Assessment case study


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Assessment case study

  1. 1. Kimberly Matthews 11/14/11 Assessment 621
  2. 2. Client Description 23 year old, white female Court ordered to Treatment by 1st District Drug Court Completed the ninth grade Self-reports as victim of complex trauma Self-reports prior diagnosis of PTSD in 2008 Completed detox at Behavioral Health in Tupelo Recent arrest for prostitution and possession of a controlled substance
  3. 3. Purpose of Assessment Intake/Assessment:  Biopsychosocial conducted by assessment therapist  Used by primary counselor for:  Case-conceptualization  Treatment planning  Identifying potential strengths, stressors , and overall level of functioning  SASSI–3:  Assesses probability of client having Substance Dependence Disorder  Provides useful clinical information in regard to potential underlying issues and client-specific Tx planning.  Burns Anxiety Inventory:  Track client’s level of anxiety throughout therapeutic process  Provide client with insight into stressors  Monitor effectiveness of anxiety reduction techniques
  4. 4. Assessment Procedures and Protocol Intake/Assessment  Establish rapport while conducting a structured interview SASSI-3  Brief, objectively scored  Decisions rules for identification  Face Valid Scores FVA and FVOD can assess specific time period either entire life, past six months, or a period the clinician determines. FVA and FVOD clients rank statements from 0-3 for accuracy.  Remaining 8 scales determined from 62 true/false questions  RAP score of 2 or more suggest results might not be meaningful Burn’s Anxiety Inventory  Self-administered or clinician administered checklist  Three categories: anxious feelings, anxious thoughts, physical symptoms  Ranks 0-3 “not at all” – “a lot”  Total score represents anxiety on a continuum from mild to extreme.
  5. 5. Medical/Developmental History Client reported:  No significant medical issues  Potential learning disability  Repeated sexual abuse from age 5 until 13  Multiple sexual assaults related to drug use in teenage years  Social isolation due to peer shaming during school  Began using alcohol age 9, marijuana age 11, methamphetamine age 14
  6. 6. Family Psychiatric History Client Reported: Mother suffers from depression and a long history of alcohol consumption. Father is absent from life, but mother reports that he is a drug addict. History of addiction on both sides of family.
  7. 7. School/Academic History or Work history Client Reported: Completed ninth grade Difficulty in reading comprehension and writing Limited work history, reports working in fast food for short periods Prostitution was her means to support her drug usage
  8. 8. Home Behavioral/Social Client Reported: Basically homeless, sleeps in various locations usually “crack houses” Virtually no support system, because “mother is still drinking” Only friends are gang members Only child DHS put foster care in 2009
  9. 9. Assessments used and appropriate interpretations Intake/Assessment:  Presenting problem  Diagnosis  Medical, psychological, family, social, occupational, educational, substance abuse, and personal history  Interpretation potentially biased by clinician’s worldview and accuracy of client disclosure SASSI-3:  “Test-retest stability coefficients ranged from .92 to 1.00, accuracy of the SASSI-3 was not significantly affected by gender, racial or ethnic group membership, occupational status, marital status, age, and educational level, the levels of accuracy for males and females were 96% and 97% respectively.” (Lazowski, Miller, Boye, and Miller, 1998).  Identifying probability of substance dependence  Identifying potential treatment barriers  Treatment planning  Clinical hypotheses Burn’s Anxiety Inventory:  Determines level of current anxiety as: minimal/none, borderline, mild, moderate, severe, or extreme/panic  Differentiates feelings, thoughts, and symptoms of anxiety  Monitor anxiety levels, gain insight into stressors, and track effectiveness of reduction strategies.  “The scores of 498 outpatients seeking treatment for mood disorders suggested excellent reliability and internal consistency with an alpha score of .94. The BAI scores correlated highly with the anxiety subscale of the Hopkins Symptom Checklist” (Marcus & Dubi, p. 224, 2011)  Common and assessable instrument
  10. 10. Summary of Findings Intake/Assessment:  Substance Dependence resulting in legal consequences  No reported medical issues  Family history of substance abuse and depression  Survivor of chronic childhood trauma (sexual, emotional, and physical); traumatic occurrences continued into adulthood  Reported prior PTSD diagnosis  Deficient educational experience  Only child is in DHS custody  Lacks sufficient support and has limited work experience
  11. 11. Summary of Findings SASSI-3:  FVA 30, FVOD 40 (High probability of having Substance Dependence Disorder)  SYM 11 (Consider client’s world and environmental norms of substance use; encourage client feedback on SYM applicable items, mutually working toward insight about the negative effect of substance use on their life)  OAT 7 (Suggests client is willing to consider the negative effects of continued substance use)  SAT 5 (Suggest limited insight into presenting problem)  DEF 1 (Suggests low self-esteem, negative self-talk, helplessness, and shame based thinking strategies)  SAM 10  FAM (Suggests need to explore codependency/ boundaries/emotional insight and modulation)  COR 9 Burn’s Anxiety Inventory:  Scored 42 on initial scale indicating severe anxiety: Anxious Feelings 13, Anxious Thoughts 23, Physical Symptoms 6  Scored 21 prior to exiting program indicating moderate anxiety on the cusp of mild.  Mindfulness techniques of meditation, grounding, and self-affirmations proved most effective to alleviate existing anxiety and recurring episodic anxiety.  Cognitive reframing assisted in overall symptom reduction and prevention
  12. 12. DSM Diagnosis Axis I: 304.4 Amphetamine Dependence 303.9 Alcohol Dependence 304.30 Cannabis Dependence 309.81 Posttraumatic Stress Disorder, Chronic Axis II: V71.09; R/O Borderline Personality; Strong Cluster B Traits Axis III: None Axis IV: Long term Hx of Sexual, Physical, Emotional Abuse; Lacks Support System, Financial Means, Housing, Job Skills Axis V: GAF = 40 (on admission)
  13. 13. Treatment Plan and Recommendations Plan:  Holistic, strength-based, collaborative treatment approach aimed at gaining insight into the consequences of continued substance use, reframing distorted cognitions, developing healthy boundaries, building emotional modulation skills, developing safety, improving relational skills, empowering her to build a cohesive sense of self, and changing her frame of reference from victim to survivor. (Clinician will utilize relational-empowerment model, Stage 1 trauma techniques, mindfulness practices, and cognitive reframing to increase choices and control over recovery) Recommendations:  Long-term residential treatment  Individual counseling (weekly)  Women’s trauma group (2x per week)  Group therapy (daily)  Psychoeducational classes  Aftercare  12-step meetings  Continued weekly individual session after discharge
  14. 14. ReferencesAmerican Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IVTR. Washington, DC: American Psychiatric Association.Lazowski, L. E., Miller, F. G., Boye, M. W., & Miller, G. A. (1998). Efficacy of the Substance Abuse Subtle Screening Inventory-3 (SASSI-3) in Identifying Substance Dependence Disorders in Clinical Settings. Journal of Personality Assessment, 71(1), 114-128.Marcus, S. & Dubi, M. (2011). The relationship between resilience and compassion fatigue in counselors. American Counseling Association, (50 )223-225, Retrieved from,G.A.(1985,1999). The Substance Abuse Subtle Screening Inventory (SASSI) Manual, Second Edition. Springville, IN: The SASSI Institute.