issues. Client is aware of triggers. Based on client’s age, work history, and level of motivation, it is highly probable that client will be successful in recovery. Development of a social network, adherence to legal ramifications of driving under the influence of alcohol, and maintained healthy activities are areas that should be addressed and a relapse prevention plan should be designed to support and encourage these areas.

It is recommended that the client be admitted to an outpatient treatment program. Individual therapy and attendance to a self-help group are also recommended. Client needs to develop a support network. Continual work on self- image, goal setting, and relationship issues is advised. A comprehensive exploration of suicidal fantasies is strongly recommended. A psychological assessment is also recommended to address any possible mood or anxiety disorders, with continual monitoring and adjustment as needed. Coping skills training and stress management activities are recommended. Arrangements have been made for client to begin outpatient treatment on Monday, May 16, 2005.

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