Case Study Assessment Paper

PSYC 305

Case Study Assessment Paper Template

Use these headings as a template for your own assessment paper.

Chemical Use Assessment/History and Treatment Recommendations

Name:

DOB/Age:

Dates of Interviews:

Evaluator:

Reason for Assessment

Sources of Information

Background Information

Current Status

Indicators of Use/Abuse/Dependency

Attitude and Behavior

Social Functioning

Occupational Functioning

Financial Aspects

Familial Relationships

Legal History

Health History

Spiritual History

Diagnostic Impression

Recommendations

Assessment paper – additional information from the instructor

I usually get a number of questions regarding the assessment paper that is due in module/week 7. I am happy to answer any questions you have, but everyone might benefit from this additional information. There is no sample paper for you to see, but I will try to describe what you should have.

Some students ask if you should fill in the template and then write a paper. I suggest you start by using the template as an outline. Save the template as your paper and begin filling in the information you have under each section. Use the template sections as the headings for your paper. Then you could go back and begin to discuss each section, using the information you have gathered from the class material. Add any additional information from your class material to help with this assessment.

Document your sources in the paper. You should be using APA format to document your sources. You are welcome to include sources other than the class material, but it is not necessary. You should have enough from what we have learned in the course modules to write this paper.

The case studies are not very long, so, while you should not “make stuff up,” you certainly may need to speculate, based on the information given, about deeper issues. As long as what you are speculating seems to correspond to the information given, you will be staying on track. You may want to mention additional information that would be good to know; questions you might ask the subject if her or she were present.

Remember that the paper should be 6-8 pages long. It should be double-spaced, with 1 inch margins all around and written in 12 point Times New Roman or similar font. The 6-8 pages do not include your title page, reference page, or abstract (if you have one). You should have 6-8 pages in THE BODY OF YOUR PAPER. Having less than 6 full pages will cost you points.

A word of advice—Make sure you check your spelling, grammar, and punctuation. All of these things are part of your grade. Some students have written good material, but because they misspelled words, used bad grammar, or had run-on sentences, they received a lesser grade than they might have otherwise. Also, make sure you are following APA style for your paper. Not doing so will also cost you points.

Some of the most common mistakes I see students make on this type of assignment are these:

· Using non-scholarly sources such as websites and magazines (not peer review journals). For example: Wikipedia is NOT an appropriate source for a research paper. You are not required to use additional sources for this paper, but if you do, make sure they are appropriate. (Exceptions to this rule include government websites where statistics are available.)

· Failing to use APA style when writing.

· Using contractions. Contractions should never be used in formal writing.

· “Preaching” to the reader. I may agree with what you are saying, but be careful to keep the voice of the paper objective. This is not a persuasive paper; it should be based on the research and literature.

· Failing to document sources within the text of the paper. Every statement or idea, whether it is a direct quote or paraphrased, must be supported by the literature and the source of the information cited.

· Failing to use headings in the body of the paper. For this paper, you have the headings already given to you. Use them.

· Not proofreading your paper before submitting. I have graded papers with multiple spelling, punctuation, and grammar errors. These will cost you points. It is a good idea to have someone else read through it for you. If you struggle with writing skills, it would be a good idea to make use of the services of the LUO writing center. They can help you with some of these things.

I hope this helps and answers some of your questions. Please let me know if you have additional ones.

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1. Jennifer

Jennifer is a white female, 45-years old, and a stay-at-home wife and mother. She has been married for 25 years to Michael, a plumber, with two daughters (23 and 20 years old) and one son (11 years old).

