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Book Reference Perkinson, R. R. (2012). Chemical dependency counseling: A practical guide (4th ed.). Thousand Oaks, CA: SAGE. Appendix 6 Sample Biopsychosocial Interview DATE: 2-2-11 CLIENT NAME: Jane Roberts DEMOGRAPHIC DATA: This is a 28-year-old single white female. She is childless. She lives in Sioux, South D akota , by herself. She has lived in Watertown for the past 5 years. She has a high school education. She is elf-employed as a beautician at The Cut Above. CHIEF COMPlAINT : "I could not go on drinking the way I was." HISTORY OF THE PRESENT ILLNESS: This client 's father died when she was very young . She was raised by an overly demanding alcoholic mother. Her mother had strict rules and made the client work hard to k e ep the house clean. The client never made an emotional connection with her mother. "I grew up feeling le ft out, abandoned, lost, and alone. I think I was loved, but I was not shown it. " In school, she continued to feel isolated from her peers. She began drinking during her early teens. In high school , the client did not date a lot, but when she did, she fell immediately in love. She began a series of addictive relationships with m en. In these relationships , she was able to ex perience the affection she had always longed for. The client w as " devastated" when her boyfriends would go out with someone else. She would frantically "keep grasp­ ing" to hold on to these relationships . After high school, the client had an affair with a married man. This m an was demonstrative in his affection, and this fooled the client into thinking that he "really loved me." The client was unable to disengage from this relationship , even though the man was married and emotionally and physically abusive. The client 's drinking began to increase. Her tolerance to alcohol increased . She had blackouts . The client began to use Valium for sleep. Her dose of Valium has more than doubled. She currently is drinking at least a six-pack of beer and taking 30 milligrams of Valium every night. The client cu rrently is suffering from acute alcohol and anxiolytic withdrawal. Her withdrawal will probably be pro­ rract ed because she has been on Valium for 5 years. In withdrawal, she reports that she feels restless and is leep ing poorly. The client has few assertive skills and can be excessively dependent. She enjoys men who are powerful and controlling. The client has few healthy relationship skills, and she is dishonest. The client acc epting of treatment and has a strong desire to get help for her chemical dependency. PAST HISTORY: This client was bo rn in Livingston , South Dakota, on June 28, 1983. She reports a normal birt h and normal developmental milestones. She was raised with her mother and two younger sisters. Her -th er died when she was too young to know him. Her ethnic heritage is Irish. She describes her home of mi gin as "I did not like it. I felt alone ." In grade school, "I was timid, not very outgoing." In high school, "I

*Responsible professional: Carla Smith , C.C.D.C., Level II Objective 2: Patty will verbalize her powerlessness and unmanageability in group by 2-15-11. Intervention: Encourage the client to share her powerlessness and unmanageability in group.

*Responsible professional: Carla Smith, C.C.D.C. , Level II Objective 3: Patty will verbalize her understanding of her chemical dependency with her group by 2-15-11. Intervention: Assign the client to complete her chemical use history, and encourage her to share her story in group .

*Responsible professional: Robert Johnson, C.C.D.C. , Level III Objective 4: Patty will share her understanding of how to use Step Two in recovery with her counselor by 2-20-11. Intervention: Assign the client to meet with her clergy person to discuss how to use a Higher Power in recovery.

*Responsible professional: Father Larry Jackson Objective 5: Patty will log her meditation daily and will discuss how she plans to use the Third Step in sobriety with her clergy person by 2-25-11. Intervention: The staff will administer medications as ordered and monitor for side effects.

*Responsible professional: Margaret Roth, RN Objective 6: Patty will develop a written relapse prevention plan by 2-30-11. Intervention: Help the client to develop a written relapse prevention plan.

*Responsible professional: Carla Smith, C.C.D.C., Level II Objective 7: Patty will develop a continuing care plan with her counselor by 3-5-11. Intervention: Have the continuing care coordinator help the client to develop a continuing care program. ;'Responsible professional: Martha Riggs , C.C.D.C., Level I Problem 2: Chronic fear of abandonment, as evidenced by fear of losing all interpersonal relationships CoalE: To alleviate the fear of abandonment by connecting the client to her Higher Power and her Alcoholics Anonymous (AA)/Narcotics Anonymous (NA) support group Objective 1: In one-to-one counseling, Patty will share her feelings of abandonment by her parents and how this relates to her chemical dependency by 2-15-11. Intervention: In a one-to-one session, encourage the client to share her feelings of aban­ donment by her parents, and help her to connect this to her chemical dependency.

*Responsible professional: Carla Smith, C.C.D.C., Level II Objective 2: Patty will share her feelings of fear, loneliness, and isolation with her group by 2-20-11. Appendix 6 Samp le Biopsychosocia l Interview 265 Intervention: Assign the client to share her feelings of fear , loneliness, and isolation in group.

*Responsible professional: Carla Smith, C.C.D.C., Level II Objective 3: Patty will discuss her fear that the group will abandon her and receive feedback from the group by 2-25-11.

Intervention: In group, encourage the client to share her fears that the members of the group will abandon her .

*Responsible professional: Carla Smith, C.C.D.C., Level II Objective 4: In one-to-one counseling, the client will discuss accepting her ANNA group as her new sup­ port system by 2-28-11.

