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Running Head: Case Study
Case Study Assessment of Jessica
Rachel Nunez
Liberty University
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Case Study Assessment Paper
Chemical Use Assessment/History and Treatment Recommendations
Name: Megan
DOB/Age: 19
Dates of Interviews: 10/4/2019
Evaluator: Rachel Nunez
Reason for Assessment
Jessica is seeking help related to her drug abuse/use. She would like to overcome her
addiction to heroin. On multiple attempts, Jessica has tried to quit abusing heroin and has been
unsuccessful. She can maintain her sobriety for a few months at a time, but soon relapses.
Jessica is aware that she is unable to stay clean on her own. Jessica is struggling with finding a
method that allows her to maintain her sobriety, however, she does have the full support of her
mother and father and appears to have the motivation and determination to be sober. Jessica
first experienced heroin unwillingly by her boyfriend and quickly lost control. It is estimated
that 15.6 million people in the world abuse or are addicted to heroin; the United States accounts
for at least 1 million of that population (Doweiko, 2015). This assessment will help aid in the
recovery process for teenage girls and young women seeking to break the chains of addiction.
Sources of Information
The sources if information about Jessica’s condition were obtained during the interview
process from Jessica and her parents. All the information is both Jessica’s and her parent’s
truth, based on their own memory of each occurrence. Additional scholar resources have been
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cited throughout the case study in order to gain a better understanding of Jessica’s drug use, as
well as to support the best treatment options specifically for her case.
Background Information
Jessica was considered a “normal kid.” She grew up in a home with both of her parents
and her siblings. Jessica is the youngest of four daughters and ethnically caucasion. Jessica was a
member of the swim team at her high school. She enjoyed art class, French class, and the
company of her fellow classmates. Megan looked forward to trips with her mom, especially the
trips they took to the zoo together. Megan stated, “I didn’t drink, smoke pot or anything.”
Therefore, drugs and alcohol had never been a problem for her. However, that was not the case
with Megan’s boyfriend. Her boyfriend was a user of heroin. On a few occasions, Megan
admitted to being “tempted” to try heroin, however she never did. A few years into her
relationship, for no rhyme reason, Megan states that her boyfriend jabbed her with a heroin-filled
needle as she was walking past him. Megan was in a state of shock. As a consequence of the
actions of her boyfriend, she grew dependent on the drug.
Current Status
Megan is currently seeking therapy to receive further treatment for her addiction, as all
previous treatment methods were unsuccessful. She currently has the support needed from her
parents to seek the proper treatment needed to maintain her sobriety. If Megan continues to have
the drive and passion she is currently showing, the likelihood of success in sobriety is greater.
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Indicators of Use/Abuse/Dependency
Megan clearly admitted that she quickly became addicted to the drug. She openly
stated, “I’d use once every couple of weeks, but then it progressed… and I was doing it every
day.” Megan was able to feed her addiction by stealing money from her parents. The mixture of
lying, stealing and addiction consequently led to a breakdown. Megan was able to confess her
wrongdoings to her parents with the help of a counselor and attempted to put a stop to her drug
addiction. This was unsuccessful, as Megan began using again on a daily basis within only a
few months. Megan then proceeded to explain that she brought drugs and needles drugs during
a three-day senior class retreat with her high school. As a result, Megan’s parents were called
to come pick her up and she was expelled from school only two months shy of her high school
graduation. Megan was given a job at her father’s business in an effort to keep her busy while
her parents tried to seek the help Megan needed. However, the craving of addiction got the best
of Megan and she confessed to only being able to maintain sobriety for a few weeks at a time.
This vicious cycle of attempting to quit, only to relapse back to heroin use are all indications of
addiction.
Attitude and Behavior
Although Megan has tried but failed numerous times to overcome her battle with
chemical dependency, she has a positive and hopeful attitude towards maintaining sobriety.
Megan has not loss all hope. It appears when life becomes too stressful or overwhelming,
Megan struggles and falls back into addiction. Megan openly admitted being back in school and
dealing with the pressure has provoked her to start using again. A major setback recently
occurred during Christmas break. Megan stated, “Normally when I relapse, I use once or twice,
but this time it was every day.” While these repeated relapses do contribute to a somewhat
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deflated attitude, Megan does her best to maintain the drive to obtain a high school diploma or
peruse getting her GED. She did go on to mention she has a difficult time staying on task.
Social Functioning
There was little to no information given pertaining to her social functions at this time.