Jennifer’s gambling began approximately 10 years ago. At that time, she began to go out with her friends to horse races and bet small amounts. She never won very much but she does remember that she had a good time. At home, her husband did not know that she would go to the races, but she dreamed of hitting it big and giving him a nice surprise. Nevertheless, she never lost control with this kind of betting. Later on, she began buying lottery tickets. The weekly expenditure was around $22, which she continues to spend to date. Case Study Assessment Paper

Jennifer began to lose control playing slot machines. It all began 6 years ago. She was at a coffee shop waiting for a friend. While waiting, she saw how a man who was playing on a slot machine won a special prize. Ever since then, she got into the habit of spending the change from the price of coffee on slot machines. However, she became increasingly hooked and spent more and more time playing the slot machines. As a result, she began to drift away from her friends. She preferred to be by herself so as not to be seen and to feel more at ease. At first, she would play slot machines in her hometown, but then she began to go to the track and casino in a nearby town, so neighbors and people who knew her would not see her.

Jennifer grew up in the Catholic Church, but has not gone to mass for many years. When she married Michael, it was not in the church, and she has rarely attended since. She did not take her children to church, and they did not attend on their own. One daughter, Emma (the 23-year-old), has started attending a non-denominational church in their town. She has invited Jennifer, but so far she has not attended.

Jennifer continues to play the lottery (with an approximate weekly expenditure of $22) and play slot machines (approximately $165 every week). She goes about three times a week to the track and casino in the next town—never anywhere else—and spends around $54 each day, although she does recognize that on one occasion she even managed to lose $270. When she wins money, she does not leave the gambling area, but, instead, stays gambling longer until she loses everything. She only allows for $5, which she keeps in a separate pocket, for the bus trip back home. She feels depressed and ashamed because she is forced to lie. When she gets back home, she usually finds people from her town on the bus and she no longer can think up an excuse for making the trips. When she arrives back in her town, old friends are usually at a coffee shop near the bus stop, and when she is with them, she has to think up new excuses. She is totally despaired, can no longer take it, and thinks nobody believes her any more. When she is very down, she often drinks too much, “to forget it all.” At home, the situation is not any better. She is very nervous and has difficulty sleeping. When she gets home, she does not like talking nor does she feel like doing any housework. Nobody in her family knows anything about her gambling, although she does think they suspect something.

On one occasion, she commented to them that she had a problem but did not dare tell them the truth. She has let the house run down and even her personal appearance. Her daughters confront her because it is not possible to talk to her, and Michael, who until recently has not worried about money at home, has begun to ask her to account for her spending. Jennifer is very desperate because she has spent all of her savings. Her gambling has added up to become a $1,650 debt from a small personal loan that she can no longer meet. She has never stolen, but on some occasions has begun to go through the drawers in her daughters’ rooms searching for money to use for gambling. Every night when she goes to bed, she thinks that she is not going to gamble the next day; however, she cannot help it. Her thoughts about gambling are continuous. The relationship with her husband is worsening. They have not had sexual relations for two months, because she feels incapable, and he has lost interest. Jennifer insists that if Michael were to find out, he would file for divorce. She has come to the therapist’s office ready to do anything she can to quit gambling because she can no longer cope with the situation she finds herself in, and she feels she is incapable of controlling it by herself.

2. James

James is a black male, 42 years of age, and father of five. He has been married twice, and his wife, Nanci, has become increasingly distant from him in their marriage due to her anger and hurt over his use of Internet pornography. Nanci did not know that James used pornography until they were married, and every time she has asked him to stop, his use has only intensified. Now, they have experienced numerous financial consequences because he has reached the credit limit of two of their credit cards paying for pornography. Nanci no longer wants James around their children because she feels that he is a bad influence. Case Study Assessment Paper

James comes to treatment recognizing that he has a problem with pornography and the accompanying compulsive masturbation. He still has his job as an information technology (IT) professional at a large corporation, which provides him with insurance to access treatment, and his wife has agreed to let him stay in their home while he completes his outpatient treatment (but he must stay in their basement guest room).

James does not consider himself a spiritual person, so he does not see praying or contact with God as a resource. His mother, Margaret, who introduced him to pornography at the age of 11, does not feel he has a problem. James was very young when his father left the family, and his mother gave him pornographic magazines because she felt guilty that a father was not there to teach him about sex. She stays actively involved in his life. This is a problem for Nanci, since she reports that James and Margaret often spend time together and exclude her and the children.

