Assessing these. You may need to offer a client a referral for additional, out-ofprogram services. The following ASI items are important to consider when you are developing a treatment care plan:. Is the client currently receiving services for a medical problem? If so, is the client satisfied with the treatment? Is further assessment indicated? What level of distress is reported M7 and how important is it to the client to receive treatment services M8?
General Information Balancing Treatment Priorities No single problem area is always the most important or the one that should be treated first. Concurrent treatment of multiple problems is generally better than sequential treatment.
Addiction occurs in the context of other problems that may either contribute to or result from substance abuse. You will rarely be able to identify causal relationships between problem areas and it is important not to assume that any single problem is the key to resolving all other problems. You have to start somewhere and it is not always easy to prioritize treatment goals. You may need to defer goals in some areas until the patient is stabilized or till you can get a referral for additional out-of-program services.
While the initial treatment plan may focus on reducing substance use first, the master treatment plan should address all problem areas for which treatment is indicated.
Now, as you read this manual, you will see how we use the ASI to design treatment plans. Demographic data reported in this section may provide important information early on that will be relevant to treatment care planning.
Does the client report gender G10 or cultural G17 issues that may affect participation in treatment? Does the clients age G16 present special considerations, i.
Medical Section Does the client report chronic medical problems M3 that require ongoing care or daily monitoring, such as asthma, diabetes, high blood pressure?
Has the client been prescribed medication M4 on a regular basis for a medical problem? Is the medication taken as prescribed? Does the medication prescribed need to be re-evaluated by a physician? How many days M6 has the client experienced physical medical problems and what symptoms have they experienced?
Does the client. Has the client ever been able to maintain a period of steady employment? Is the client currently employed? Does the client have a family to support E18? What has been the clients source of income in the past 30 days E? You will want to look at item E If unemployed, has the client actively looked for work in the past 30 days? If employed, is the clients job in jeopardy? How important is it to the client to get. Look at indicators of the severity of the addiction, such as overdoses D17 , delirium tremens D18 , and treatment history D, D If a significant history and current substance abuse problems are reported and client ratings D are low, denial may be indicated.
Is the client court stipulated to treatment or currently on probation or parole? Will the client suffer legal consequences as a result of noncompliance with treat-. Look at the clients criminal history L If an extensive legal history is reported, are there issues, attitudes or behaviors that you will want to address as part of treatment?
Are there any pending legal charges L, L? Is the client awaiting charges, trial or sentence L? Has the client reported engaging in days of illegal activity in the past 30 days L27? Look at the client ratings L Does the client indicate a need for legal services for current legal problems?
Is the client satisfied with current status in theses areas or merely resigned to his or her situation? Does the client report stable living arrangements or is there a need for referral for housing?
Consider problems like loneliness, social isolation, and the need for a sober support network F Has the client ever been able to maintain a close mutual relationship with others F? Look at items F Does the client report a history of lifetime or current serious relationship problems?
How might these problems impact on treatment? Are past or current abuse issues reported that may undermine recovery efforts F? Is the client in a life-. Is follow-up treatment recommended? Does the client need to be referred for a psychological evaluation? Has the client been prescribed medication for a psychological problem P4? How many days P12 has the client experienced psychological medical problems? Carefully consider the interviewers clinical impressions P Now that we considered the background to treatment planning with the Addiction Severity Index, we thought the best way to help you use the ASI in a practical way was to simply demonstrate with some sample cases.
So lets talk about Mary. Mary lives in a major urban center, is poly-drug dependent, has been earning money as a prostitute and has numerous medical, legal and family difficulties. Critical items will be identified and we will think through the implications of these items. In a sense, we have attempted to think out loud so that you, the reader, can examine the thinking process behind developing an ASI-based treatment plan.
Meet Mary. She has lived at the same location for about 10 months, which suggests at least some degree of stability. She doesnt have any religious affiliation and has not been in a controlled environment in the past 30 days G The only additional information that we can draw from this page is a snapshot provided by her Severity Profile. As you can see, Mary has significant challenges in most areas of her life. Many of our clients have serious medical conditions that might never have been diagnosed.