Occupational Functioning
Since Megan’s current expulsion from her High School, she has been working for her
father. She was given this position by her parents in hopes to keep her busy, and away from
heroin, until her parents are able to find the proper help their daughter needs.
Financial Aspects
Megan is currently working for father, it was not disclosed if she was being paid for the
her the work she does at his business. It was stated that Megan, at one point, began stealing
money from her parents to buy drugs. No information was provided regarding her financial
situation.
Familial Relationships
Megan’s relationship with her parents seems to be strong, as they regularly do what they
can to help her, such as providing a job for her. Her relationship with her sisters is unknown.
There was no mention of extended family relationships or a family history of substance use or
abuse.
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Legal History
Given the information provided, Megan has not been in any legal trouble pertaining to
her drug use.
Health History
No medical problems were mentioned during her interview.
Diagnostic Impression
After an in-depth assessment of Megan’s history and background information, the first
thing that needs to be done is a medical examination, urine drug screen and labs. During this
medical examination, it is crucial to have a test done to determine the cause of her incapability to
remain focused. The results of these test will need to be positive in order to support her alleged
drug use. Megan freely chose to admit she was an addict who is unable to handle her addiction
on her own and needs professional help; a large number of addicts choose not to do this.
There are not many issues pertaining to Megan’s mental health. She has given the
impression of understanding there are consequences to her addiction. Her thoughts and goals are
realistic and manageable. Megan still has hope and has not given up pursing her goals and
having a bright future.
Recommendations
It is my professional opinion that Megan be admitted into a rehabilitation center for
treatment. Megan appears to be in the level-3 stage of abuse as outlined in The Continuum of
Recreational Chemical Use chart (Doweiko, 2015, p. 11). Level-3 is late problem use/early
addiction: individuals who fall into this category are people who may be physically dependent
on a compound, and perhaps experience classic withdrawal syndrome if they abruptly stop
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using their drug of choice (Doweiko, 2015). Though Megan has refrained from heroin for 90
days and has the drive to get her high school diploma or GED, she has agreeably stated “it is
hard to stay on task.” Due to the difficulty of treatment and remaining sober, this many indicate
it will only be a matter of time before Megan relapses once more. Megan will undoubtedly
need professional help in order to get a better understanding of what coping mechanisms will
work best for her. Additionally, she will need to be provided with the methods required to
refrain from addiction. Megan will need to surround herself with family and friends whom
support her recovery and have a positive influence on her life. These individuals will need to
hold her responsible for her actions. Megan seems to respond well to counseling but struggles
when life gets difficult. My recommendation is for Megan to continue counseling while in the
rehabilitation program, as well as after she leaves the program. Megan will only need to be
counseled by an independent counselor who is specifically trained in addiction. I trust that
independent counseling is the best method of treatment for Megan. Individual therapy offers
the advantage of letting Megan to discuss issues to private to discuss in an open group set-up
(Doweiko, 2015). With Megan being young and her addiction not fully consuming her life, she
still can be taught proper coping strategies that will allow her to better resist another relapse.
The key advantages connected with outpatient treatment are the considerable opportunities for
interaction between the treatment program and the realisms of each client’s daily existence
(Doweiko, 2015). Counseling allows someone to freely open up and work alongside a trained
professional, to overcome and understand the underlining issues that keep pulling her back to
drug use. For Megan to entirely defeat her addiction to heroin, these treatments are essential to
keep her from falling back to using heroin.
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In addition to continued counseling, it is strongly suggested for Megan to regularly
attend a Narcotics Anonymous meeting. This will help her increase her faith in recovery as well
as give her the chance to be part of a supportive social circle that fully understands her
addiction. Being around a group of persons with comparable backgrounds will allow Megan to
cope with feelings of being alone and avoid turning to heroin to deal with these negative
emotions. If Megan can follow this recovery plan, along with the support of her loved ones and
family, she should be able to overcome addiction. Overcoming her addiction will allow Megan
to have a happy, well-balanced life that is free from the chains of addiction. In the therapy
group environment, addicts are able to learn how to develop healthy, non-substance-centered
relationships alongside rebuilding their self-esteem (Brooke, 2008).
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References
Doweiko, H. E. (2015). Concepts of Chemical Dependency (9th ed.). Boston, MA
USA: Cengage Learning.
May, G. G., M.D. (1988). Addiction and grace: Love and spirituality in the healing of
addictions. New York: NY
Brooke, D. W. (2008). Group therapy. In M. Galanter & H. D. Kleber (Eds), Textbook of
substance abuse treatment Washington, DC: American Psychiatric Publishing, Inc.