James believes that he has a right to sex since it is his most important need. He appears to be good-natured, and he says he always strived to be faithful to the women he was with. However, James says he was very promiscuous when he was not in a relationship. When his wife refuses to be sexual with him, he sees it as rejection and believes she does not love him. He says his first wife treated him similarly when he was married to her.

3. Virginia

Virginia is a 65-year-old white woman, married for 35 years to Bill, an accountant. They have 5 grown children and 12 grandchildren. She taught elementary school for 28 years and has not worked since retiring 15 years ago. Her mother suffered with hypertension and died of a stroke 10 years ago at age 81. Her father died after a heart attack more than 30 years ago at age 55. She has 2 younger sisters, aged 61 and 59 years old, who are basically in good health. Case Study Assessment Paper

She had an appendectomy at age 28, and a cholecystectomy at age 55, 1 month after her mother died. She sees her family doctor for control of asthma and high blood pressure. The same family doctor has treated the patient for nearly 20 years.

Virginia has been drinking, sometimes to excess for a number of years. Her drinking apparently began in the early 1970s after she was involved in a lawsuit initiated by a parent of one of her pupils. Although the school backed her, and the case was eventually resolved in her favor, she remembers the two-year period as one of constant fear and uncertainty. She recalls subsequently experiencing blackout spells. On three separate occasions, she was hospitalized for detoxification, and brief periods of sobriety ensued.

Recently Bill and their daughter called the family doctor to request time to “talk about mother.” The husband related that his wife had resumed daily drinking (about 1 pint of vodka) 3 months ago. At times, he noticed that she slurred her words. Daughter has become fearful of leaving the grandchildren with her mother. When they each spoke with her, she denied “heavy drinking” and thought they made “more of the problem than there was.”

When Virginia came to the center, she validated the history of her alcohol habit, as presented by her primary care physician. She added her several brief attempts to attend Alcoholics Anonymous (AA) meetings, until about a year earlier when she quit because she “was bored.” She describes her husband as a “workaholic who is domineering and often makes me feel defensive.” She acknowledged drinking daily for the past 3 months. She had slept poorly for 6 months, which she attributed to “bronchitis and a chronic cough.” Her energy, appetite, and weight were all stable. She denies being depressed or anxious. She reports that she recently drank very little while they were away from home for a week-long vacation. Case Study Assessment Paper

Virginia and her husband attend a local Presbyterian church regularly. They have friends there and have served on various committees. When asked about her spiritual condition, Virginia indicated that she saw nothing wrong with her drinking since Jesus drank wine.

Virginia is neatly-dressed, cooperative, and appropriately behaved. Her mood is stable, and her affect was full in range. She does not see a need for therapy, but has agreed to counseling because her daughter is threatening to not let her see her grandchildren if she does not get help.

4. Angela

Angela is 32 years old Hispanic female. She is divorced and employed as an administrative assistant at a local human services program. She drinks alcohol and uses cocaine (crack). She lives with her 11-year-old daughter, Katie, in an apartment near her job. Although she makes a relatively low salary, Angela has managed to support herself and her daughter without financial support from Katie’s father. Angela was married briefly to Katie’s father when she was 20, but she left him after he became physically and sexually abusive toward her. He also was an alcoholic. She had almost no contact with him for many years. Her mother is a strong support for Angela and Katie. Angela reports growing up in a “normal family” and states that her childhood was “good” despite her father’s occasional drinking binges, which she says were related to him celebrating a special account he had landed (he was in advertising), and her mother’s “occasional bad depressions.” She is the youngest of five children and the only girl. Case Study Assessment Paper

Angela describes having little pleasure in life and feeling tired and “dragging” all of the time. She says her difficulty in standing up for herself with her boss at work is a constant stressor.

