Dopesick

Content of service: Information gathered from client concerning goals, objectives, perception or progress of what actually happened (include reported interventions used in session).

“Clinician met with the client for an individual session. The client reported that he is having a lot of cravings that he is struggling with. The client reported that he feels very uncomfortable in his skin right now, and it feels like things are crawling on him. The client stated that he would have left treatment an went and used already if he had his money in his pocket. The client stated that he wants to be sober but is struggling with the idea because he is “dope sick” all the time. The client stated that he believes that life would be simpler for everyone if he was no longer here. The client reported that he had some suicidal thoughts earlier today but doesn’t have any right now.

“The client stated that he has been having very disturbed sleep. The client reported to only getting 2 hours of sleep at night maybe because he is having a lot of night sweats. The client reported that he feels he is at a stand still right now. The client stated that he has been having using dreams when he does sleep. The client reported that he has restless legs and they are making his body very uncomfortable. Clinician and client discussed triggers or stressor that he may have back in his home environment. The client reported that everything in (hometown) is a trigger for him because everywhere he turns he can go get dope. Clinician and client discussed him getting coping skills to help him deal with his triggers and manage his cravings. The client stated that he is not opposed to staying in Arizona as long as he gets help. Client expressed wanting to connect to his higher power and the 12 step program and the aftercare but feels right now he remains at high risk for relapse if he does not continue in residential treatment at this time.

ASSESSMENT Provider assessment/interpretation of what happened, including assessment of client status, progress and barriers to progress (included mood/supported affect).

“Client presented as anxious, shaky, depressed, irritable, restless, tearful, tired, unfocused but remained engaged with this clinician. The client struggled to sit through the session as he was very restless, anxious, and unfocused. Due to the post – acute withdrawal symptoms he continues to need staff support in residential treatment as he remains at high risk for relapse at this time. The client seems to want to be sober but is struggling due to his strong cravings.”

The above is the clinical breakdown on MP, tall, athletic (formerly, now more than a little rusty), gregarious, charming, snap-witted heroin junkie trying – again – to get clean, to get sane, to stop living in skanky motels shooting up and scraping together money for the next high. Favorite sayings: “that’s what’s up” and “that’s fire.”

He was pretty sick, insufferably crabby when he first got to the house, then got over the hump and – after pissing off everyone, residents and staff – quickly became quickly became a house favorite, a funny, uber-open, overgrown 19-year-old puppy who has been playing with fire, figuratively and literally.

Not sure about his mom, but his dad is in the picture, somewhat. After monitoring one of his phone calls, when MP hung up, he grumbled that he’s all alone, no family. I told him that, from what I could hear, it sounded like his father was on his side. “No, he hates me.

“I tried to burn his house down”

 

Excerpt from one of my daily notes:

-1: MP.: Upon Tech’s arrival CT was in bed sleeping. Tech woke up CT to start the day. CT submitted UA. CT took his vitals and medications. CT attended opening, meditation group, and group counseling groups. At opening, CT shared that he had great phone call with his father last night. CT told his father he wanted to pay him back for various things; father told him all he wanted was for his son to be sober and that he loved him. CT stated this gives him great motivation. CT broke for lunch.  CT met with therapist who informed CT he will be going to PHP tomorrow. Tech later spoke to CT about this, attempted to re-direct negative thoughts about PHP and leaving RR, where he is comfortable. CT attended afternoon groups