Multidimensional Assessment: Case Study on Drug and Mental Health Issues

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Multidimensional Assessment: Case Study On Drug And Mental Health Issues

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Table of Contents

  • Reason for Referral and Presenting Problem
  • Physical Functioning
  • Cognitive Perceptual Functioning
  • Emotional Functioning
  • Social and Family Functioning
  • Behavioral Functioning
  • Motivation
  • Spiritual/Religious Affiliation
  • Environmental Systems
  • Barriers to Service
  • Worker’s Impressions of the Client

Reason for Referral and Presenting Problem

Nic Sheff, age 23, came to the Safe Passage Center for treatment to address drug and mental health issues. Client was encouraged to attend treatment by his parents. Client discloses that he has used a variety of drugs since being a teenager and has been in multiple treatment programs in the past. Client states that he recently experienced hallucinations from using multiple drugs and was told by his parents that he must either attend treatment or go to jail. Client reports that even though he has sought treatment for his addiction in the past, the treatment was ineffective. Client states that because he has been in treatment before he knows he suffers from mania, depression, and anxiety. Client states also that he does not believe he is “deserving” of treatment or sobriety. Client states that he acknowledges the hurt he has put his family and friends through and does not care for himself. Currently, no suicidal ideations have been made.

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Physical Functioning

Client disclosed that he has been using multiple drugs since high school. Client stated that he started off using alcohol and then moved to marijuana and occasionally mushrooms with friends. Since his recent relapse, client reports using crack cocaine, cocaine, methamphetamines, pills (Xanax, Klonopin, and Carisoprodol), heroin and smokes cigarettes. Client informs that he is a constant user and uses some form of drugs every day. Client reports that he was doing well with his sobriety until he was introduced to Suboxone by his girlfriend Zelda. Client states that he has been hospitalized because of his drug addiction a few years ago while in New York. Clients expressed that other than his addiction to drugs he believes himself to be in good physical condition. Client states that he enjoys bicycling and surfing regularly. Client also disclosed that he has had seizures in the past, however the episodes only occur when he has been using.

Cognitive Perceptual Functioning

Client indicates that his recent stable employment was working at a hair salon as a receptionist which his friend Spencer’s wife encouraged him to be hired on at. However, he was fired from said job and does not know why he was fired. He speculates he was related to his drug use. Client stated what he enjoys writing and has written for magazines in the recent past. Client states that he enjoyed working at the salon and made friends while working there. Client states he liked the responsibilities he had while working. Client appears to be very self-critical and speaks poorly of himself. Client speaks often of the past and expresses that he understands the amount of disappointment his friends and family have in him because of his drug use. Often, when referring to his past, if it is about something positive, he will downplay his accomplishment and then refer to his drug use. Client appears to be regretful and embarrassed of his past. He often expresses that he is disappointed in who he became while using drugs and never thought he would be someone to steal from his siblings or parents.

Emotional Functioning

Client displays a lack of confidence in his sobriety and ability to stay sober even though it is something he wants. Client does not speak well of himself and believes this treatment program will be like the rest and will not make a difference for him. Client is uncomfortable with who he is and does not have the confidence in himself to be able to stay sober if he is alone. He states that he is worried that being in treatment will only give his family hope for him and he is afraid that they will be disappointed when he does not stay sober. Client admits that he is a people pleaser and has always be a nice person to anyone which has been taken advantage of in the past. Client explains that the only his girlfriend truly understands him and knows who he is. Client also claims she is his only support.

Social and Family Functioning

Client grew up in California and his parents divorced when he was young and have both since remarried. Client has a relationship with both parents and states that he communicates better with them when he is sober. Client has two half siblings and cares greatly for them. Client’s relationship with his mother, as he describes, is okay however, he does not get along with his step-father, however he admires his step-mother. Client explains his relationship with his father has never been a traditional father/son relationship. Client states he was forced to grow up and exposed to adult behaviors before he should have been. Client states that he has a sponsor, Voltaire, who is his second sponsor. Spencer was his first sponsor. Client discloses that his relationship with Voltaire is much different than his relationship with Spencer. Client says that with Voltaire, he is unable to discuss his personal life and only discusses his sobriety with him. Whereas with Spencer, he was able to talk about all aspects of his life and was more involved personally with Spencer’s life. He states that his girlfriend is also a drug user and is currently in a rehabilitation facility and is working on her own sobriety. Client expresses that he knows, even though he communicates with his parents, there is not much trust left in their relationship. Client states that he knows that his parents worry about him stealing from them and lying to them because of his addiction. Client states that he will attempt to repair the relationship with both his mother and his father. Client explains that he understands if his family is reluctant to believe in him in regards to his treatment because he has “given them hope” in the past and disappointed them more than once.