Intervention: Teach the client about how her recovery group can be her new support system.

*Responsible professional: Carla Smith , C.C.D.C., Level II Objective 5: Patty will write a letter to her father and mother telling them how she felt as a child , and she will share this letter with her counselor and in group by 2-20-11.

Intervention: Assign the client to write a letter to her father and mother telling them about the abandonment she felt as a child, and have her read this letter to her primary counselor and the group.

*Responsible professional: Carla Smith , C.C.D.C., Level II Problem 3: Poor interpersonal relationship skills, as evidenced by inability to share emotions, wishes, and wants with others Goal C: To develop healthy interpersonal relationship skills Objective 1: Patty will verbalize an identification of her problem with relationships with her counselor by 2-15 -11. Intervention: Teach the client about interpersonal relationship skills and how her addiction affected her ability to have healthy relationships.

*Responsible professional: Carla Smith, C.C.D.C., Level II Objective 2: Patty will ask five treatment peers for something she wants and share with them how she feels, keeping a log of each conversation and sharing this with her counselor by 2-15-11.

Intervention : Assign the client to ask five treatment peers for something she wants and share how she feels, and have her log each event and share in a one -to-one session.

*Responsible professional: Carla Smith, C.C.D.C., Level II Objective 3: Patty will complete the Addictive Relationships exercise (see Appendix 12) and share her understanding of the differences in addictive and healthy relationships with her counselor by 2-20-11.

Intervention: Assign the client to complete the Addictive Relationships exercise, and teach her the difference between addictive and healthy relationships.

*Responsible professional: Carla Smith, C.C.D.C., Level II Objective 4: Patty will use and log 10 "I feel" statements a day until the end of treatment, and she will share her daily feeling log with her counselor weekly by 2- 25-11. 266 CHEMICAL DEPENDENCY COUNSELING Intervention: Assign the client to log 10 feeling statements a day and to share in one-to-one sessions.

*Responsible professional: Carla Smith, C.C.D.C., Level II Objective 5: Patty will discuss her normal and addictive relationships with her group by 2-30-11.

Intervention: In group, encourage the client to share her understanding of addictive relation­ ships and the tools she can use to develop and maintain healthy relationships in recovery.

*Responsible professional: Carla Smith, C.C.D . C., Level II Problem 4: Dishonesty, as evidenced by chronic lying about chemical use GoalD : To develop a program of recovery based on rigorous honesty Objective 1: Patty will complete the Honesty exercise (see Appendix 8) and verbalize in group 10 times when she was dishonest about her chemical use by 2 -15-11.

Intervention: Assign the client to complete the Honesty exercise, and in group have her verbalize 10 times when she was dishonest about her addiction.

*Responsible professional: Bill Thompson, MSW Objective 2: Patty will discuss in group how her alcohol use contributed to her dishonesty by 2-20-11. Intervention: In group , have the client discuss the connection between addiction and dishonesty.

*Responsible professional: Bill Thompson, MSW Objective 3: Patty will keep a daily log of the times when she lies in treatment and will share this log with her counselor weekly by 2-25-11 .

Intervention: Help the client to keep a daily log of the lies she tells in treatment, and discuss with her how it feels to lie and how it feels to tell the truth.

*Responsib le professional: Carla Smith, C.C.D.C. , Level II Objective 4: Patty will give a 20-minute speech to her group about why it is important to be honest in recovery by 2-25-11.

Intervention: Assign the client to write a 20-minute speech about why it is important for her to get honest, and then encourage her to read her paper in group.

*Responsible professional: Carla Smith, C.C.D . C., Level II Objective 5: In a conjoint session with her mother, Patty will share her chemical use history by 2-30-11. Intervention : In a family session , have the client share her chemical use history with her mother.

*Responsible professional: Ronda Vocal, L.M.F.T. Objective 6: Patty will discuss how dishonesty separated her from her Higher Power with the clergy by 2-20-11 . ~ Intervention: Have clergy meet with the client and discuss how her lies kept her away from her Higher Power. o4 *Responsible professional: Pastor Steve Schultz >.ppendix 6 Sample Biopsychosocial Interview 267 Problem 5: Poor assertiveness skills, as evidenced by being too passive and allowing other people to make important decisions Goal E: To develop assertiveness skills Objective 1: In group, Patty will verbalize an identification of her problem of being passive and will directly relate her passivity to her chemical use by 2-20-11. Intervention: The psychologist will help the client to understand passive traits and how this relates to addiction .

*Responsible professional: Frank Rockman , PhD Objective 2: Patty will verbalize an understanding of how her passive behaviors l ead directly to increased chemica l use with her group by 2-15-11. Intervention: Assign the client to discuss in group how her passive traits lead to chemical use.

*Responsible professional: Carla Smith, C.C.D.C., Level II Objective 3: Patty will practice the assertiveness formula with two treatment peers per day, keeping a daily log of each interaction by 2-20-11. Intervention: The psychologist will teach the client the assertiveness formula and, using behavior rehearsal, will role-play several assertiveness situations.

*Responsible professional: Frank Rockman, PhD Objective 4: Patty will have weekly individual sessions with the psychologist in which she will role-play assertiveness situations by 2-30 -11 . Intervention: The psychologist will meet with the client weekly to role-play assertiveness situations.

*Responsible professional: Frank Rockman , PhD