Narrative of an Addict's Struggles

ASI Interview Narrative
GENERAL INFORMATION
JL is a 30-year-old white male, unmarried client. JL lives in Covington, KY, at 101 Main St. with his mother. They attend the local Catholic parish down the block most Sundays. He has lived there with his mother 3 months since his release from prison, where he served 10 months for parole violation (drug possession). He lives in the garage behind the house and does not share the main house with his mother. He has access in and out of the garage through the rear of the property. The garage is fixed up with a bathroom, kitchen, bed and TV and serves as a self-contained unit. JL was brought to Gateway by his older sister. JL is youthful in appearance though with a thin beard and semi-hollow cheeks. He appears to be adhering to standard hygiene. JL was not making a court-mandated appearance but rather arrived at the encouragement of his family and mainly his sister to get treatment.
SUBSTANCE USE
JL’s primary drugs of choice are heroin and opioids with fentanyl being used more frequently in recent months. JL last used 11/14/2018 and since his parole on 8/15/2018 he has been using consistently every week. JL is not currently employed and he uses about $100 to $200 per week using fentanyl and other opioids, and heroin on occasion. His income comes from selling drugs for a friend and also through odd jobs for his mother, who gives him a small allowance, and delivering food through DoorDash. JL has been using drugs since he was 15. He started smoking marijuana at that time and then began snorting heroin and has since moved to fentanyl.
JL consumes alcohol daily, drinking 1-2 beers per day and consuming 1-2 bottles of rum per week. JL has been drinking since he was 17. He has been arrested twice for driving under the influence of alcohol. He has been arrested thrice for drug use and possession. JL has a diagnosis of substance abuse, alcohol dependence and opioid dependence.
MEDICAL STATUS
JL has been hospitalized six times for drug use—thrice for heroin overdose, twice from fentanyl overdose, and once from alcohol-opiates car crash. His last hospitalization was two weeks ago and before that it was a month prior, one month following his release from a controlled environment (prison). JL does not have any chronic medical problems and is not taking any prescribed medication for depression or any other mental or physical health issues. He does not receive a pension for anything and has never held down a serious job for more than a few months at a time because of his drug addiction. He has a persistent cough but has not had it checked out by a medical professional and does not consider it important. JL has checked into substance abuse clinics five times in the past and each time has been court-mandated. JL last attended a 12-step program 2 years prior in May 2016 but only lasted in the program for one month.
EMPLOYMENT/SUPPORT STATUS
JL completed high school but never attended higher education. He completed high school via the technical vocation curriculum and focused on mechanics. He has worked side jobs fixing cars in the past but has never worked under a certified mechanic. His sister says that he is good with cars but JL does not express much confidence or enthusiasm in this skill and only shrugs his shoulders when it is mentioned, giving a faint smile.
JL is able to drive himself around using an old car that he fixed up and that allows him to make DoorDash deliveries. He says that he prefers this method of work because it gives him flexibility and the ability to work when he wants. If he has a hard night or long day or one of his friends needs him, he feels like he should be able to leave and go support them. His friends, however, all use drugs and he says he likes them as they are supportive and he feels he should be supportive of them as well.
His main friend is named Clarence and he is also his main drug supplier; and JL’s recent hospitalization two months ago was the result of an outing with this friend that started off as a show of support and ended up with JL passed out and unresponsive. His friend called the paramedics after leaving JL in a car and the paramedics saved his life. His friend had been upset about his wife’s death from overdose. JL went to console him and together they got high.
His family does not like Clarence and does not want JL to visit or see or talk to Clarence anymore, but JL does not have any other friends. The sister of JL’s brother-in-law is also a recovering heroin addict and has shown support for JL in recent weeks, but a counselor advised the family against supporting such a relationship because, so the counselor said (so it was related) if the two of them who are struggling with their addictions were to blow up they would be worse off than they were before; the counselor said JL needs to overcome his addiction on his own before he enters into another relationship with a woman. The counselor was not certified or trained, it was revealed, but was rather a recovering drug addict himself, 12 years sober, who worked with the county in assisting families of drug addicts in the hospitals and getting them work. He offered to get JL a full-time job that would be 30 minutes from where he lived, but JL declined saying he did not want to drive that far to work every day.
