interview

Running head: Written Assessment Interview Reflection and Written Assessment Permission Granted to use by Student Written Assessment 2 Interview Reflection and Written Assessment I. Client Identification Ms. Darcy Cook is a 28 -year -old African American woman who presented to the Substance Abuse Treatment Center alone and without a referral . She speaks Engl ish and is unemployed, and therefore is classified as low socioeconomic status. She is single and lives in a house with her grandmother, but she did not describe the neighborhood in which she lives. She prefers to be called Darcy. II. Presenting Situation Darcy presented to the agency to receive treatment fo r alcohol and substance abuse. She regularly uses alcohol, marijuana, and crack cocaine. She has four children of whom she does not have custody, and she wishes to quit using all substances so that she m ight eventually regain cus tody of her children. Three or four month ago, she attempted to quit using all substances “cold -turkey” and without professional help. She was able to stop using for two months, but “because of the stress of life not going anywher e,” she began using again. She was successful in discontinuing her use of marijuana when she was pregnant with her first child but started again when the child was born. The duration of her substance abuse is significant, as she has been using since she wa s fourteen years old. Due to the health and legal risks of using these substances, this is a severe problem. She has received no previous assistance from social agencies for the presenting problem . Darcy stated that she has limited social supports and spen ds time with other addicts, but she does have a strong relationship with her grandmother. She also has training as a welder and stated that she is confident in her ability to succeed. Historical Information Written Assessment 3 Darcy stated that her mother had issues with aggression and was physically and emotionally abusive to Darcy and to her father. Her father physically abused her mother as well. Darcy stated that she has never sought professional treatment for substance abuse prior to t his meeting and has twice been unsuccessful in trying to permanently stop using on her own. She also has a history of inability to maintain employment due to substance abuse issues. III. Intra -Interpersonal Factors a. Emotional/behavioral functioning Darcy did not describe any dysfu nction in her emotions. She did not report suffer ing from hallucinations, delusions, mood swings, sleep changes, sexuality issues or appetite changes, and did not report acts of aggression. She did report that she has behavioral d ysfunction in the form of drug and alcohol abuse. She lost legal custody of her four children due to her issues with substance abuse. Reckless behavior and impulse problems appear to be contributing factors to this issue as she stated that she uses as “an outlet” and “a way out.” These statements suggest that Darcy may be experiencing symptoms of anxiety and/or depression. b. Mental Status Exam i. Attention Darcy did not appear to be distracted. She maintained eye contact, and her speech did not stray from the topic at hand. She did not appear to be easily distracted. ii. Affect Darcy’ s affect wa s consistent with the content of the interview. It was appropriate and stable. Her facial expressions coordinate d appropriat ely with her affect. She appeared to be slightly optimistic. iii. Mood Written Assessment 4 Darcy’ s mood wa s stable throughout the interview. She wa s calm and slightly anxious. She expressed an increase in anxiety at the end of t he interview, likely associated with the large amount of paperwork completed during the last several minutes of the session. She stated that she uses drugs and alcohol as “an escape” which suggests she may be regularly experiencing symptoms of anxiety and/or depression . iv. Appearance Darcy is a 28 -year -old African American female who appeared to be slightly older than her chronological age. Her attire wa s worn but the style wa s appropriate for the weather and for the occasion. She wore no accessories and had no physical deformities but appear ed to be slightly underweight in proportion to her height. v. Motor Activity Darcy had an unremarkable gait, normal motor coordination, and slouched posture . She had no remarkable mannerisms or gestures. The volume and rate of her speech were normal. vi. Thought process Darcy’ s speech was coherent and easy to understand , suggesting her thought process was normal . The rate, volume, tonality , and quantity of her speech were normal. She did not exhibit magical or grandiose thinking, nonsense words, or a bnorm al speech. Her comments were relevant and did not exhibit tangential or circumstantial thinking, a flight of ideas, or loose associations. vii. Thought content Darcy’ s thought content did not appear to contain abnormal features. She did not report delusions, d epressive thoughts, aggressive ideation, or obsessions. She did not Written Assessment 5 appear to experience overvalued ideas or inappropriate preoccupations. She did not report feeling heightened anxiety without a specific cause. viii. Memory Darcy’ s long -term memory appeared to be intact as she wa s able to recall childhood events. Her s hort -term memory was not formally assessed during the interview. However, she did not report concerns regarding lapses in short -term memory, and none were identified during the session. ix. Intellect Darcy stated that she has had training as a welder. It is unknown if this was during high school or post -secondary education. Sh e was well -spoken and able to clearly state her concerns. x. Orientation Darcy’s orientation to date, time, and location was not formally assessed. However, she dated all documents correctly. She was also able to provide many personal details on the intake form and during the assessment. xi. Judgment Darcy acknowledge d that she has a problem with substance abuse and that her life circumstances would likely improve if she received treatment. She also acknowledged that the people she uses with are a bad influence on her, and the relationships are unhealt hy. She was willing to comply with treatment options offered during the session. c. Use/Abuse of alcohol and/or other substances Darcy is currently regularly using alcohol, marijuana, and crack cocaine. She stated that she want s to minimize her use of alcohol and discontinue her use of marijuana and crack Written Assessment 6 cocaine. She started u sing alcohol at the age of 14 , marijuana at a ge 17, and crack cocaine at age 22. She state d that she uses these substances as “a way out ” and “as an outlet” wh ich is why her attempt to quit without professional help was ultimately unsuccessful . She agree d that using is a stress reliever for her. She uses marijuana and crack c ocaine with people she refered to as “acquaintances.” d. Suicide risk assessment Darcy did not report any instances of current or past suicidal ideation. She did not report past attempts of suicide. Her risk of suicide appears to be negligible. e. Harm to others Darcy did not report any instances of current or past desire to harm others. She did n ot report past attempts to harm others. Her risk of harming others appears to be negligible. f. Cultural Issues/Values/Ethnicity Issues Darcy stated that she has limited involvement with her church and only att ends on major holidays. She did not identify her church as a significant sou rce of support in her life and did not identify any other spiritual practices or beliefs. As a young African American woman experiencing substance abuse and low socioeconomic status, she belongs to several categories of vulnerab le populations and as such, is at risk of experiencing problems unique to these populations. It is worth noting that she may face discrimination from future employers, landlords, or legal authorities based upon any one of these factors. This has the potent ial to present significant obstacles as she works toward regaining custody of her children. g. Family : Darcy’s nuclear family is not intact. She has three sons aged 11, 7, 4 years old, and a daughter aged 2 years old. The youngest two children are in foster care, the second oldest lives Written Assessment 7 with Darcy’s paternal uncle, and the oldest child lives with Darcy’s paternal grandparents. The youngest two children share th e same father, Darcy is divorced from the fath er of the second - oldest, and she had a brief relationship with the father of her oldest child. She stated that she has “sporadic” contact “every once in a while” with her youngest two children and has limited contact with the oldest two . Darcy did not prov ide the age of the fathers of her children and did not disclose the year of her marriage or divorce to the father of her 7-year -old child. Darcy has limited contact with nearly all members of her family of origin and identifies this as a weakness . The only close relationship she has is one with her maternal grandmother, and she identified this as a strength . Her maternal grandparents were married, and her maternal grandfather is deceased , but the year of his death is unknown . She has a maternal aunt and unc le but has no contact with them or their children. She has no contact her mother who m Darcy stated may have had psychiatric issues with aggression when Darcy was a child as she physically and emotionally abused her . Her paternal grandparents live in a nothe r state, and Darcy has limited contact with them. She stated that she has no contact with her father because he was abusive to her when she was a child . Her father has one brother, but she “never really got to know him.” Her uncle is married and has two da ughters and one son, but she has no contact with her uncle or his children . Darcy’s parents are married, but they are separated and not living together . Darcy’s only sibling is a sister with whom s he has limited contact. Her sister is not married and has two sons , but Darcy was uncertain if the father of the children is involved in their lives . She did not disclose th e age of most people in her family or the year of significant dates such as marriag es. IV. Environmental Factors Darcy has very few significant interpersonal relationships. She has a close relationship with her grandmother, but she has limited contact with her children and describes all other Written Assessment 8 individuals in her life as “acquaintances” with whom she abuses drugs and a lcohol. Darcy, therefore, has a very poor social support network. When asked about involvement with hobbies or commun ity events, Darcy stated that the only activity she partakes in is drug and alcohol abuse. She is currently living with her grandmother and express ed no concerns regarding the potential loss of her living situation as she and her grandmother have a good relationship. Her grandmother is financially able to provide electricity to the house. However, they are struggling to afford food. Darcy is currently unemployed and cannot contribute to basic life necessities in the household. Darcy stated that she has training as a welder and was working as a waitress “six or seven months ago” but lost the job because she was “using and not coming into work.” Because of her inability to maintain employment, her financial situation is unstable. She states that s he and her grandmother are not currently receiving public assistance, so during the interview, I recommended that she meet with another member of our st aff immediately after the interview to arrange for EBT assistance. As previously stated, Darcy belongs to several vulnerable populations and may face d iscrimination from future employers , landlords, or legal authorities because of this. This discrimination has the potential to present unique difficulties . V. Summary, Goals, and Recommendations Ms. Darcy Cook presented at the Drug and Alcohol Treatment Center primarily to seek treatment for alcohol and substance abuse which has resulted in the loss of custody of her four children and inability to maintain employment. Darcy stated that to regain custody of her children, she would like to work towards two goals - limit ing her alcohol consumption and discontinuing her use of marijuana and crack cocaine, and securing employment. She currently has an exceptionally poor social network to support her in these endeavors, but she has a strong relationship with her grandmother and stated that she has confidence in her ability to succeed “if Written Assessment 9 she puts her mind to it, ” she is “good at working with her hands ,” enjoys manual labor, and is punctual. Due to Darcy’s appropriate appearance, intellect, and motivation to change, I predict that she will comply with treatment. Immediately foll owing the session, the agency will assist Darcy with obtaining EBT, provide her a schedule for Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), and schedule an appointment for a follow -up session in one week. Written Assessment 10 References Cuerin, P., & Pendagast, E. (1976). Evaluation of family system and genogram. Family Therapy: Theory and practice. Gardner Press, New York. Tracy, E. M., & Whittaker, J. K. (1990). The social network map: Assessing social support in clinical practice. Fami lies in Society, 71 (8), 461 -470.