Some of these conditions, when left undiagnosed, can be fatal or disabling. Therefore, the purpose of this section is to find out whether--and to what extent-Mary may need help with medical problems. In addition, some of our clients have a tendency to neglect their health. Even when they know theyve got medical problems, they may choose to ignore them. Of course, this can lead to even more serious health problems.
Consequently, this is one of the most important sections of the ASI. What About Mary? Looking over the Medical section of Marys ASI, we find the following: Marys had three hospitalizations two overdoses and a back injury. Notice, by the way, that the counselors note is critical to our understanding here. In addition, Mary is concerned about some private medical problems which she didnt want to discuss at least, not yet.
It is worth noting that although theres a lot of information on this page, we got most of the treatment planning elements from just six items--plus some important notes by the counselor. This is often a serious medical condition that requires ongoing medical management.
We probably are going to want her to get this checked out by a doctor. M4 Since Mary is using pain. Also, when we get to. These two items tell us that Mary is extremely concerned about her health.
Consequently, weve got to be sure that her treatment plan will rapidly and effectively address her medical concerns. Marys got several medical issues that will require a physicians attention. When was the last time she has seen a physician? Has she been getting adequate medical attention? We will need. In this section were interested in determining to what degree, if any, Mary needs help in finding employment, vocational training or economic support.
For many of our clients this can be an extremely important section. Chronically Unemployed Sort of E1 E2 and E3 reveal that Mary lacks technical and professional skills. With items E4 and E5 her situation gets a little worse--she doesnt drive either so she is dependent upon public transportation. Figure 3. In fact, Mary has been unemployed E10 for at least the past three years.
This has been her primary means of support for the past 3 or 4 years. Please notice that item E21 reveals that she is quite interested in being assisted with employment counseling. Summing Up. Mary has significant employment challenges. The longest period of employment for Mary was only a year and a half E6 ; she has been unemployed for the majority of the past 3. Consequently, our treatment plan should help Mary attain the employment skills she will need to find and maintain legitimate employment.
Marys already got several challenges in front of her and we havent even gotten to the drug and alcohol section yet. A coincidence? Probably not. Problems multiply and then invite more problems along. On the other hand, our recognition of her employment needs could instill hope in Mary and strengthen our therapeutic relationship.
Drug and Alcohol Use Now, what are Marys substance use history and treatment needs? D1 through D12 plus the coun-. When we look over here D15 we find that she can not recall ever being abstinent for a month. Marys got a strong habit. One which demands obedience to its call. And it calls about five times a day. In addition, it appears that Mary is using street and prescribed medications whenever she can get them. A Brief History of Her Addiction. As D13 indicates, Marys been using substances in combination for seven years.
As the note on D5 suggests, Marys drug use increased after a car accident in which her boyfriend died. Is this when her pain started? Since Mary was the driver, she might have some unresolved guilt and grief. We need to keep this in mind when we get to the Psychiatric section of her ASI. Well want to suggest a more intensive commitment to treatment this time.
Although Marys been in treatment four times, a closer look reveals that three of those treatment experiences were detox only. She was in a methadone program for six months, but continued using heroin the whole time she. Looking at her responses to D29 and D31, it appears that Mary is only moderately motivated to quit using heroin at this time. It will be a challenge to get her to examine her addiction and increase her readiness to make meaningful changes.
We need to develop a treatment plan with Mary that addresses her drug dependence. Methadone again? The ASI doesnt answer these questions, though it offers some clues. Well need to discuss this issue with Mary. In addition, Marys been taking pills for a long time. We may need to help her find alternative ways of managing her physical and emotional pain. As you can see from L3-L17, Marys been arrested 11 times and has had four convictions. However, one of the most important items in this section is right here: One of the pressures leading Mary to seek treatment is that she is awaiting charges, trial or sentencing for her second probation violation.
Mary has been involved in prostitution for about four years L This may be another habit which could be difficult for her to break.