JL was engaged to a girl when he was 24 but the relationship ended after a series of fights that culminated in the girl calling the police on JL one night when JL was drunk and the fight turned into a physical altercation. The ex-fiance obtained a restraining order against JL. He had one serious relationship following that and his sister and mother both thought he would marry this girl but JL began drinking again and another round of fights put an end to that relationship as well.
The family likes Sara, the recovering heroin addict who is the sister of JL’s brother-in-law (JL’s sister’s sister-in-law), but they feel that the “counselor” is right and that JL needs to face his addiction issues on his own. Thus, JL has a support network that is somewhat unstable and unreliable. The family is protective of JL but not entirely helpful. Their impulses are also contradictory: the mother enables JL by giving him a place to stay and an allowance and wants him to grow out of his ways but at the same time prevents him from entering into a serious relationship with Sara by telling Sara it would be best if she did not come around. At the same time the family wants JL to develop a better support group but does not know how to make this happen or how to get JL new friends.
PSYCHOLOGICAL / PSYCHIATRIC HISTORY
JL has not been treated for any trauma or for any psychiatric/psychological issues. He has been arrested twice for domestic disturbances—once when his fiancé called the police and once when his mother called the police following a threat of violence from JL when she refused to return his cell phone after his first hospitalization in October 2018 after his release from prison the month before.
JL has not been diagnosed with any type of depression or bi-polar disorder, though there may be an occasion to investigate his explosive rage, which seems to have become an issue for him in recent years. JL admits that he does not handle anger well which is why he tries to avoid people and situations that will make him angry. This is why, he says, he prefers his friends who are drug addicts—because they are relaxed and put him at ease. They do not challenge him or threaten him or make him feel uneasy about himself or his life. That is why he says he likes them—that and he enjoys using drugs.
FAMILY
JL is concerned about his health he says but he says he is not sure he wants to be sober because he has never been able to handle it and every time he tries he ends up getting angry with himself and his life and falling even harder than before. He says he wishes he could just plateau and stay even-keeled, not dropping any higher or lower, and just existing on this one plain—and that would be all right with him. He says he would not mind having a family but that providing for them would be a challenge as he cannot obtain work (though when work was offered him he turned it down), so there is a trace amount of denial in what he says with regard to his own situation. The truth appears to be that he cannot find the type of work that he would like to find.
JL says he would be interested in anger management counseling and that he has never had it before. He says he is angry about a lot of things but mostly that he is such a disappointment to his family and also that they don’t want to give him his space. He says he loves his sister and mom but they are very pushy at times and want him to become holy for some reason as though that could even happen or were something that he wanted to do. He feels that so long as he goes to church on Sunday with his mom, they give him some space, but as soon as he messes up again they are right back to wanting him to devote the rest of his life to God because that is the only way he will ever get better, and that really makes him angry because he is not sure he wants to get “better” as they call it as it does not look like getting better to him but just doing what they want. He says he watched his mom and dad fight so much growing up that now he kind of resents them both and says he never sees his dad since his mom moved out of the house and his dad is kind of mean anyway. JL also has one brother who is distant because he is upset that JL has had so many relapses and keeps doing this to the family. JL doesn’t know what to say to that other than to shrug. He says it hurts him that his brother is distant that way but he is not going to let it keep him down. “What can I do about it?” he asks shrugging and looking irritated.
EDUCATION / VOCATION
JL obtained his high school diploma through vocational school and is skilled in mechanical work with cars but does not have any plans to pursue this work as his record prevents him from obtaining a good job, he says. He is not thrilled about the idea of more school and says it would not be worth it anyway. He says he would like to farm on land that the family owns further south but has no definite plans for this and has not shown any inclination to follow up on this idea. At present, he appears satisfied in continuing on where he is, selling drugs on the side and doing side jobs for family, friends and neighbors. He says he would like to settle down and have a family but that he is not actively looking for that and will just take one day at a time.
LEGAL STATUS
JL is on probation and has in fact violated his probation but the state is not interested in pursuing the case as the prisons are already full as they are and the state does not intend to spend any more time or money on incarcerating JL. His parole officer has told him that the violation will be overlooked so long as JL gets a job and gets himself into treatment. That was one month ago and so far JL has not done either but he is presented himself for treatment now—though his resolve does not appear to be very solid or of his own volition. Still, he says he is not opposed to treatment but that there are other things that he needs to take care of first before he feels he can quit using drugs. He feels he has to address some of his other issues—his anger and his lack of initiative—he says he wants to address these and see how they go before he commits to making a decision about getting sober.
