Essay: Patient assessment

Rosa Lee is a 52 year old African American female who is of below average height and slightly overweight. Rosa has given birth to a total of eight children who were fathered by six different men. Rosa has a thirteen year history of substance abuse. The substances that she has a history of using include heroin, amphetamines, and cocaine. She has been arrested twelve times. Some of her offences have been drug related convictions and others have been related to theft. In addition to receiving public assistance for her children, now grown, and her grandchildren, who are frequently left in her care, Rosa has held several waitressing jobs, engaged in prostitution, sold drugs, and has stolen merchandise to resell it in order to support her children. Five of these children are still dependent on Rosa to meet their basic needs of food, shelter, and heat, despite their adult status. They also look to Rosa to support their addictions when they are unable to and to provide them with medication as needed. Three generations, including Rosa, her children, and her grandchildren, consisting of nine total people, share her residence. Rosa has recently begun to have seizures, which are likely related to her substance use, and is starting to experience difficulties with short term memory loss. She has also recently been diagnosed with the AIDS virus. She has been referred for assessment by a hospital social worker in an attempt to help her correct the maladaptive behaviors that are impeding her functioning.
SOURCES OF INFORMATION:
Self-report, family input, concerned other observation.
PSYCHOSOCIAL HISTORY:
Rosa is the daughter of North Carolina share croppers who migrated to Washington DC in an attempt to escape the constrictions of rural poverty. Upon arriving in DC, her father, now deceased, worked as a cement finisher, branded a laborer by his employer to suppress his pay, for a local cement company. Her mother, also deceased, worked as a maid on Capitol Hill. Rosa was one of eleven children who were raised in extreme poverty. Rosa asserts that she was raised in an abusive household, and although her siblings do not agree with her assessment of abuse, this was a common occurrence for the children of migrant sharecroppers.
Rosa’s relationship with her mother was strained after her father’s death, and her relationships with her siblings are likewise strained, largely due to her history of stealing. As such, Rosa is lacking a positive familial support system.
Rosa became pregnant at thirteen in an attempt to hold on to her first boyfriend. Her attempt failed, and she gave birth to her son at the age of fourteen. She has a history of entering into relationships with abusive men and has historically employed pregnancy and other attention seeking behaviors, including suicidal threats, in order to keep these men in her life. In addition to her maladaptive romantic relationships, she has also engaged prostitution, but she is not currently enjoying a healthy sexual relationship. Nor is there evidence of her ever having done so.
Rosa has a history of criminal activity and has been incarcerated on many occasions for drug offenses and theft related offenses in an effort to support her substance abuse. She has been incarcerated twelve times for these offenses and has served a total of five years.
Rosa’s recreational history largely revolves around her addiction and her attempts to support her addiction through often illegal means. She is known in the neighborhood she lives in as Mama Rose, and her reputation has been built on the quality of the drugs that she sells. She takes care of five of her adult children and her grandchildren in times of parental incarceration.
Rosa sporadically attends church and admits to having once stole from members of the congregation. She has also admitted to sealing clothes for her grandchildren to attend church in and has used both her attendance at church and the custody of her grandchildren as a manipulative move to avoid incarceration.
Rosa’s support system is lacking at best. Rosa has very little support from her siblings due to the strained nature of their relationships. Her non-functioning children take rather than give, and her functioning children are hesitant to offer support to Rosa. This is directly due to the reality that they are aware by helping Rosa they are also inadvertently enabling their non-functioning siblings.
CURRENT STATUS:
Rosa’s typical day begins in the early morning upon seeing her grandkids off to school. If she has money, or drugs, she will engage in substance use immediately upon awakening. If she does not, she will make her way to the methadone clinic in order to control her withdrawal symptoms just long enough to buy herself some time until she can figure out how to earn some money to obtain the substances that she wishes to use. This could mean selling drugs to make a small profit, selling her food stamps, using her state assistance money, shoplifting and selling the merchandise, or engaging in prostitution in order to support her habit. She has engaged in each at one time or another to avoid the impending withdrawal. She also freely admits that she has often had her grandchildren transport the drugs or stolen merchandise to avoid detection because she knew that they would not be searched. She will engage in use with her grown children as long as any of them have money or drugs to share, and when the effects have worn off and the money runs out, the cycle repeats itself.