She has had periods of sobriety in her recent past. Her most recent stretch was more than 6 months with no drugs or alcohol. After that, she started having a harder time getting up each day, and began again to drink daily. She started experiencing bouts of feeling worthless, sad, guilty, hopeless, and very anxious. Her sleep problems increased, she began having nightmares, and she lost her appetite. After a month of this, she saw friends and family less often, instead stayed home and watched TV. She started her crack use again one night after her boss got very upset with her not finishing something on time. She went to a local bar after work that day and hooked up with a guy she met there to get crack. In accompanying him to a local dealer’s house to get some crack, she was raped by several men. Angela did not return home that night (Katie was at a friend’s sleepover party) and did not show up for work the next day. She does not recall where she was the rest of that night. However, shortly after that, she came to the center for help.

Angela reports that she began drinking around the age of 13 and it became progressively worse over the years, although she did not begin to see it as a problem until after she began using crack, at around age 28. She says her depression got much worse after she began using crack.

Angela reports having had gynecological problems during her 20s, resulting in a hysterectomy at age 27. When asked if she was ever physically or sexually abused as a child, she says no; however, she confesses (with some difficulty) that when she was 11, she had an affair with her 35-year-old uncle (father’s brother-in-law).

Angela does not attend church at all, although she was faithful to Sunday school as a child. She says she sometimes prays, but hasn’t lately since she doesn’t believe God listens to her.

Angela says she feels hopeless about her ability to put her life together and stay sober. Of her recent rape, she says that she “only got what she deserved” for being in the wrong place with the wrong people at the wrong time. Angela speculates that maybe she is an unfit mother and should give up custody of her daughter. While Katie is currently staying with Angela’s mother, Angela is concerned that her ex-husband will try to get custody of Katie if he hears that she is in the hospital for alcohol and drug treatment. He has been in recovery himself for two years and began demanding to see Katie again about 2 months ago. Case Study Assessment Paper

5. Dominic

Dominic is a 74-year old Italian-American man, living alone in an apartment complex for older adults. He came to the center that is associated with the housing units. Dominic and his wife, Marie, owned and operated a small, local grocery for 44 years (they emigrated from Italy when they were newlyweds at age 19). They sold the business to their son Frank when Dominic turned 70. The plan was to enjoy travel and retired life together. However, shortly after retiring, Marie was diagnosed with an aggressive leukemia, and she died within 4 months. Dom has been living alone for over 3 years. Because Dominic and Marie spent most of their time working and involved with family activities, there are few close friends in his life. Frank’s family has Dominic to dinner every Sunday, but has little time during the week because of competing demands. Dominic’s other children include a daughter living in another state who calls daily (but seldom visits because of the cost); a daughter oversees in military service, and a son with Down’s syndrome who lives in a group home about an hour away. Dominic indicates that he was a “hard drinker” during his 20s and 30s, when he developed stomach problems and high blood pressure. At that point, he limited his use of alcohol to his Friday night poker club and to Sunday dinner with the family. Since Marie’s death, he has regularly consumed 3 to 4 drinks a day. He says it alleviates some of the pain, stress, and loneliness. It also helps him sleep, along with the over-the-counter medications that he takes for arthritis pain and as sleep aides. He went to the local health clinic because his hypertension and gastritis have become extremely labile and intractable. When you ask Dom how he is doing, he says, “Oh, I guess I’m okay for an old widower. I don’t think it really matters how I feel or what I do anymore at my age.” Case Study Assessment Paper

Dominic reports that he and his wife were faithful to the Catholic Church all of their married life. Even now, he attends mass weekly and goes to confession regularly.

