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Case Presentation

By Felicia Williams
Background Information
28 year old Native American Female
1 child, 2 deceased
Addiction to opiates at age 19 after a car accident which caused premature
labor at 34 weeks pregnant and the death of her twins.
At 23 she progressed to using crack/cocaine
Client has been having severe seizure disorder since the accident and drug
Client reported having 4 such seizure in the last 60 day while attending prior
treatment facility.
Client reports having tried inpatient and outpatient treatment in the past and had
never complete any until she attending the latest which was a 60 day faith based
No reports of childhood or adult abuse
Good relationship with her mother who also has an addiction but she is not in
She has voluntarily agreed to become a inpatient recipient after being referred by
the local Department of Social Services who had custody of her child before she
came to GC.
Conceptual Framework
Family: Gain custody of her daughter
who is currently in DSS custody

Health: To follow up with

her doctors visits. Because of
recent reoccurring seizures
Client Sobriety: Remove herself
from her current

from lack of care and drug environment which has
always led to her relapse

Treatment: Get serious about

wanting treatment by attending group
session and NA meeting on a regular
basis and taking drug screens and
continue with Family Drug Court
Problem Statement
Client states she has failed in treatment before on numerous occasion and
she knows without some type of intense treatment she will not be able to
stay sober and get her child back. She does not want to return to old people
places and things because she knows she will quickly relapse.
She desires a clean start and a better living environment.
Services offered
Because of a little less than 60 days clean client will be place in a close
supervised apartment with numerous restrictions.
She will have her own apartment for the first time.
Required to attend SACOT which is recovery at the beginning stages.
SAIOP is stage two
Routine drugs creens and one on one counseling along with group
Strength's and Limitations

Strength Limitations
Wanting to be a better mother for her Getting to know her daughter again after
daughter. being away from her.
Removed herself from the negative How to maintain a healthy relationship
influences that fed her addiction. with her mother who is also in addiction.

Seeking out treatment and completing Working on anger issue and maintaining
sobriety while in treatment. Not giving up
first 60 days of recovery. Entering into and quitting treatment.
a inpatient program.
Assessment Goals
To seek healthcare for her seizures.
And take meds as instructed.
Remain seizure free.
Maintain sobriety and work the steps.
Gain custody of her daughter for good.
Working on going back to school for a high school diploma.
Stay in treatment until she graduates the program.
Learn and develop relapse prevention Time frame for all goals will be 60 days
skills to help recognize and block triggers. while maintain sobriety which means no
dirty drug screens.
Drug Screens per. Family Treatment Court
and Grace Court. Also that meds have been taken as they
Redirect negative behaviors.
Substance Abuse Education and guidance
No rules have been broken
for support recovery. And all meeting have been accounted for.
Learn coping skills When all goals have been accomplished
client can proceed to advanced treatment
group. She will be allowed more privileges.
What did I take away from the assessment
process about the client?
Biases going into interview- Client had Events or Life experiences that have
an I dont want to come to inpatient shape them into who they are- She has a
treatment. That she felt she was being lot of pain and hurt from the accident and
forced and she really wasnt going to come the death of her twins. She has a deep
back for entry. disappointment from family because she
let the addiction cause her to lose her
Value and differences between me and daughter after the lost of the other babies.
Client- She is Native America. I'm African
American She is younger. Ive never used Her mother has become more of an
drugs. We both have a deep love for our enabler and contributing factor to her
children. I also know what is like to lose a addiction because they would usually use
child. We are both southern and speak together.
with a deep accent.
Staff recommendation about What does research say on their
diagnosis, Interventions or diagnosis/problem/treatment?-
treatment?- Intense inpatient Client can be successful if she
treatment is needed immediately. If continues to utilize treatment. That
she returned home she would have there is a high risk of relapse but if
relapsed because that has been the intervention happen quickly
pattern of recovery and relapse she enough she will be able to pick up
has faced in the past. her recovery again.
What changes are recommended for the agency or service
(Needs of agency, changes, and rights issues)?
Implement more structured environment.
Give them onsite responsibility so they will learn to appreciate their place of residency.
Re-enforce the zero tolerance letting them see that just because they have a strike system
doesnt me they can continue to get strikes until they cant anymore.
Make it mandatory that all client have a savings fund so when it is time for their discharge
they will having funds for housing necessities.
Research other NA locations introduce them to a different scene so they dont get
complacent with the local one. Many times they become to friendly at the meetings and
develop unhealthy relationship and are not going for recovery.
I think some of these changes may boost the moral and ethical decisions of the clients.
Because some are still having trouble dealing with their old behaviors.
Competencies Used

Competency 3. 1-2:
Competency 1. 1-4:
Competency 2. 1-3: Advance Human Rights Competency 5. 1-3:
Demonstrate Ethical
Engage Diversity and and Social , Economic, Engage in Policy
and Professional
Difference in Practice and Environmental Practice

Competency 6. 1-2: Competency 7. 1-3: Competency 8. 1-5 Competency 9. 1-4:

Engage with Assess individuals, Intervene with Evaluate Practice with
Individual's, Families, Families, Groups, Individual, Families, Individual, Families,
Group, Organizations Organizations and Groups, Organizations Groups, Organizations
and Communities Communities and Communities and Communities