Psychosocial Assessment Describing Problem

Personal Status

Current Pattern of Use and Drug History

Substance Abuse and Treatment History

Medical History and Current Position

Family History and Present Relationships

Positive Support Structures

Crime and Law-breaking

Education

Employment

Inclination for Treatment

Social History

Resources and Accountabilities

Mental Status Exam Narrative

Treatment Plan

Psychotic Disorder

Post-Traumatic Stress Disorder

Drug Dependence, in sustained remission

Depression

Psychosocial Assessment

PSYCHOSOCIAL ASSESSMENT-William Burg

Describing Problem

William is a 35-year-old, black male. William Living in CUCS supportive housing, alcohol addiction/sober for 6 months and has PTSD. He also does not have rent money and needs employment to be able to pay the minimal rent required.

Personal Status

William is the middle of three brothers and sister. He has an older brother and a younger sister. William was born and raised in Kentucky. He moved to New York at the age of 21. He was thrown out of the family home after revealing his addiction to drugs. He has been taking part in promiscuous, unprotected sexual activity ever since the age of 18. William was involved with drug trafficking in Brooklyn area during the ten years he lived there. Upon moving to New York, he began frequenting going to cocaine houses in NYC. The majority of William's social circle is made up of individuals he met in these institutions. William reports that they are all methamphetamine users. William has been sexually involved with several of the women that were drug users.

Current Pattern of Use and Drug History

William first began experimenting with drugs at the age of 15. He smoked marijuana on an almost daily basis and drank alcohol every weekend and all through his teen life. At 21 he began experimenting with Ecstasy and drinking heavily. At 25 William was introduced to methamphetamine. He was originally doing it 4-7 times weekly. Five years ago he started injecting himself. Within a few months he turn out to be an everyday user. He is at present the present injecting methamphetamine 3-5 times daily.

Substance Abuse and Treatment History

William was in a recovery center in Illinois for twenty days, five years ago. He positively finished treatment and attended Narcotic Anonymous meetings for some months. He reverted after seven months. After being arrested in New York for methamphetamine possession he went into a local detox center. William effectively finished its twenty-one day Rehabilitation Program. William did not follow up with NA meetings or aftercare. After testing positive for methamphetamine at probation, William was placed into another detox facility for six days. There he faces a three-year prison term or will have to finish an Intensive Outpatient Program.

Medical History and Current Position

William has PTSD positive and has been for four years. He has been dealing with this for years but has gotten worse in the past. William has had gonorrhea and syphilis in the past. PTSD is a type of anxiety disorder. This disorder can happen after you have gone through an extreme emotional trauma that had a lot to do with the threat of injury or death (Woods, 1999).

Family History and Present Relationships

William was raised in a two parent household in rural Kentucky. The family was African-American Ancestery. William's father stayed intoxicated and was also verbally and physically abusive. The family was considered to be an upper middle class household. His father was a lawyer. His mother was a nurse. Both parents are no longer living. William was alienated from his father from the age of 18. He kept recurrent phone contact with his mother until she died three years ago. His sister, father, and brother stopped speaking to him when the found out him was doing drugs. William has strained relationships with women and does not have many friends.

Positive Support Structures

One of William's friends at the CUCS supportive housing is drug free and supportive of William seeking treatment. William recently started going to services at the church. At the church, he has been able to make a few networks there and states that the Pastor has been a huge support to him. Also, the Pastor has been asking William to get involved with the church's homeless outreach program.

Crime and Law-breaking

William was...

Each times he was fined $400. William was arrested for possession of methamphetamine in New York just a few months ago and then placed on probation. A diagnosis of posttraumatic stress disorder (PTSD) is related with a wide range of mental health and physical health problems, as well as substance use disorders; nevertheless, not much is recognized about the ways in which PTSD effects the use of some drugs, for example crystal methamphetamine (Cox, 2005). William has also tested positive for methamphetamine a couple of times since being put on probation. If William does not sign up and finish an Intensive Outpatient Program he could possibly be facing up to two years in prison.
Education

William did graduate from high school. He for a short time went to a community college but then later dropped out after about two semesters. William appears to be of above average intellect. William reports being a 3.2 GPA student in high school.