6. Jill

Jill is a 25-year-old white female writer who grew up in Texas and started binge drinking as a teenager.  She says, “I started drinking alcopops and putting spirits into bottles of pop from the age of 13. My friends and I would go to local discos or drink at our houses. I made friends with some older boys in my area and a group of us would spend our weekends hanging out at their houses and drinking from their parents’ supplies. Case Study Assessment Paper

“I think the first time I was actually drunk was when I was 14. By that age, I was able to go out clubbing and not get carded – so I was drinking heavily and regularly every weekend. It’s much stricter these days than it was 10 years ago.”    Unlike many others, peer pressure was not a factor in Jill starting to drink from a young age but she admits she may have exerted it on others. “My childhood was really solid and I went to a good school with strict discipline. Peer pressure was not a factor for me at all – if anything – I think I was probably the one pressuring others! I had always had a rebellious nature. I liked to be a leader and was one of the first, if not the first girl in my year to date older boys and drink alcohol and I liked the feeling of being ahead of the others.    “By 18, drinking came naturally and felt like the ‘thing that everyone did’. I always had a good tolerance of alcohol. I could drink a lot and rarely threw up. I suppose my social life revolved around drinking and the ′funny′ stories we′d remind each other of the following day. I was not aware of it at the time, but I definitely used alcohol as a social crutch – I wouldn’t go out and socialize without it.”    On an average night, Jill would drink a bottle of wine before going out, followed by four or five cocktails and numerous shots, or a second bottle of wine, often losing track of how much alcohol she had actually consumed. Jill says she was lucky in that she never needed hospital treatment because of her excessive drinking, but she thinks alcohol is beginning to have a harmful impact on other aspects of her life.

She says there seems to be more chaos in her life. She frequently gets in fights with her friends and boyfriend, but cannot remember why. She often loses her phone or keys when she is out. Sometimes she passes out and wakes up not knowing how she got home. She says more than once she has awakened in a place that she does not recognize. These recent incidents have frightened her. Jill says she needs to stop her destructive habits, but she is not sure she needs to completely quit drinking. Case Study Assessment Paper

7. Sarah

Sarah has come by the free “drop-in” counseling clinic were you work to get some information and advice. Sarah is a 22-year-old black single woman who has been living with her boyfriend Jimmy for the last four years. She and Jimmy have been heroin addicts for as many years. When Sarah was 10 years old, her father, whom she says was a very heavy drinker, left her mom and the kids, and never came back. At 14, she started drinking and smoking marijuana. At 16, she had dropped out of high school and at 18, she moved in with Jimmy. He introduced her to heroin. She reports using about a 1/2 gram of heroin per day just to be able to function and feel comfortable. Jimmy does not work. In order to pay for the heroin and pay the rent on their apartment, she works the streets at night. She usually drinks four or five beers each night before going out to work. If she cannot score enough heroin, she will try to score either some Valium or Klonopin to “tide me over until I can get some ‘horse’”. She says she has tried cocaine but, “I really didn’t care for the high all that much.”

Sarah tells you that the alcohol and heroin help to calm her nerves and get her through the night. She and Jimmy are not having sex all that much. When they do make love, he never wears a condom. He says that is what makes him different from her “john’s” “Which is true because I won’t work without a condom.” Lately she has noticed that her breasts have become swollen and more tender. She also has not had her period in the last 12 weeks. She is pretty sure she is pregnant and knows it is her boyfriend’s baby. However, she is not sure she can stop using dope or work to have the baby even though Jimmy wants her to keep it. She is really confused at what she should do and is her asking for you to help her make some decisions. Her friend who works with her at night told her not to stop using dope if she is pregnant “Because it’s worse for the baby than to keep using.” “I just don’t know what I should do?”

When Sarah was a child, she went to Sunday school regularly, but stopped going to church when she started to middle school. She says none of her friends went, so she didn’t see the need to go either. She says she believes there is a God, but isn’t sure He cares about her or even knows who she is. Case Study Assessment Paper

8. Megan

For most of Megan’s 19 years of life, she was a “normal kid” who swam on the school swim team and looked forward to trips to the zoo with her mother. She is white and the youngest of four sisters. Megan enjoyed art and French class, and her classmates at the high school she attended. Drugs and alcohol had never been a problem. “I didn’t drink, smoke pot or anything,” she says. However, Megan’s boyfriend was another story.