Well want to bring that up when we sit down to do treatment planning. Figure 5. Looking at L29, we discover that Mary is highly motivated to deal with her legal problems even though she doesnt think theyre very serious. What do you suppose this means? When we get to the Family section of the ASI, we will want to explore this aspect of her life to determine whether there is a history of sexual abuse. Perhaps Mary wants to get her probation officer off her back but doesnt think that she did anything that was too serious.
Is this an aspect of her denial, or simply defiance? We will need to help her think through the seriousness of her legal problems and risks. Typically, someone else--perhaps quite early in her life--introduced Mary to the idea of exchanging.
We see from L1 that Marys got a probation officer who thinks shes got a drug problem and that she needs help. Thats the good news. The bad news is that Mary disagrees. Nonetheless, because her probation officer is forcing her into treatment, Mary is willing to comply, if only minimally. If we can work with her in designing an attractive treatment plan, her. Our challenge will be to use Marys legal difficulties as leverage in gaining her compliance, while at the same time maintaining a positive, therapeutic relationship with her.
To do this, it may be important to work closely with her probation officer. Consequently, we will want to get a consent from Mary so that you can interact with her probation officer.
Even a relatively quick examination of Marys Family History adds some color to her clinical picture. What does this compact section tell us? Moms Side. From H1 to H5 , we notice that on her mothers side, there is a strong history of alcoholism.
Her grandmother, mother, at least one aunt and uncle were or are alcoholic. In addition, we can see now that theres a strong history of psychiatric problems on her mothers side, too. Sibling Substance Use.
In addition, H11 shows us that Marys brother had, or has, both drinking and drug problems. In other words, Marys addiction was not unusual in her family. What about Dads Family? Mary never knew her father, and so we dont know anything about him or his side of the family.
Whether you subscribe to a genetic, an environmental or a combined view of addiction, Mary appears to have an extremely strong pedigree for addiction. Her ASI reveals three generations of addiction and two generations of psychiatric problems. Even without knowledge of her dad, we can see that Mary had powerful familial history.
So what does this mean for Marys treatment plan? First of all, Mary probably cannot expect to get a lot of healthy support from her addicted mom or brother if they are still active in their addictions. If they are not in recovery, we should probably begin thinking early on about encouraging her to establish a supportive network of other people.
Along these lines we might want to explore whether she can get support from her sister. Lets see if the next section: Family and Social Relationships sheds any more light on our understanding of Mary and her treatment needs. What types of relationships has Mary had in her background? If we take just a minute to scan this page, a disturbing scenario begins to take shape: Poor Relations. We know from F1 through F6 that Mary is single and reports no stable living arrangement for the three years prior to living with her current partner.
While he does not appear to be abusive FF29 , he drinks heavily and uses heroin F7F8. Since Mary is expressing indifference with many important areas of her family and social relations, we will want to explore this aspect of her life later on.
In F9 Mary tells us that she spends most of her time with associates and later reports that she has never had a close friend F11, F Although she reports having had a close relationship with a sexual partner and with a sister F14, F15 , on balance, it does not appear that she has had much nurturance or support as a child or currently as an adult. In addition, given Marys involvement in prostitution, the fact that she reports being sexually abused earlier in her life takes on special meaning; we will want to address this in individual counseling.
Mary wants to have better social and family relations F34 and F Consequently, her treatment plan will need to provide her with guidance in addressing this important need. Before we begin developing a treatment plan with Mary, weve got one more important ASI. Lets see what it tells us about Marys treatment needs. This section of the ASI adds some very useful information about Marys emotional problems and her treatment needs. Untreated Depression. Her answers to items P2, P4, P5, P9, P10 and P12 present a clear picture of someone who may be suffering from clinical depression and anxiety.
Every day, for the past 30 days, Mary has been experiencing anxiety and depression. She even reports to us that she had attempted suicide about two years ago. Mary had been prescribed medication at least once for her depression.
Why didnt she take it then? Were there obstacles to her complance? Did she take it long enough to get any relief? Most importantly, would she be willing to take an anti-depressant now? Figure 8. It is interesting, and possibly significant to note that despite reporting a long history of depression, Mary only rates her emotional problems as being considerably bothersome rather than extremely.
