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Assessment Practice

Tierainie C. Johnson

Assessment of Addiction- ADD5106

Capella University

Dr. Ken Moskowitz

November 19, 2023

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Assessment Practice

Demographic Information

Rose Ingram, 50-year-old woman residing in Brown Trout Bay, presents complex

demographic profile. Her marital status and grown children provide glimpse into her family

structure. Working part-time as cashier at retail store indicates her employment status. The

struggle with alcohol abuse adds layer of complexity to her demographics, highlighting

substantial challenges in her life.

Strengths

Within Rose’s challenging circumstances, several strengths emerge. Despite part-time

employment, she contributes to her family’s support. Three close friends signify potential support

system for her recovery journey. Acknowledging her health status and making decision to quit

smoking demonstrates proactive steps toward better health, showcasing resilience amid

difficulties (Fancourt & Finn, 2019).

Client Problems

Rose’s client problems revolve around alcohol abuse, strained marital relationships, and

challenges related to her husband’s drinking. Her difficulties with employment, specifically

lateness attributed to hangovers, reveal impact of alcohol on her professional life. Understanding

these client problems is crucial for tailoring an effective treatment plan that addresses her

multifaceted issues.

Medical Status

Rose’s medical status reflects history of gall bladder removal two years ago and potential

hypertension requiring medication. Her acknowledgment of health issues, such as quitting

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smoking, indicates proactive approach to well-being. Exploring her medical status unveils

aspects that can influence her treatment and recovery journey.

Strengths

Rose’s strength lies in promptly addressing health issues, as evidenced by her decision to

quit smoking and seek medical attention for her gallbladder. Her proactive approach to health

contributes positively to her well-being, showcasing resilience and a commitment to self-

improvement.

Employment/Support Status

Rose’s employment and support status paints picture of her educational and occupational

background. With a GED, some community college education, and history of innumerable part-

time jobs, she has navigated through different roles. Her challenges, such as lateness due to

hangovers, provide insights into potential barriers affecting her employment (Wright, 2022).

Strengths

Despite challenges, Rose’s ability to secure employment with GED demonstrates

resourcefulness. Her contribution to her family’s support through part-time work showcases her

commitment to financial responsibilities. Understanding her employment and support status is

crucial for tailoring interventions that address the specific challenges she encounters.

Alcohol and Drugs

Rose’s history of alcohol use from young age and her family’s alcoholism and drug use

underscore significant aspects of her life. Her avoidance of drugs due to her brother’s heroin

overdose reveals complex relationship with substance use, necessitating comprehensive

understanding for effective intervention.

Client Problems

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Rose’s primary client problem centers around her alcohol abuse, leading to DUI incidents

and ongoing issues, such as frequent lateness to work due to hangovers. Recognizing depth of

these client problems is essential for formulating targeted treatment strategies that address root

causes of her substance use and related consequences.

Legal

Rose’s legal history, including DUI and other charges, provides insights into her

interactions with legal system. Understanding the legal dimension of her life is crucial for

tailoring interventions that consider potential legal implications and collaboration with legal

professionals.

Family/Social History

Exploring Rose’s family and social history reveals complex web of relationships, trauma,

and support. Her family’s history of alcoholism and drug use, coupled with her experiences of

physical abuse and rape, highlights profound impact of her upbringing on her current challenges.

Understanding these dynamics is vital for nuanced and effective treatment approach.

Client Problems

Rose’s family and social history contribute significantly to her client’s problems.

Childhood trauma, ongoing strained marital relationships, and past abusive experiences shape

her current struggles. Recognizing interconnectedness of these issues is essential for developing

a treatment plan that addresses the multifaceted aspects of her life.

Psychiatric Status

Rose’s psychiatric status delves into her mental health, revealing anxiety, depression, and

history of self-harm during her teenage years. Her current coping mechanism comprises using

alcohol to manage these mental health challenges. Understanding her psychiatric status is pivotal

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for tailoring interventions that address underlying factors contributing to her substance use

(Fearon, 2023).

Client Problems

Rose’s psychiatric status indicates ongoing challenges with anxiety and depression,

exacerbated by her alcohol use. The interconnectedness of mental health and substance use

underscores complexity of her client’s problems. Recognizing these intricacies is crucial for

formulating treatment plan that addresses substance use disorder and underlying mental health

issues.

DSM-5 Diagnosis

Considering Rose’s history of alcohol abuse, family background of alcoholism, and

impact on her mental health, probable DSM-5 diagnosis would be Alcohol Use Disorder (AUD).

DSM-5 diagnosis aligns with her prolonged and problematic alcohol use, legal consequences,

and impact on innumerable life domains (Bassingthwaighte, 2020).

Initial Treatment Recommendations

The initial treatment recommendations for Rose should revolve around addressing her

AUD and underlying mental health issues. Combination of individual counseling, group therapy,

and potential psychiatric evaluation is recommended. Tailoring interventions to her needs will be

crucial for a holistic and effective treatment approach.

Treatment Goals

The treatment goals for Rose Ingram center on achieving and maintaining abstinence

from alcohol and breaking cycle of dependence that has led to negative consequences. The focus

is on developing coping strategies for managing anxiety and depression without relying on

alcohol. The goals aim to address interconnected issues of substance use and mental health,

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fostering comprehensive approach to Rose’s recovery. Ultimate objective is to improve her well-

being by providing alternative coping mechanisms and strategies for navigating life’s challenges

without resorting to alcohol (Minton, 2022).

Legal and Ethical Issues

Dual Relationships

Rose’s small community may raise concerns about dual relationships. Clinicians must

navigate it carefully to avoid conflicts of interest, ensuring their primary focus remains Rose’s

well-being. Regularly revisiting and discussing therapeutic relationship boundaries is essential to

maintaining ethical standards.

Informed Consent

Given Rose’s legal history, obtaining informed consent becomes crucial if legal or court-

ordered aspects are involved in her treatment. Transparent communication about potential

disclosures is essential. It ensures Rose understands parameters of confidentiality and potential

information sharing, fostering trust in therapeutic relationship.

Confidentiality

Rose’s legal history raises challenges in maintaining confidentiality. Clinicians must

navigate these challenges while adhering to ethical standards and ensuring information sharing is

done responsibly. Balancing need for collaboration with legal professionals while safeguarding

Rose’s privacy is crucial for ethical practice. Navigating legal and ethical issues requires

thoughtful and transparent approach. Clinicians must continually assess and reassess these

considerations throughout treatment process, ensuring that Rose’s rights and well-being are

consistently prioritized.

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References

Bassingthwaighte, A. (2020). The Social Construction of the DSM-5 & its Impact on Patient Dignity.

Dr.library.brocku.ca. http://hdl.handle.net/10464/14944

Fancourt, D., & Finn, S. (2019). What is the evidence on the role of the arts in improving health and

well-being? A scoping review. In iris.who.int. World Health Organization. Regional Office for

Europe. https://iris.who.int/handle/10665/329834

Fearon, D. O. (2023, November 6). Examining the Connection: Traumatic Life Events, Substance Use,

and Service Utilization Among Persons Admitted to Inpatient Psychiatry in Ontario.

Uwspace.uwaterloo.ca. https://uwspace.uwaterloo.ca/handle/10012/20086

Minton, E. A. (2022). Pandemics and consumers’ mental well‐being. Journal of Consumer Affairs,

56(1), 5–14. https://doi.org/10.1111/joca.12444

Wright, K. (2022). Barriers to help-seeking for mental health issues in young rural males.

Researchbank.ac.nz. https://doi.org/10.34074/thes.5858