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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 Dakota, by herself. She has lived in Watertown for the past 5 years. She has a high school education. She is self-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 keep the house clean. The client never made an emotional connection with her mother. "I grew up feeling left 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 men. In these relationships , she was able to experience the affection she had always longed for. The client was "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 man 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 currently is suffering from acute alcohol and anxiolytic withdrawal. Her withdrawal will probably be pro­ tracted because she has been on Valium for 5 years. In withdrawal , she reports that she feels restless and is sleeping 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 is accepting of treatment and has a strong desire to get help for her chemical dependency. PAST HISTORY: This client was born in Livingston , South Dakota, on June 28, 1983. She reports a normal birth and normal developmental milestones . She was raised with her mother and two younger sisters. Her father died when she was too young to know him. Her ethnic heritage is Irish. She describes her home of origin as "I did not like it. I felt alone." In grade school, "I was timid, not very outgoing." In high school, "I was scared to relate." The client denies ever serving in the military. Her occupational history includes a 5-year stint as a secretary. She has held her current job as a beautician for 5 years. She is happily employed .

Sexually, the client is heterosexual. She has a complex history of addictive relationships with men who have been abusive both verbally and physically. The client currently is involved with a new boyfriend. She has been seeing him for the past few months. She reports that this relationship is going well. Her friends and family support her coming into treatment. Spiritually, the client believes in God. She was raised in the 261 262 CHEMICAL DEPENDENCY COUNSELING Lutheran faith. She attends church regularly. She denies any legal difficulties. For strengths, the client identifies that "I am caring. I get along with people real well. I think that I am intelligent. " For weakness, the client states, "I have a drinking problem. " For leisure activities , the client enjoys biking and jogging. Her leisure activities have been only mildly affected by her chemical use. MEDICAL HISTORY: • Illnesses: Measles, mumps , chicken pox • Hospitalizations: None • Allergies: None • Medications at present: 5 milligrams of Valium three times a day for withdrawal FAMILY HISTORY: • Father: Age of death, "in his 20s"; cause of death, unknown; client does not remember her father • Mother: Age 53, in good health; history of alcoholism; described as "quiet, demanding" • Other relatives with significant psychopathology: None MENTAL STATUS: This is a tall , thin , 28-year-old white female. She has short , curly light brown hair and blue eyes. She has a broad smile and a freckled face. She was dressed in white jeans and a white sweatshirt. Her sensorium was clear. She was oriented to person, place, and time. Her attitude toward the examiner was coop­ erative, friendly, and pleasant. Her motor behavior was mildly restless. The client fidgeted in her chair. She made good eye contact. Her speech was spontaneous and without errors. Her affect was mildly anxious. Her range of affect was within normal limits. Her mood was mildly anxious. Her thought processes were productive and goal directed. Suicidal ideation was denied. Homicidal ideation was denied. Disorders of perception were denied. Delusions were denied. Obsessions and compulsions were denied. The client exhibited an above aver­ age level of intellectual functioning. She could concentrate well. Her immediate, recent, and remote memories were intact. She exhibited fair impulse control. Her judgment was fair. She is insightful about her alcohol prob­ lem and is in minimal denial about her drinking. She is in more denial about her problem with Valium. Diagnostic Summary DATE: 2-10-11 CLIENT NAME: Jane Roberts This is a 28-year -old single white female. She is childless. She lives in Watertown , South Dakota, by her­ self. She has lived in Sioux Falls for the past 5 years. She has a high school education. She currently is self­ employed as a beautician. She comes to treatment with a chief complaint of a drinking problem. The client's father died when she was very young. She was raised by an emotionally distant alcoholic mother. Patty grew up feeling a profound sense of abandonment. All her life, she has felt empty and lost. She could gain her mother's approval only by being a hard worker. In grade school, the client was timid and shy. In high school , she began a series of addictive relationships with men. Patty gets love and sex mixed up. She is starved for attention and affection. She is vulnerable to manipulation. She had an affair with a married man. Her relation­ ships with men have been dysfunctional and abusive . The client has few assertive skills. She cannot ask people for what she wants or share how she