Perhaps, this is an expression of the apathy that so often accompanies depression. We will not know whether this is related to her sexual abuse until we discuss this with her, but we will want to be sure and keep this in mind, as well. Mary clearly needs to be evaluated for possible depression and anxiety disorders. Her depression has existed for several years and has been severe enough to lead to a suicide attempt P She had been prescribed antidepressants once, but ended up not taking the medication P Now that Mary has returned to treatment, perhaps she will be willing to give medication another try.
We should probably point out that there are some new anti-. Our treatment plan will need to address Marys long-term depression and anxiety. In developing that portion of her treatment plan, we will want to be sure to think through with her any possible objections she may have about taking medications and following through with counseling. Having now reviewed the seven sections of the ASI, lets take a step back and develop with her a Problem Summary list--the next step in the treatment planning process.
Master Problem List As we worked our way through the seven sections of the ASI, we were jotting down on Marys Master Problem List all of the items that seemed to be important enough to address in her initial treatment plan. On review, it looks like Marys ASI assessment revealed eight significant problems. This isnt necessarily all of her difficulties, and if you were writing up the problem list for Mary you might have come up with some different items.
In any event, as you can see, Marys got challenges in just about every area of her life. Take a Step Back Before moving on to Marys Treatment Plan, it a good idea to pause for a moment and ask Mary to consider how the various problems in her life might be prioritized and addressed. Since nobody likes writing lengthy documents, lets see if it is possible to come up with an efficient treatment plan for Mary--one which addresses her problems in the simplest manner and will be accepted by Mary.
Looking over Marys Master Problem List, we see lots of medical issues. These can be addressed by getting her to the right physican. He or she will have to accept Medicaid insurance and should be aware of addictions and psychiatric issues. Next, theres a cluster of problems that all seem to be somewhat interrelated: lack of education and job skills, poor support system and high risk occupation prostitution.
Fortunately, there are a number of excellent recovery houses for women which are ideally suited to meet Marys needs in these areas. Here shell get support for recovery, distance from her life on the street and, after she completes the recovery house blackout period, theyll help her find a job. Shell need more training than the recovery house. Heroin dependence and anxiety and depression are next on the Problem list.
Its best if these three conditions can all be addressed in the same setting a co-existing disorders program , but a fundamental issue still needs to be resolved: should Mary enter into a drug-free or methadone maintenance program? Of course, as we mentioned earlier, treatment planning is a collaborative process. The clinician needs to. Its their life and its their choice.
Marys Turn Having come up with some possible solutions for Mary, its now time to sit down with her and see what she wants to do. Since shes sitting in our waiting room right now, lets talk with her. Mary was clearly receptive to getting help for her pain so we thought wed begin our treatment planning session on a point of agreement. Although Mary was concerned about what problems might get uncovered by a physical exam, she was ready to move forward and we scheduled an exam while she was still in our office.
She also promised to bring the findings of her exam to her outpatient counselor, including the results of any lab studies. As it turned out, Mary did in fact have a significant chronic pain condition resulting from a car accident. Her counselor and physician have begun working together to get Mary into a pain management program involving physical rehab, medication and supportive counseling.
She has been referred to a specialist for this condition and is exploring treatment options now. Finally, Marys diabetic condition was seriously out of control. She has now returned to a regular routine for managing her diabetes and the recovery house has been able to accommodate her need for a special diet and exercise. It was a good thing that Mary was forced into treatment. If her medical conditions had been allowed to continue to worsen without proper treatment, she may have developed even more serious health problems.
Unfortunately, our discussion with Mary about changing her support system didnt go nearly so well Mary refused to even consider moving out of her current living arrangement. While she was not happy with her current boyfriend, and she realized how his substance use might compromise her recovery, she simply wasnt ready to commit to taking such a big step. This is Marys treatment plan, not ours. As counselors our role in the treatment planning process is to offer recommendations and encouragement.
