Leon is a 29-year old gay black male who presents a history of 12 years of alcohol use. He is currently being treated in an outpatient program but is inconsistent with his attendance. This is a major treatment issue with his counselor. At present, Leon’s weekly breathalyzer tests are negative for alcohol use and the urine toxicology shows no evidence of other substance use.
He has been assigned to attend group once a week, individual counseling twice a week and attend a self-help meeting twice a week. The treatment issue is that Leon tends to anger quickly and leave the sessions (individual and group) abruptly. He believes that his schedule is too restrictive and interferes with his social life.
Personal History: he is in a 2-year relationship with his partner who is a non-user. He says the relationship could be better but refuses to have his counselor arrange a couple session with them. He reports a distant relationship with both parents and his older brothers. He works full time as a graphic designer and enjoys his work. He reports no significant medical or mental health issues. Denies any arrest or pending legal issues; never in the military.
In the summary, give a short synopsis of the assessment. Then give your clinical impressions of this case, i.e., what areas of his life should be addressed in treatment (e.g. trauma, eating disorder, abuse, domestic violence, psychiatric issues, sexuality, etc.), give any concerns you may have about him and explain why.
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CASE STUDY: DWAYNE
Dwayne is a 45-year-old black male who was referred for an alcohol assessment by the courts. He recently received his first DUI charge. His appearance was well kempt, affect appropriate, attention somewhat distracted but polite during the interview.
He informed his counselor that the night of his DUI he had 3 shots of tequila while celebrating a friend’s birthday. He states that he never drives when intoxicated and that he was stopped because of a broken tail light. Nothing would have happened if he wasn’t stopped for that infraction.
He says he drinks on weekends and rarely gets drunk. He denies any other drug use except for occasional marijuana use.
He is recently divorced after 15 years of marriage. He misses his 3 children whom his wife has custody and moved to a different state.
Dwayne works as a stock trader in the financial center. States his job has a high stress level. He is a college grad.
He reports having high blood pressure, and is on medications to treat it. He does describe feelings of anxiety but uncertain of the cause. He reports no psychiatric history, or other medical conditions. Except for his current DUI, he has no past legal problems. He served 2 years in the military in his 20’s.
In the summary, give a short synopsis of the assessment. Then give your clinical impressions of this case, i.e., what type of treatment modality should he be referred to (outpatient, inpatient, self-help meetings, etc.); any other areas that should be addressed in treatment (e.g., trauma, eating disorder, abuse, domestic violence, psychiatric issues, etc.), give any concerns you may have about him and explain why.
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CLINCIAL IMPRESSIONS:
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