hse 350 final project part 1
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Dec 6, 2023
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HSE 350
Final Project Part 1
Southern New Hampshire University
Kimberly Ranftl
The 12 Core Functions
Throughout this course, I created several clinical documents based on the information provided to me. The case study provided is based on an intake interview with client Joe Smith. The information provided was thorough and complete enough for me to complete an assessment and come to an educated diagnosis. I was limited to the information provided and was unable to obtain further information if necessary. The core functions that I used in this case were assessment, treatment planning, case management, referral, reports and record keeping.
The information that was provided to be in the case file was, as I said before, thorough and complete enough for me to complete the required documents, however, there were some areas where I would have liked to have more information. One area I believe was missed was past relationships. The client goes into some detail of his belief that he could be bisexual and that
some of his friends believe him to be gay, but he does not go into detail. Has he ever had a long-
term relationship? Has he had relationships with members of the same sex, opposite sex, or both.
It is important to get to know your client on every level, especially in relationships. The client stated that his main reason for getting treatment is so that he can find love and have children. This is an area that I believe we should concentrate on. Our interpersonal relationships can have a direct role in our sobriety and should be explored further.
The 12 core functions are an excellent tool for an addiction counselor. If these are utilized
in the way they are intended, and used correctly, anyone who picks up a file will have the information they need to help treat the client. It is important that everyone in the agency is on the
same page and documents correctly and thoroughly. Client files can be requested by insurance companies, the court system, and other agencies and must be clear and precise and easily
understandable. Using the 12 core functions will help make that happen. Remember that client records are legal documents too. Nothing should be scratched out or scribbled out. Any error should have a line drawn through it, initialed and the correct information following the error. I have experience in a clinical setting, working with pregnant patients. The setting is different, but the rules are the same. I sat with patients and completed intake interviews of both the patients and their significant others. They shared sensitive information with me, and they had to trust in me that I would keep that information safe and share it only with the doctors and nurses who would be treating them. This is very much the same as what I will be doing in the addiction space. The difference is that they are in a very vulnerable situation, dealing with the disease of addiction and not waiting to give birth. I have no doubt that my past experiences will help me as I move into this new space of addiction counseling. I like having the 12 core functions to guide me in my journey. If I use the functions in my
practice, anyone the client files go to will understand them and be able to extract appropriate information because they are the universal tool in addiction counseling. They will be extremely helpful going forward.
Gathering Client Information:
Using the case study as a reference, I completed the biopsychosocial assessment. I was able to extract information needed to complete the assessment and come to a diagnosis. The client shared relevant information about his lifestyle, drug usage, living situation, and more that allowed me to make an educated decision. It also allowed me to complete the SMART goals worksheet which led to a treatment plan. I found the biopsychosocial assessment approach more
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than adequate in terms of having the information needed to make a diagnosis. I did not find any limitations that I can think of. The biopsychosocial assessment is much more detailed than the ASI. The ASI requires the clinician to score a client on their answers which leads to a treatment plan. The biopsychosocial assessment is much more thorough and gives anyone who reads it much more information than the ASI.
In the diagnostic interpretation I ranked the clients three most significant problems as
1. I.V. Heroin Use, 2. Homelessness and 3. Unemployment. I chose these three problems as the most significant based on the client case file. I read the case file several times and it appeared to me that these were the most important of his issues. He obviously has a drug problem that needs to be addressed but with him not having a permanent place to live or a steady income, he is less likely to maintain sobriety and will return to using if these issues are not addressed.
Using the DSM-5
Opioid use disorder is described as a disorder that involves long-term self-administration of opioids for nonmedical purposes. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision
(DSM-
5-TR) considers opioid use disorder to be present if the pattern of use causes clinically significant impairment or distress as manifested by the presence of ≥ 2 of the following over a 12-month period:
Taking opioids in larger amounts or for a longer time than intended
Persistently desiring or unsuccessfully attempting to decrease opioid use
Spending a great deal of time obtaining, using, or recovering from opioids
Craving opioids
Failing repeatedly to meet obligations at work, home, or school because of opioids
Continuing to use opioids despite having recurrent social or interpersonal problems because of opioids
Giving up important social, work, or recreational activities because of opioids
Using opioids in physically hazardous situations
Continuing to use opioids despite having a physical or mental disorder caused or worsened by opioids
Having tolerance to opioids (not a criterion when use is medically appropriate)
Having opioid withdrawal
symptoms or taking opioids because of withdrawal
Based on the information from the DSM-5, and information given to us by the client, I concluded our client suffered from Severe Opioid use disorder. The client gave several statements in his intake interview alluding to the severity of his addiction. He had used several different drugs before becoming severely addicted to herion. He has used some sort of opioid since he was 19 years old. That is 11 years of addiction to opioids. He has tried and failed to stop using opioids. Below are examples taken from the biopsychosocial
assessment and quotes from Joe himself from the intake interview.
Joe is a 30-year-old unemployed, homeless I.V. heroin user. He began using heroin at the age of 21. He currently uses 8-10 bags of heroin per day I.V. He sells drugs to support his
habit.
Joe states, “My life is unmanageable. I need to get myself together so I can have a normal
life.” “I just want to find love, be loved, and give love,” Joe states. “I know I’ve screwed
up my life. Drugs are my weakness, I can be lazy, and I’m hard on myself. But, I know there’s a good person inside of me. I can be great with people, resourceful, and loving. I just need a chance at sobriety.”
Joe is on probation for bouncing a check, and as part of his probation he is to complete drug treatment. He states that “That’s not the only reason I’m here though. I think there’s a problem with living your life drugged all the time. Just not sure how to stop it. It’s like a merry-go-round that I can’t get off of.”
These statements contributed to my diagnosis of severe opioid use disorder.
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References:
Herdman, J. W. (2012). Global Criteria: The 12 Core Functions of the Substance Abuse Counselor (Sixth Edition)
.
O’Malley, G. F., & O’Malley, R. (2023, September 29). Opioid Use Disorder and Rehabilitation
. MSD Manual Professional Edition. https://www.msdmanuals.com/professional/special-subjects/illicit-drugs-and-intoxicants/opioid-
use-disorder-and-rehabilitation/?autoredirectid=20985