SOCIAL RELATIONSHIPS
JL has been in a controlled environment (prison) for 3 out of the last 5 years and he does not want to return. He gives conflicting indications about his satisfaction regarding his current living arrangements. At the same time he says he does not like living with his mother, he gives the impression that he is not eager or in any rush to improve his conditions. He says his friend Clarence wants him to move in now that his wife is dead, but JL’s family is against this idea and will not allow it. JL gives the impression of making decisions based on what his mother and sister say to do and that there is not a lot of will being demonstrated on JL’s part other than in the desire to escape through drugs and alcohol.
TREATMENT RECOMMENDATIONS
JL is looking for a way to control his anger and obtain motivation to improve himself and his position in life. He is not ready for counseling for his drug problem but is correct in saying that there are underlying issues that need to be resolved before he can begin to address his dependency issues. For that reason, JL would benefit from anger management counseling and from cognitive behavioral therapy to help him identify goals and find ways to pursue them especially when he feels tempted to take the easy way out and use drugs to escape the burdens of life.
The Addiction Severity Index (ASI) is a useful tool in assessing JL as it allows for assessment to take place through the structured interview process, which gives the care provider the ability to collect information pertaining to seven different areas: (1) medical conditions, (2) employment/support, (3) use of alcohol and drugs, (4) legal issues, (5) family history, (6) family/social relationships, and (7) psychiatric disorders (Samet, Waxman, Hatzenbuehler, & Hasin, 2007). Moreover, there are 12 steps to the assessment process according to Saks and Ries (2005) and these include:
· Assessment Step 1: Engage the Client—the rationale being to obtain information directly from the source.
· Assessment Step 2: Identify and Contact Collaterals (Family, Friends, Other Providers) To Gather Additional Information—so as to obtain information from secondary sources.
· Assessment Step 3: Screen for and Detect Co-Occurring Disorders—so as to understand the full scope of the patient’s problems.
· Assessment Step 4: Determine Quadrant and Locus of Responsibility—so as to understand the best approach to treatment.
· Assessment Step 5: Determine Level of Care—so as to design adequate and effective intervention.
· Assessment Step 6: Determine Diagnosis—so as to be able to treat effectively.
· Assessment Step 7: Determine Disability and Functional Impairment—so as to understand obstacles beyond the patient’s current level of control.
· Assessment Step 8: Identify Strengths and Supports—so as to ensure that intervention will be efficacious.
· Assessment Step 9: Identify Cultural and Linguistic Needs and Supports—so as to ensure that treatment is holistic.
· Assessment Step 10: Identify Problem Domains—so as to understand potential threats to successful intervention.
· Assessment Step 11: Determine Stage of Change—so as to plan treatment appropriately.
· Assessment Step 12: Plan Treatment—so as to implement the intervention strategically.
Having assessed JL, it is evident that the young man suffers from an inability to control his impulses and from a lack of incentive and goal-oriented motivation. He is indifferent to his present situation and knows only that he wants to make his family happy, though he wishes at times they would also just be content with who he is and how he lives. He is not ready to quit using but realizes that by getting treatment for his anger and lack of motivation he could begin to get to a point where he wants to stop using and he is willing to try this course of action. He is dependent on opioids and particularly fentanyl now, and according to Gorelick and Baumann (2016), chronic drug use “is associated with cognitive impairment that may persist for at least several months of abstinence. Most affected are visuomotor performance, attention, inhibitory control, and verbal memory. Several studies have found abnormalities of behavioral regulation and risk–reward decision making. This type of impairment is associated with lesions of the frontal cortex, a brain area that shows decreased regional blood flow and metabolic activity in abstinent cocaine abusers” (p. 230). JL’s drug addiction may have impaired his mental and physical condition, leaving him feeling unable to do much at this point in his life. However, it could be that he is also mired in self-pity and delusion and that he simply is not willing to engage in personal development yet. This will have to be determined over the course of counseling, and it is recommended that JL engage in both anger management counseling and in cognitive behavioral therapy.