Clearly, on this particular part of her plan, we were moving more quickly than Mary was prepared to go. When it became apparent that Mary was strongly opposed to moving into a recovery house, we put this page of her plan aside, pulled out a blank form, and asked Mary: What do you want to do about these problems? Marys Choice Mary did not offer any new solutions to her difficulties except to say, Dont worry, I can find some other job. Noting her defensiveness, we apologized to Mary for misunderstanding her situation.
We asked her to help us get a better understanding of her responses to the items on the ASI that led me to make these recommendations e. By taking a respectful, collabora-. In the end, Mary agreed to visit our Recovery House. Follow Up Mary set and kept her appointment with the Recovery House intake worker--and she seemed to like what she saw.
Fortunately for her, there was an opening, and after some initial resistance to the House Rules, she eventually agreed to comply with the program, and moved in. Mary has requested that she be transferred from our drug-free service where her ASI was completed to our methadone program. Based upon her addiction history, the high risk behaviors that she had been engaging in and her relative lack of motivation for becoming drug-free, this seemed like her best choice.
Fortunately our center offers methadone as well as drug-free treatment and so we were able to transfer to that division of our program. Dual Capabilities In addition, Mary agreed to be evaluated by a psychiatrist who works in our methadone program.
Having her psychiatric issues addressed at the methadone clinic increases the likelihood that she will follow through this time. In addition, it will enable her to have her medications periodically re-evaluated without having to go to a different clinic. Follow Up Report After a rocky start, Mary eventually became stabilized on 60 milligrams of methadone.
She has been coming to the clinic on a regular basis for about a month now, and she has significantly reduced her use of all other illicit substances. Mary was seen by our psychiatrist who diagnosed her as having PTSD and depression.
Her anxiety disappeared once she began treatment. She was prescribed an antidepressant, but once again, Mary elected not to take it. She indicated that she preferred to see how she was doing after a month or so off the streets and in her new life.
Mary agreed that if, after a couple months, she wasnt feeling better, she would be willing to reconsider her decision. Ultimately, research has tively new to treatment planning shown that by directly addressing Naturally, it is important that we and want to get some technical client needs, programs and remain authentic when we praise assistance.
Even if you are an counselors will be more effective a client. If our comments come experienced counselor, you in assisting their clients in pro- off as phony or insincere, our might still find this section useful gressing towards a lasting recov- whole credibility can be compro- because it demonstrates how ery.
However, if we honestly ASI data can be used to develop consider the challenges that our treatment plans. Affirmative Focus clients face, we usually will come to the conclusion that their gains Treatment Philosophy Our second treatment principle are in fact extraordinary and Before we consider Marys case, recognizes the benefits of praise more than worthy of our compli- it might be a good idea for us to and acknowledgement in the ments and recognition.
As to conduct assessments and The ASI client ratings of problem the assessor, you need to insure develop treatment plans accord- importance and treatment need the clients privacy during the ing to specific standards. Simi- are our way of involving the interview and confidentiality larly, programs that are patient directly in the discussion afterwards.
Otherwise, the client accreditted by the Joint Commis- of the treatment plan. You will may be motivated to distort or sion for Accreditation of Health want to review the completed hide important information.
It is important that we capture tionship between the intensity information about our client as and duration of symptoms re- While the ASI offers an excellent early as possible so that we can ported in a problem area and the start towards complying with use that information to guide the clients rating of need for treat- State and JCAHO assessment treatment process.
Clients ment services in that area. For this reason, many ment. On the other hand, we more intensive services. If the patient has reported rather an initial or preliminary treatment For example, two of the worst serious evidence of problems in plan. In these assessment. Then, using all of These conditions will severely cases, probe for further clarifica- their assessment information limit the usefulness of your tion of problem status and check including the ASI , they develop assessment.
When treatment plan. If there is disagree- one part of an ongoing assess- completed the ASI interview ment, it will be important to ment process that builds upon yourself, you will notice that it resolve it early.
Effective treat- patient about how much they are bothered by each of these prob- Clients may have problems in ment planning and counseling is many areas. A clients problems enhanced when we obtain the lems. These aspects of the ASI are discussed below. Assessing these clients personal challenges and treatment needs. Is the potential strategies for dealing client currently receiving services with them are important to the The ASI is designed to assess for a medical problem?
