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Running head: CASE STUDY 1
Case Study of Jessica
Rachel Nunez
Liberty University Psychology 305
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Case Study Assessment Paper
Chemical Use Assessment/History and Treatment Recommendations
Name: Jessica
DOB/Age: 19
Dates of Interviews: 9/30/2019
Evaluator: Rachel Nunez
Reason for Assessment
Jessica is seeking help in order to refrain from drug use/abuse. She has come to us today
in order to get to the root of her addiction issues. Through this assessment we hope to be able to
get Megan the help that she needs in order to refrain from drug use/abuse. Although Americans
only make up 5 percent of the worlds populations, we use 60 percent of the illicit drugs
(Doweiko, 2015). So this assessment is for the help of a young women who is searching for a
way out of addiction.
Sources of Information
All sources of information have come from the client, high school, and parents, through
an interview process. All information is based on truth from the clients own memory, as well as
high school officials, and recounts of events from her parents. All information is based off of
truth from these sources. Additional sources have been added in order to allow for reasoning’s
behind this overall assessment of Jessica and the best treatment options for her.
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Background Information
Jessica could be considered as the “typical normal teenager” she grew up with both
parents, she enjoyed art and french class in high school. She enjoys trips with her mother, such as
going to the zoo. She is the youngest of four daughters. She had good friends in high school.
Jessica enjoyed Art and French class in school. She stated that “drugs and alcohol were never a
problem; she never drank or smoked pot in high school.” It seems however, that her boyfriend
was another story and could be the influencing factor in Jessica’s drug abuse. Jessica had never
used or thought about using heroin until her boyfriend one day decided to suddenly jab her with
a filled syringe as she walked by him. Since that day she has become dependent on the drug.
Indicators of Use/Abuse/Dependency
It wasn’t long before Jessica became addicted and her addiction progressed to daily use.
Jessica says, “I’d use once every couple of weeks, but then it progressed…and I was doing it
every day.” She began stealing money from her parents to feed her addiction. The combination
of lying, stealing and chaotic lifestyle led to a breakdown. “I was going through counseling and
I told my therapist about all the lying and using behind my parents back,” she says. Jessica told
her parents about her drug use and tried hard to quit using on her own. but she was not
successful. Jessica had returned to daily use and brought needles and heroin with her to a senior
class retreat, but when a teacher found out they called her parents and she was sent home and 2
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months away from graduation, was expelled from school. The above information all indicates
signs of addiction.
Attitude and Behavior
Jessica has tried many times to get clean and maintain sobriety off of heroin. She has
relapsed many times during the last few months of the school year with Christmas break being
the hardest time. Jessica, stated” Normally when I relapse I use once or twice. This time she went
back to full blown dependency. Jessica has a somewhat deflated attitude because of her constant
urge to use. She currently is holding strong with 90 days sober. She is trying to get her GED,
however, she said she can feel herself slipping. Jessica seems to have an attitude of desperation
and a true want to learn how to maintain her sobriety. She stated she wants to, “finish high school
but has difficulty staying on task.”
Social Functioning
Jessica is a white female and the youngest of four sisters. Jessica enjoyed her fellow classmates
in school but not much is known about her social functioning to date.
Occupational Functioning
Jessica works for her father at his business. He has allowed her to work for him while they are
trying to figure out what to do to help her. Two months shy of her high school graduation she
was expelled. She now is unable to hold down a job other than the one her father has offered her.
Financial Aspects
Her boyfriend pays for her addiction as well as whatever money she makes from working
for her father.
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Familial Relationships
Jessica’s addiction has caused stress and worry to her parents. They are now at a stand
still on what to do in order to get their daughter the help that she needs.
Legal History
Jessica reports no legal trouble
Health History
Jessica reports no health issues in her past.
Spiritual History
Although not formally discussed, Jessica’s spiritual history, that she has at least heard of
God. We do not have to be Christians to believe in God. Jessica grew up with two loving parents
and siblings, and throughout her adolescence she had no desire to use drugs. Her boyfriend
introduced heroin to her, which she became addicted.
Diagnostic Impression
After a thorough assessment of Jessica’s history and background information, the first
thing that needs to be done is a blood workup, followed by a urine drug screen, and a medical
examination. Within this medical examination should be a test of her inability to remain focused.
These are needed to help acknowledge alleged drug use, and also to have a positive. Not many
clients readily admit to drug abuse. Jessica has come in on her own and answered all questions
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about her situation seemingly truthful. She has begun the process of getting help for her
addiction by admitting to the abuse. Jessica understands that she has a problem and that she can
no longer handle this alone and needs professional help.
Recommendations
In my professional opinion I believe that she should be admitted into a rehabilitation
clinic for ongoing treatment. According to the continuum of chemical use Jessica falls into
level 3. Level 3 is late problem use/ early addiction: individuals who fall into this category may
be physically dependent on a compound, and possibly also experience the classic withdrawal
syndrome for the compound being abused if they should abruptly stop using alcohol or drug of
choice (Doweiko, 2015). Though Jessica now has 90 days of sobriety and is working toward
her GED she reports that “it is hard to stay on task.” This may indicate a relapse. I believe that
Jessica needs professional help in order to cope with every day stresses as well as, give her the
tools needed for maintaining sobriety. Jessica must make the decision to stay away from her
boyfriend as he continues to use. She must surround herself with positive people who can
influence her positively and hold her accountable for her actions.
Jessica seems to have been helped in the past by participating in counseling. My
recommendation is that she continues counseling both inpatient and outpatient after completing
a rehabilitation program. Jessica needs a counselor who is adequately trained in heroin
addiction. Jessica would benefit from both individual and group counseling as part of her
treatment plan. Individual therapy offers the advantage to discuss issues on a personal level,
while discussions in an open group format offer support and advice to similar situations.
(Doweiko, 2015). Counseling is a way of allowing someone to open up and to work through the
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underlining issues that both stem from addiction and have helped form the addiction. The
primary advantages associated with outpatient treatment are the considerable opportunities for
interaction between the treatment program and the realities of each client’s daily existence
(Doweiko, 2015). For Jessica to maintain her sobriety from heroin these treatments are
necessary.
Reference
Doweiko, H. E., (2015) Concepts of Chemical Dependency (9th Ed, Pgs. 12-451) Stamford CT,
Cengage Learning.
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