According to DSM-5, JL may be diagnosed with polysubstance abuse, as “among opioid addicts, cocaine and alcohol are the most frequently abused substances,” which is exactly JL’s case (Signs and Symptoms of Polysubstance Abuse, 2015). The criteria for this diagnosis include strong desire to use, continued use, long history of use, inability to quit usage, taking large quantities of the substance, and becoming impaired by the substance. The tools to assess the substances used include urine testing and various assessment techniques. JL does appear to suffer from polysubstance abuse and looks to have substance dependence.
JL may have suffered from some early childhood trauma related to his parents’ altercations (Ekinci, Kandemir, 2015). It is evident that his parents are not on speaking terms and that he is not on speaking terms with his father. He did not go into specifics but showed that he feels disturbed by what he witnessed growing up that he does not have much inclination to want to renew a relationship with his father. JL could be suppressing some trauma and seeking escape from this trauma through drugs and alcohol. Trauma therapy may also be recommended.
JL may also benefit from family therapy, as his family plays such a strong role in his life. His mother and sister seem constantly to making decisions for JL and he may let them considering that he is used to this kind of treatment as he has been in a confined space for much of the past few years. He is not completely under their control, however, and that may irritate them just as much as his perception of their desire for control irritates him. The family overall could benefit from family therapy so that they can all get things off their chests and receive guidance from a trained professional rather than from a recovering drug addict who has not certification and no professional license and should not even be employed by the county to offer advice.
JL should be enrolled in group therapy so that he can be provided with a support system, since the family and friends he has are unreliable. However, JL is not currently interested in doing a group therapy for his drug addiction and first wants to address some of his mental issues as he feels these are the obstacle to his success. JL could possibly also benefit from a pharmacological treatment, with naltrexone or methadone as possible interventions to help deal with his withdrawal. Cognitive behavioral therapy (CBT) should be prescribed to address his behavioral patterns and the negative impulses that steer him towards substance use. Recognizing these impulses and implementing a plan of behavior to overcome them would benefit JL immensely. JL’s most basic needs according to Maslow’s (1943) hierarchy of needs have never been met, so these must also be met initially before implementing any further intervention.
The main techniques of the treatment options for a case like JL’s are to stabilize the patient through a detox program if possible; but in JL’s case this is not likely to be acceptable as he has shown he is not interested in being treated right now for substance abuse but rather for some of the underlying issues that are impacting his behavior and cognitive processes. For that reason, cognitive behavioral therapy could be used to get JL to a place where he can begin to make a better decision about his state of health and going forward with his life. Trauma-focused therapy is one technique that could also be used for patients who are substance-dependent as a result of childhood trauma (Giordano et al., 2016) and this may be of some benefit to JL as it is possible that he is still coping with a childhood trauma that is unspecified.
JL’s risk factors include lacking an adequate support system other than a mother and sister who are overbearing at times and often disapproving of his decisions, which just makes him want to escape more. For this reason, family therapy may be of use and group therapy could also be helpful for JL who likes being there for others but also is not sure of being ready to be sober.
Relapse prevention would ideally be structured by having JL’s treatment occur in a highly-controlled environment, with post-intervention follow-ups conducted in the environment into which he is released, post-incarceration. He would need support from his family and a more positive environment. However, relapse prevention should not be the primary focus of treatment at this time. Instead, the counselor should work with JL to address those areas that JL is willing to address—namely, mental health and goal-setting to help increase motivation and start pursuing an appropriate state in life that does not require him to maintain his drug dependency.

References
Ekinci, S., Kandemir, H. (2015). Childhood trauma in the lives of substance dependent
patients: The relationship between depression, anxiety and self-esteem. Nord Journal Psychiatry, 69(4): 249-253.
Giordano, A., Prosek, E., Stamman, J. et al. (2016). Addressing Trauma in Substance
Abuse Treatment. Journal of Alcohol and Drug Addiction, 60(2): 55-71.
Gorelick, D. & Baumann, M. (2016). The pharmacology of cocaine. Retrieved from
https://basicmedicalkey.com/the-pharmacology-of-cocaine-amphetamines-and-other-stimulants/#head8
Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50(4), 370.
Signs and Symptoms of Polysubstance Abuse. (2015). Buppractice. Retrieved from
https://www.buppractice.com/node/12376