feels. She is dishonest. She lies to get what she wants. Patty began drinking during her early teens. After high school, her drinking began to increase. Her tolerance to alcohol increased. She has had multiple blackouts and has suffered withdrawal symptoms. She is drinking at least a six-pack of beer per day. Patty has been taking Valium for sleep for the past 5 years. She has increased her tolerance to Valium, and she has more than doubled her bedtime dose. The client currently is experienc­ ing symptoms of alcohol and Valium withdrawal. She has been anemic for the past severa l years. She is being treated with vitamins . She has cold symptoms and is taking aspirin and an antihistamine. She has a history Appendix 6 Sample Biopsychosocial Interview 263 of a rthritis , but she exhibits no current symptoms. She has a history of a heart murmur. The client is highly m otivated for treatment, and her relapse potentia l is low. She is psychologically minded and is opening up "'-ell in group. She shows minimal resistance to treatment. Her current recovery environment is poor. She has no social support system except for her boyfriend of the past 2 months. The psychological testing shows th at Patty is emotionally unstable and manipulative. She will break the rules of society to get her own way. She will openly defy authority She is suffering from mild depressive symptoms, and she is experiencing ignificant daily anxiety These symptoms seem to relate to the client's ch emical dependency DIAGNOSIS : Axis I: 303.90 Alcohol dependence 304.10 Anxiolytic dependence 291.80 Alcoho l withdrawa l 292.00 Anxiolytic withdrawal Axis II: V 71.09 No diagr:osis Axis II Axis III: Anemia, mild cold symptoms Axis IV: Severity of psychosocial stressors, personal illness, Severity 3 (moderate) Axis V: Current global assessment of functioning : 50 Highest global assessment of functioning past year: 70 PROBLEM LIST AND RECOMMENDATIONS : Problem 1: Extended withdrawal from alcohol and Valium, as evidenced by autonom ic arousal and eleva ted vital signs Problem 2: Inability to maintain sobriety outside a structured program of recovery , as evid enced by cli­ ent having tried to quit using chemicals many times unsuccessfully Problem 3: Anemia , as evidenced by a chronic history of low red cell counts Problem 4: Upper respiratory infection, as evidenced by sore throat and rhinitis Problem 5: Fear of rejection and abandonment , as evidenced by client feeling abandoned by both her mother and her father and now clinging to relationships even when abusive Problem 6: Poor relationship skills, as evidenced by client not sharing the truth about how she feels or asking for what she wants , leaving her unable to establish and maintain intimate relationships Problem 7: Dishonesty, as evidenced by client chronicall y ly ing about her chemical use history Problem 8: Poor assertiveness skills, as evidenced by client allowing other people to make important decisions for h er, inhibiting her from developing a self-directed program of recovery Treatment Plan Problem 1: Inability to maintain sobriety outside a structured program of recovery, as evidenced by repeated unsuccessful attempts to remain abstinent as well as increased tolerance and withdrawa l symptoms Goal A: Acquire the skills necessary to achieve and maintain a sober lifestyle. 264 CHEMICAL DEPENDENCY COUNSELING Objective 1: Patty will discuss three times when she unsuccessfull y attempted to stop drug and alcohol use with her counselor by 2-15 -11.

Intervention : Assign the client to list three times when she unsuccessfully attempted to stop or cut down on her drug and alcohol use, a nd have her discuss this in a one-to-one session.

*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 professiona l: 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 b y 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 Obje ctive 5: Patty will log her meditation daily and will discuss how she plans to use the Third Step in sobriet y 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 dev elop 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-on e 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 Sample Biopsychosocial 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 -o ne counseling, the client will discuss accepting her AA/NA 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 counse lor 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 comp lete 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. '''Responsible 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 .

*Responsible professional: Pastor Steve Schultz - Appendix 6 Sample Biopsychosoc ia l Interview 267 Problem 5: Poor assertiveness skills, as evidenced by being too passive and allowing other people to make important decisions CoalE: 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 lead directly to increased chemical use with her group by 2-15-11.

Intervention: Assign the client to discuss in group how her passive traits lead to chemical use.

*Responsib le 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 Rock man , PhD Objective 4: Patty will have weekly individual sessions with the psychologist in which she will role-pla y 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