Behavioral Functioning

Client expresses that he has concern for his ability to cope with life stressors and the decisions he makes based on those stressors. Client reports his coping mechanisms has more or less always been to turn to drugs as an escape and for avoidance. Client explains he feels as though he is just surviving but not really living. Client believes that when he is high his problems disappear and does not worry about pleasing others as much while being high. Client expresses that he knew of his father using marijuana and felt that it was accepted because so many people (adults) he knew used it as well. Client discloses that since the beginning of his drug use he has always been “chasing my first high”. Client states that he has been arrested one time. When he was arrested his younger siblings witnessed it and felt the need to protect him from the police. Client states that he also has had other run-ins with the police but has only had the one arrest. Client reports previously prostituting in order to obtain money for drugs. Client acknowledges there is a possibility that his reasoning for prostitution was not just for money, but also to feel accepted.


Client was instructed by his parents to attend treatment or go to jail. Client seems to have some encouragement to be in treatment because he was his “life back” and wants to be sober however, he doubts his ability to do so. Client acts reluctant when attempting to be more open about his past however, he admits to being willing to try to make the program work for him.

Spiritual/Religious Affiliation

Client explains that he is not a religious or spiritual individual. Client claims with his previous sponsor he was encouraged to pray and look for a higher power, even if he did not believe in the conventional “God”. Client claims that praying has help him achieve relief with anger, anxiety and his inner thoughts. Client also states that since being with his new sponsor he has been focused on the spiritual aspects of his life.

Environmental Systems

Before treatment, client was living with his girlfriend Zelda in a one-bedroom apartment. Client does not have a vehicle, he was previously using his bicycle as a means of transportation. Client states that because he is not currently employed, he and Zelda have been working to sell some of her possessions so that they are able money. Client’s apartment is in Hollywood and he has public transportation and medical facilities easily accessible to him. Client states that where he lives is a nice area surrounded by individuals with higher income levels. Client has attempted to go to college, however he has dropped out of college twice due to his drug use. Client enjoys writing and hopes to be an author someday. Client states that his girlfriend is a habitual drug user and that she is currently attending treatment of her own back in California. Client expresses that he “cannot live without” his girlfriend and they have an amazing relationship. Client believes that his friends and family do not understand their relationship Client’s parents disagree stating that their relationship is toxic/unhealthy and she will pose a threat to his sobriety. Client states that he still plans to marry and live with Zelda after they both complete their treatment programs. Cultural Factors Client is a white/Caucasian male. Client states his parents were well known in their community. Client grew up in an upper middle-class family and lived in nice neighborhoods that he considered safe. Client and his family did not regularly attend church. Client graduated high school and was a 4.0 student with no other issues than his drug/alcohol abuse. Strengths Client understands that his drug use has heavy affected all of his relationships. Client has the ability to hold and maintain jobs when not using. Client seems to be able to better explain himself while writing. Client understands that going through treatment will require him to work hard and may take a lot of time. Client also states that he is outgoing in some situations and has many acquaintances.

Barriers to Service

Currently the client is expressing that he is not going to terminate his relationship with his girlfriend, Zelda. Client believes this treatment will be like his previous treatments and render not effected to help him achieve long term sobriety. Client also states that his relationship with family members is damaged and does not believe they will be able to support him through his treatment process.

Worker’s Impressions of the Client

The client is currently displaying cooperativeness with the treatment program and seems open to receiving treatment. Client appears to have built up emotions and anger with both his past and present. Client also displays a great reluctance when discussing breaking up with his girlfriend. Client is worried about his ability to speak to his family or his former sponsor about his emotions and articulating his thoughts/feelings to them. Clients’ treatment plan consists of him attending individual therapy (for forty-five minutes) as well as group therapy, in order for him to address the issues that hinder his chances of sobriety. SW will meet with the client weekly to check in with him and reassess as necessary.

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