Patricia_DoughertyGahm_Unit 3_Assignment 1_Biopsychosocial Assessment

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Oct 30, 2023

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Substance Use Assessment Client Demographic Data: Name: Alex Gonzales Age: 35 Gender: Male Social-Cultural Information (race, ethnicity, religion, sexual orientation, etc.): Latino, Heterosexual – uses He/Him pronouns. Current Employment: Construction Educational Background: Alex reports little education; second or third-grade level education. The client indicated working with his father at the age of 9. Military Background: Alex reports no military service.

Presenting Problem Developmental crises: Alex reports receiving 2 DUI - Driving Under the Influence charges as well as a Possession of marijuana charge in the past several months. Disabilities: Alex does not report any disabilities. Previous Mental Health Issues/Treatment: Alex reports no previous mental health treatment but does report having panic attacks if he does not drink and smoke marijuana. He also reports using alcohol and marijuana to deal with stress in the home. Situational and environmental factors impacting the problem. Alex reports he was recently separated from his wife because of an affair. He reports experiencing a lot of stress when he is at home and alleviates the stress by drinking and smoking. He stated that he "never got to be a kid," because he was raised in a family where he had to work rather than go to school. He was 9 years old when he would drink a "few beers" during the workday with his father. He reported that his mom died by suicide when he was 15 years old. He stated his father was an abusive man and frequently abused his mother. Family History Who was in the family of origin? Alex reports his family was his mother, father, and himself. His mother has passed.

Describe family environment in childhood/adolescence: Alex stated "never got to be a kid," because he was raised in a family where he had to work rather than go to school, he was 9 years old and he would drink a "few beers" during the workday with his father, mom died by suicide when he was 15 years old, he stated his father was an abusive man and frequently abused his mother. Alex reports his father has a history of alcohol and cocaine abuse and his mother had significant untreated mental health issues. Special circumstances or events in childhood/adolescence: Alex reports the death of his mother when he was 15. He also reports that his father was abusive to himself and his mother. He reports not going to school for very long and started working with his father at the age of 9. He reports starting to use alcohol at the age of 9 “few beers during the workday with his father”. Immediate Family Marital/partnership status: Alex reports he is married but currently separated from his wife due to infidelity on his part. Intimate relationships: He reports an affair with a woman as well as wanting to fix the relationship with his wife. Relevant relationship history: He does not report any other significant relationship.

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Children (ages and where they are currently living, issues/concerns): Alex reports he and his wife have two children ages 5 & 6 and they currently live with their mother at this time. He wants to repair his relationship with his wife so he can be there for his children. Current Living Situation and Environment Housing: Alex reports he is currently living with a friend while he and his wife work out their problems. Who is living in the current household? Alex reports he is currently living with a friend while he and his wife work out their problems. Social Connections: Alex reports that he has several friends and co-workers whom he socializes with. Financial Situation: Ales reports currently working part-time for a construction company. He also reports that there is a possibility of a full-time position, but he is reluctant to take the job. Other Circumstances: legal, transportation, etc. Alex reports dealing with two DUIs and a possession charge at this time.

Substance Abuse History Include substance, pattern of use, and frequency of use in the past month: Alex reports that he started drinking at 9 years old while working with his father, and drinking became more frequent as he became older. He reports using alcohol and marijuana on a daily basis to deal with stress. Client Strengths List strengths and describe how they will assist the client in the treatment process: Alex reports he is willing to stop using alcohol and marijuana to save his marriage. He reports wanting to be there for his wife and children. ASAM Dimensions Acute Intoxication and/ withdrawal potential: Due to the level of daily alcohol consumption, he has the potential to experience severe withdrawal symptoms. He demonstrates a poor ability to tolerate and cope with withdrawal discomfort. There are severe signs and symptoms of intoxication indicating possible imminent danger to self & others. Biomedical Conditions: Alex does not present with any biomedical conditions at this time. He demonstrates an adequate ability to tolerate and cope with physical discomfort. Mild to moderate signs or symptoms interfere with daily functioning but would likely not interfere with recovery treatment nor create a risk at this time.

Emotional, Behavioral, or Cognitive conditions: He indicated that he has panic attacks when he is unable to use substances to deal with stress. He will need to complete a psychiatric evaluation. Acute symptoms dominate clinical presentation and significantly compromise community adjustment and follow-through with treatment recommendations. Readiness to change: Alex has shown a willingness to change to save his marriage. However, he is not confident that he can stop his substance use. He is reluctant to agree to treatment for substance use or mental health problems but willing to be compliant to avoid negative consequences. He may be legally required to engage in treatment. Relapse, continued use, or continued problem potential: Alex reports using substances to relieve stress and does not possess positive coping skills to help him handle stress. Has poor skills to cope with and interrupt addiction problems, or to avoid or limit relapse or continued use. Frequent use of alcohol 3 or more times a week. Frequent use of drugs more than 3 times a week. Recovery/Living Environment: Alex’s current living situation is not ideal for recovery. He is currently living with a friend and had access to substances. He wants to move back in with his wife to repair their relationship. He wants to be there for his children but needs to gain insight into his use as well as gain positive coping skills to deal with the stress of home life. DSM 5 Diagnosis Indicate the DSM 5 diagnosis including specific criteria the client meets: F10.20 - Alcohol Use Disorder - Severe: Presence of 6 or more symptoms.

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F12.20 - Cannabis Use Disorder - Moderate: Presence of 4–5 symptoms. Panic Attacks (self-reported) Notes: Alex was interviewed in person. He presented with substance abuse disorder for alcohol and marijuana, He reports drinking and smoking daily. Recent DUIs and a possession charge are what brought him into our office. Treatment is being presented to the client as a diversion from jail for these charges. It is recommended that Alex attend an inpatient treatment facility that can address his mental health concerns as well. He will need to complete a psychiatric evaluation as well as a consultation for possible medication as the psychiatrist sees fit. He will need to attend group and individual therapy while inpatient. Family therapy sessions are also recommended so his wife and he can work on their relationship as well as strengthen his recovery once back in the home environment. Upon completion of inpatient treatment, the possibility of a recovery house stay should be considered to strengthen his coping skills and ability to handle stress in a sober environment. Also, he should continue with Individual and Family therapy as part of an aftercare program while in the community. A connection with a self- help program and a sponsor should also be encouraged.

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