“My boyfriend was into heroin,” she says. Though she was tempted to try it, she never did. Then a couple of years ago, he jabbed her with a heroin-filled syringe as she walked by. Megan was shocked – at first – then grew to need the drug. Case Study Assessment Paper

It was not long before Megan became addicted. “I’d use once every couple of weeks,” she says. “But then it progressed…and I was doing it every day.”

She was also stealing money from her parents to buy drugs. The combination of lying, stealing, and addiction led to a breakdown. “I was going through counseling and I told my therapist about all the lying and using behind my parents back,” she says. Megan told her parents about her drug use and tried hard to quit. However, she could not.

Within a few months, Megan had returned to a daily habit and along with an acquaintance, brought drugs and needles with her for a three-day senior retreat. Members of the school staff discovered their plans and called Megan’s parents to come and pick her up. Just two months shy of graduating, Megan was expelled from high school. Case Study Assessment Paper

She was given a job at her father’s business to keep her busy while her parents looked for ways to help their daughter. She says she stays clean for a few weeks at a time, but then the craving gets the best of her and she begins using again.

Megan’s parents are strong Christians and want to help their daughter, but are somewhat unsure of how to do so. Megan went to church as a child and continues to go most Sundays, but doesn’t believe it helps with her addiction issues.

Megan continues to struggle with her addiction. “I relapsed during the school year,” she says. Throughout the last few months, Megan has experienced several relapses, the worst coming over the Christmas holiday. “Normally when I relapse I use once or twice,” Megan says. This time she used every

Megan has currently been sober for 90 days, but she says she feels herself slipping. She wants to finish high school or get her GED, but she has difficulty staying on task. Case Study Assessment Paper

9. Greg

 Greg is a white male, of Irish decent, and a 30-year-old junior marketing executive. He shares an apartment with his brother and is not in a relationship. Greg has a very active social life. Almost every night of the week, Greg can be found at some sort of festivity that is at a bar, club or restaurant. At all of these occasions, liquor is present. Greg often jokes about how he must look like an alcoholic because in most pictures he is holding a drink. In addition, the woman he has begun a flirtation with (Jen) finds that every time she calls him he is drinking. She thinks nothing of it, since this man must just enjoy one or two social drinks. The fact that he drinks every night does not flag him as an alcoholic in her eyes. They have spoken on the phone scores of times, spent time together and been in constant communication for a two-month period. In addition, he really is such a nice guy. He casually mentions that his mother has asked him to promise not to drink. They laugh about how parents often refuse to view their children as adults.

One night before Greg goes out with Jen, he tells her a few stories. One included waking up one morning after a night of drinking with blood on his shirt. The caveat being he had no idea where the blood came from. On another occasion, upon being shoved by a young woman in a club after drinking for a while, Greg pushed her back and the woman went flying across the room. Greg admits that at this point, he realized he did not know what his alcohol limit was. He stated this in past tense; these events had happened about a year prior. Since then, Greg had allegedly altered his drinking habits. This statement was made as Greg pulled out two small bottles of vodka. One was for himself, and one for her. When she declined the offer of drink, he downed both bottles himself. Case Study Assessment Paper

Two hours later at the club where Greg and Jen had gone, Greg had two drinks of scotch and was ready for a shot of tequila. At that point, he was holding his liquor well. However, once the shot of tequila came into play Greg succeeded in alienating Jen. He spilled salt all over the bar then began dancing sloppily and said more than a few insulting things to her. By the end of the evening, Jen wanted nothing more to do with him. Greg cannot understand why.

Several of Greg’s friends are concerned about his drinking, so he has come to therapy to “shut them up.” He denies there is a problem, and wants you to confirm his opinion so he can tell his friends.