If so, is recovery effort - even when your client status in many different the client satisfied with the agency does not have on-site areas of life functioning. The treatment? Is further assessment services for those problems. You following ASI items are important indicated? What level of distress may need to offer a client a to consider when you are devel- is reported M7 and how impor- referral for additional, out-of- oping a treatment care plan: tant is it to the client to receive program services.
Does the client report marketable trade or skill E? Does the have access to public transporta- Addiction occurs in the context of clients age G16 present special tion for employment or if the other problems that may either considerations, i. You will rarely lems? Has the that any single problem is the follow-up services indicated? Medical Section Is the client currently employed? Does can get a referral for additional Has the client been prescribed the client have a family to sup- out-of-program services.
While medication M4 on a regular port E18? What has been the the initial treatment plan may basis for a medical problem?
Is clients source of income in the focus on reducing substance use the medication taken as pre- past 30 days E? Does the medication should address all problem areas prescribed need to be re-evalu- You will want to look at item E How many If unemployed, has the client days M6 has the client experi- actively looked for work in the Now, as you read this manual, enced physical medical problems past 30 days?
If employed, is you will see how we use the ASI and what symptoms have they the clients job in jeopardy? How to design treatment plans. If an exten- 31? How important iors that you will want to address is it to the client to receive treat- Items D tell you about the as part of treatment? Are there any pending legal Has the client ever been able to charges L, L? Is the Psychiatric Section maintain a month or more of client awaiting charges, trial or Has the client ever received abstinence and, if so, how long sentence L?
Is follow-up treatment recom- days L27? Look at the client mended? If the client reports an Look at indicators of the severity ratings L Has the 24? How many days has the marital status, usual living ar- client been prescribed medication client experienced problems rangements, and use of free time for a psychological problem P4?
Is the client Is the medication taken as pre- 27? Does the by a physician? How many days her level of distress or desire for client report stable living arrange- P12 has the client experienced treatment for substance abuse ments or is there a need for psychological medical problems? If a signifi- referral for housing?
Carefully consider 31 are low, denial may be need for a sober support network the interviewers clinical impres- indicated. Is the home environ- sions P Does the the clients legal status and the client report a history of lifetime or clients treatment status.
Is the current serious relationship prob- client court stipulated to treat- lems? How might these problems ment or currently on probation or impact on treatment?
Are past or parole? Will the client suffer current abuse issues reported that legal consequences as a result may undermine recovery efforts of noncompliance with treat- F? Now that we considered the background to treatment planning with the Addiction Severity Index, we thought the best way to help you use the ASI in a practical way was to simply demonstrate with some sample cases.
So lets talk about Mary. Mary lives in a major urban center, is poly-drug dependent, has been earning money as a prostitute and has numerous medical, legal and family difficulties.
Critical items will be identified and we will think through the implications of these items. In a sense, we have attempted to think out loud so that you, the reader, can examine the thinking process behind developing an ASI-based treatment plan.
Meet Mary. She has lived at the same location for about 10 months, which suggests at least some degree of stability. She Figure 1 doesnt have any religious affilia- tion and has not been in a con- trolled environment in the past 30 days G The only additional information that we can draw from this page is a snapshot provided by her Severity Profile.
As you can see, Mary has significant chal- lenges in most areas of her life. Many of our clients have serious medical conditions that might never have been diagnosed. Some of these conditions, when left undiagnosed, can be fatal or disabling.
Therefore, the pur- pose of this section is to find out whether--and to what extent-- Mary may need help with medical problems. In addition, some of our clients have a tendency to neglect their Figure 2 health.
Even when they know theyve got medical problems, they may choose to ignore them. List the next step in developing a good treatment plan. In addition, this page, we got most of the Mary is concerned about some treatment planning elements Looking over the Medical section of private medical problems which from just six items--plus some Marys ASI, we find the following: she didnt want to discuss at important notes by the least, not yet.
