Counselor's Recovery Case Study

Counselor met with Pt for a schedule individual session to process her recovery progress, feelings and discuss current recovery problems. Also, Counselor introduced himself for the first time in order to develop a therapeutic alliance. Pt. learned recently that she was assigned to a new caseload and she decided to schedule a session. Pt. verbalized her previous relationship interacts with her last AMS counselor and what she was working on during the last session. Pt. extensively talk about her problems and worries with her niece and step son. Pt. indicated that her niece is 15 years old who engages in inappropriate conversations on social media and sick negative attention and her step son is 22 years old who refused to work. Counselor encouraged Pt. to change her beliefs and improve the communication with them in order to focus on her recovery. Pt. reported that she is anxious person and can get angry easily. Pt. informed this writer that she was diagnosed with ADHD and received mental health services in the past. Pt mentioned being married and having a good relationship with her husband. Pt. indicated that he helps her financially and support her emotionally. Pt. reported that she currently working taking care of her 83 year old father and reselling different products online. Pt. explained that her family experienced major problems for the past 3 years because her sister got murdered in 2003 in California.
Counselor encouraged Pt. to talk about how she spends her free time and what she wants to work on. Pt. shared that she wants to start a blog about bulldogs and creating t-shirt and selling them to support different animal shelters. Pt. pointed out that these are her resolutions for the next years. Pt. stated that she likes to go shopping, eating out and cooking during her free time. At the end of the session, Pt. was also able to discuss the concept of spirituality and family oriented personality in her life as tools that help her remain strong in the recovery process. Pt. shared that she was not strong enough to stop on her own without help. Pt. mentioned that she refused to listen to people in recovery who knew how to stay clean, because she kept trying it her way. Pt. stated that she now understands that she must attend recovery meetings, individual sessions, maintain good relationship with family members, attend church services, and build a sober and a supportive network of people. Pt. wants to recover from the disease of addiction, therefore; she is willing to do whatever it takes to maintain her current sobriety and take home privileges. A; Pt was very respectful, cooperative and excited about her new goals for the New Year. Patient’s participation rated was “good” in each of the following areas: internal work therapy, interaction with staff, social skills and therapeutic knowledge. Pt. identified ways to improve her recovery and address her current personal problems with the assistance AMS program staff.

Pt.
was able to grasp the insight as to why addiction is problematic, that it is only symptomatic of other issues; that addiction is an external manifestation of inner dysfunction. Pt. seems to separate the fantasy of drugs being the solution from the reality that D&A only compound the problems. Pt. seems to progress appropriately in AMS of DE TX program. Pt. seems to demonstrate how well she can communicate and deal with her family issues and anger when she ask for help or discuss her personal problems in the appropriate settings, such as therapy
sessions.

AMS Nurse will help Pt. to go up in her current prescribed methadone dose. Counselor will help Pt review her current lifestyle habits and assist her in identifying areas in which he needs to change. Primary Counselor will encourage Pt. to identify things about her life that she can change and that would help strengthen her recovery during the next individual session.