Employment

William is currently unemployed. In the past he has worked mostly as a headwaiter and/or bartender at a lounge. His lengthiest place of work was at a cafeteria in New Jersey. He worked there for about three years. Over the past eight years William has been fired from ten different places of employment for extreme absenteeism and once for theft.

Inclination for Treatment

William accepts the fact that he is in need of treatment. Also, Probation is necessitating that he receive treatment or be sent to jail.

Social History

In addition to William drug addiction, he also reports her overall lifestyle has been predisposed by problem gambling throughout periods of active substance use. William reports the supposition that if he gambled he could get more money to buy some drugs. Throughout the past one year, he has not got involved in gambling behavior.

Resources and Accountabilities

William is currently trying to get Medicaid through the New York City Welfare system. This will cover the cost of all of his treatment. Also, it is William responsibility to offer some kind of proof of insurance coverage that will need to be giving to the Billing Department.

Mental Status Exam Narrative

William is a thirty-four-year-old single, black, male. He seemed older than his specified age. Also, his dress was suitable for the setting and careful. William wore brown khaki pants with black leather belt, blue polo shirt, precisely tucked in, and black shoes. His grooming was acceptable. William was helpful in the interview replying to all questions graciously. His disposition was both defensive and anxious.

William's affect was suitable to content; he was not excessively expressive but sensibly distressed over his current state. His proportion of speech was to some extent fast when speaking to stressful subjects, but other than that normal. William tone was average all through the interview. His thought manners were logical; nevertheless he did not demonstrate appropriate understanding as to his own actions, how they donated to his circumstances, and his continued incapability to remain drug free. William thought content was applicable.

William did not demonstrate psychotic indications. He repudiated any current hallucinations; on the other hand, he self-confessed to having had seen strange things in his bedroom from the hallucinations when he was up under the influence of methamphetamine. The main characteristic of meth psychosis is the presence of prominent hallucinations and misunderstandings (Goldstien, 1995). He did not refute compulsions and obsessions. He did not even refute having a germ fear. William was oriented to place, time, and person. His memory was weakened. William intelligence was projected to be above average. Also, his judgment and instinct control were insufficient. William denied both homicidal and suicidal ideation.

Diagnosis of William Berg

AXIS I: William Berg Amphetamine dependence 304.40

AXIS II: William Berg Obsessive Compulsive Personality Disorder 301.4

AXIS III: William Berg suffers from PTSD

AXIS IV: Problems related to interaction with the legal system (probation) AXIS V: William Berg GAF 61

Treatment Plan

All of these treatment interventions are outlined by importance. The measurement by purposes will be recognized with the client at his first session.

Psychotic Disorder

The first session will start with instruction in use of the New York City Crisis Line and the regional Emergency Rooms with a contract for safety. William will be referred to the CCS consulting Psychiatrist for a monitoring plan and medication evaluation; which will consist of intervention on hallucinosis, vegetative symptoms of Depression and ongoing evaluation of Bipolar as opposed to PTSD measures.

Post-Traumatic Stress Disorder

The client-psychotherapist will use the "Audacity to Heal" Notebook to reframe his developmental thoughts, reality-test rational-emotive perspectives and practice stemming behavioral change in real-life social circumstances. The sooner Post Traumatic Stress Disorder is confronted, the easier it is to overcome (Turner, 2006). Post Traumatic Stress Disorder is not a sign of weakness for William Berg, and the only way for him to overcome it is to confront what happened to him and learn to accept it as a part of his past.

Drug Dependence, in sustained remission

William will practice behavioral change in 1-to-1 locations, with counselor ["promoter"] and peers in the community of recovery; in addition to…