Notice, by the way, that that Mary is extremely concerned Employment and Support sec- the counselors note is critical to about her health. Consequently, tions of Marys ASI. This is often a serious concerns.
We Summing Up probably are going to want her to get this checked out by a doctor. Marys got several medical issues that will require a physicians M4 Since Mary is using pain attention. When was the last medication well need to have her time she has seen a physician?
Also, when we get to medical attention? In this section were interested in determining to what degree, if any, Mary needs help in finding employ- ment, vocational training or eco- nomic support. For many of our clients this can be an extremely important section.
Chronically Unemployed Sort of E1 E2 and E3 reveal that Mary lacks technical and professional skills. With items E4 and E5 her situation gets a little worse--she doesnt drive either so she is dependent upon public transpor- tation. Figure 3 In fact, Mary has been unemployed E10 for at least the past three years. Figure 3. This has been her Consequently, our treatment plan primary means of support for the should help Mary attain the past 3 or 4 years. Marys already got ested in being assisted with several challenges in front of her employment counseling.
Mary has significant employment A coincidence? Probably not. She does not have Problems multiply and then invite a GED and reports that she has more problems along. The other hand, our recognition of longest period of employment for her employment needs could Mary was only a year and a half instill hope in Mary and strengthen E6 ; she has been unemployed our therapeutic relationship. D1 through D12 plus the coun- selor notes reveal the following to us about Mary: Mary is shooting 5 bags of heroin just about every day.
When we look over here D15 we find that she can not recall ever being abstinent for a month. Marys got a strong habit. One which de- mands obedience to its call.
And it calls about five times a day. In addition, it appears that Mary is using street and prescribed medications whenever she can get them. A Brief History of Her Addiction. As D13 indicates, Marys been using substances in combination for seven years.
As the note on D5 suggests, Marys drug use increased after a car accident in which her boy- friend died. Is this when her pain started? Since Mary was the driver, she might have some Figure 4 unresolved guilt and grief. We need to keep this in mind when was there. We need to develop a treatment plan with Mary that addresses her Treatment History Readiness drug dependence. Methadone Although Marys been in treatment Looking at her responses to D29 again? The ASI four times, a closer look reveals and D31, it appears that Mary is doesnt answer these questions, that three of those treatment only moderately motivated to quit though it offers some clues.
Well experiences were detox only. It will need to discuss this issue with Mary. She was in a methadone program be a challenge to get her to In addition, Marys been taking for six months, but continued examine her addiction and pills for a long time. We may using heroin the whole time she increase her readiness to make need to help her find alternative meaningful changes. As you can see from L3-L17, Marys been arrested 11 times and has had four convictions.
However, one of the most impor- tant items in this section is right here:. One of the pressures leading Mary to seek treatment is that she is awaiting charges, trial or sentencing for her second probation violation. Mary has been involved in prosti- tution for about four years L This may be another habit which could be difficult for her to break. Well want to bring that up when we sit down to do treatment planning.
Figure 5 Marys Motivation. Looking at L29, we discover that sex for money, security or protec- compliance may become a new Mary is highly motivated to deal tion. When we get to the Family habit and the beginning of a new with her legal problems even section of the ASI, we will want life.
What do you to determine whether there is a Our challenge will be to use suppose this means? Marys legal difficulties as lever- age in gaining her compliance, Perhaps Mary wants to get her Summing Up while at the same time maintain- probation officer off her back ing a positive, therapeutic rela- but doesnt think that she did We see from L1 that Marys got tionship with her. To do this, it anything that was too serious. Is a probation officer who thinks may be important to work closely this an aspect of her denial, or shes got a drug problem and with her probation officer.
Con- simply defiance? We will need to that she needs help. Thats the sequently, we will want to get a help her think through the seri- good news. The bad news is consent from Mary so that you ousness of her legal problems that Mary disagrees. Nonetheless, because her Prostitution probation officer is forcing her into treatment, Mary is willing to Typically, someone else--perhaps comply, if only minimally.
Even a relatively quick examination of Marys Family History adds some color to her clinical picture. What does this compact section tell us? From H1 to H5 , we notice that on her mothers side, there is a strong history of alcoholism. Her Figure 6 grandmother, mother, at least one aunt and uncle were or are Her ASI reveals three genera- alcoholic. In addition, we can tions of addiction and two gen- see now that theres a strong erations of psychiatric problems.
Marys brother had, or has, both drinking and drug problems. In First of all, Mary probably cannot other words, Marys addiction was expect to get a lot of healthy not unusual in her family. If they are not in recovery, we should probably Mary never knew her father, and begin thinking early on about so we dont know anything about encouraging her to establish a him or his side of the family.
Along these lines we might want to Summing Up explore whether she can get sup- port from her sister. Whether you subscribe to a genetic, an environmental or a Lets see if the next section: combined view of addiction, Mary Family and Social Relationships appears to have an extremely sheds any more light on our strong pedigree for addiction. What types of relationships has Mary had in her background? If we take just a minute to scan this page, a disturbing scenario begins to take shape: Poor Relations.
We know from F1 through F6 that Mary is single and reports no stable living arrangement for the three years prior to living with her current partner. While he does not appear to be abusive FF29 , he drinks heavily and uses heroin F7- F8. Since Mary is expressing indifference with many important areas of her family and social relations, we will want to explore this aspect of her life later on.
In F9 Mary tells us that she spends most of her time with associates and later reports that she has never had a close friend F11, F Although she reports having had a close relationship with a sexual partner and with a sister F14, F15 , on balance, it does not appear that she has had much nurturance or support as a child or currently as an adult.
Figure 7. In addition, given Marys involve- Mary wants to have better social section: Psychiatric Status. Lets ment in prostitution, the fact that and family relations F34 and F Summing Up Before we begin developing a Mary clearly wants help in deal- treatment plan with Mary, weve ing with her current family and got one more important ASI social relations.
This section of the ASI adds some very useful information about Marys emotional problems and her treatment needs. Her answers to items P2, P4, P5, P9, P10 and P12 present a clear picture of someone who may be suffering from clinical depression and anxiety. Every day, for the past 30 days, Mary has been experiencing anxiety and depres- sion. She even reports to us that she had attempted suicide about two years ago. Mary had been prescribed medi- cation at least once for her depression.
Why didnt she take it then? Were there obstacles to her complance? Did she take it long enough to get any relief? Most importantly, would she be willing to take an anti-depressant now? Figure 8 It is interesting, and possibly significant to note that despite depressants that are more effective Summing Up reporting a long history of de- yet have fewer side effects.
Her depres- sion and anxiety. In developing that than extremely. Perhaps, this is sion has existed for several years portion of her treatment plan, we will an expression of the apathy that so and has been severe enough to want to be sure to think through with often accompanies depression. We will not know whether this is Now that Mary has returned to Having now reviewed the seven related to her sexual abuse until we treatment, perhaps she will be sections of the ASI, lets take a step discuss this with her, but we will willing to give medication another back and develop with her a Prob- want to be sure and keep this in try.
We should probably point out lem Summary list--the next step in mind, as well. Master Problem List As we worked our way through the seven sections of the ASI, we were jotting down on Marys Master Problem List all of the items that seemed to be important enough to address in her initial treatment plan.
On review, it looks like Marys ASI assessment revealed eight signifi- cant problems. This isnt necessarily all of her difficulties, and if you were writing up the problem list for Mary you might have come up with some different items. In any event, as you can see, Marys got challenges in just about every area of her life. Take a Step Back Before moving on to Marys Treatment Plan, it a good idea to pause for a moment and ask Mary to consider how the various problems in her life might be prioritized and addressed.
Since nobody likes writing lengthy docu- ments, lets see if it is possible to come up with an efficient treatment plan for Mary--one which addresses her problems in the simplest manner and will be accepted by Mary. Looking over Marys Master Problem List, we see lots of medical issues. These can be addressed by getting her to the right physican. He or she will have to accept Medicaid insur- Figure 9 ance and should be aware of addic- tions and psychiatric issues. Its their life and its Next, theres a cluster of problems that settled in.
Fortunately, there Problem list.
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