Rosa is unable to complete activities that are considered typical of daily living. Despite the fact that she is receiving government assistance for herself and her grandchildren, her family’s nutritional needs are seldom met. This is because the available resources are extended to her adult children who reside with her. Necessary utilities such as water, electricity, and heat have been disconnected for months at a time. Rosa is often unsure whether or not her rent payments have been made and whether or not it is her responsibility or her caseworker’s responsibility to make them. Rosa and her children have moved a total of eighteen times, two of which were to homeless shelters because there were no available resources for alternative arrangements. She complains of feeling fatigued, but it is unclear whether this is due to extended drug use, her illness, depression related to either of the two, or to simply being overwhelmed with so much responsibility while lacking the resources to meet the family’s basic needs.
Rosa perceives her strength to be her ability to go out and get what she wants. She prides herself in not needing anyone, in doing things for herself, and in being independent, even though her behaviors suggest otherwise. She also prides herself in her ability to make others feel sorry for her by using her tears, her body, or any other method she can. She justifies her theft with the rationalization that store owners charge too much anyway, as if this is enough to justify her behavior. She views her willingness to do whatever it takes as a strength while simultaneously overlooking the aspects of a normal standard of living that are lacking to both herself and the children that are in her care.
Rosa is lacking in coping skills beyond her ability to beg, borrow, or steal her way out of trouble. She acknowledges that her drug use is a problem, but she does not seem interested in giving it up, rather she simply accepts it as part of her existence and does whatever is required to maintain it, regardless of the effects that maintenance has on others. This includes her tendency to use the methadone clinic as a stop-gap arrangement in between her fixes.
INDICATORS OF USE/ABUSE/DEPENDENCY:
Attitude and Behavior of Rosa: Rosa’s activities are focused on her addiction, whether it is the use or figuring out how to obtain the desired substances. Her existence revolves around supporting her own habit in addition to the habits of her children. Rosa has shown that she is not afraid to engage in illegal activities in the interest of supporting her habit including the selling of drugs, the engagement in prostitution, and theft as needed. The majority of her children have followed her lead into this lifestyle and she has already begun to introduce her grandchildren into it. She has even praised their intelligence for moving the drugs Rosa was selling periodically in order to avoid detection.
Social Functioning of Rosa: Rosa has surrounded herself with other addicts, including the presence of her adult children. As a result, her activities revolve around obtaining and using drugs to maintain her addiction. She and her children share limited resources to engage in use. This includes the sharing of needles to get high in social situations, despite her knowledge of the obvious dangers of doing so as she has been diagnosed with the AIDS virus.
Financial Aspects of Rosa: She has habitually been unemployed. Resources are limited to government assistance and what can be scraped together through the above listed illegal means. She does not have any money at this time as her resources go to maintaining the household drug habits. She has demonstrated a history of making poor financial decisions as a result of her addiction.
Familial Relationships of Rosa: Her relationships with her siblings are almost non-existent as everyone is aware of her tendency towards theft for personal gain. Rosa’s continued use in addition to her enabling behavior towards her addicted children continues to further alienate her from her functioning children. Her enabling behaviors are also endangering the welfare of the grandchildren that remain in her custody.
Legal History of Rosa: She has been arrested twelve times. Eight of these arrests were for various forms of stealing to supply her addiction and the remaining four were for direct drug related offenses. Rosa has served a total of five years in correctional facilities.
Health History of Rosa: She has been diagnosed and is receiving treatment for AIDS. She shares her AIDS medication with her daughter who is also infected. Recently, she has begun to have repeated seizures and has begun to experience deficiencies with her short term memory. As per her medical records, the seizures appear to be a result of her persistent continued substance abuse and the short term memory loss appears to stem directly from the seizures.
Spiritual History of Rosa: While she asserts that she believes in God, she is not attending church nor is she involved with any religious activities at this time.
DIAGNOSTIC IMPRESSION:
Rosa has a long history of substance abuse. She has contracted the AIDS virus, possibly through sharing needles with her infected child or through prostitution that she has engaged in to support her habit. She has been hospitalized due to recurring seizures and had tested positive for both heroin and cocaine when she was admitted. Family members have reported short term memory loss which the doctors have linked to the episodes of seizures. She has admitted to having a heroin addiction and to the recreational use of cocaine at times when she is unable to obtain heroin.
At this time, there is an absence of depressive and manic symptoms which eliminates the likelihood of bipolar, unipolar, or mixed mood disorders. There is also an absence of hallucinations and delusions which eliminates the likelihood of psychotic disorders. The recent occurrence of hypersomnia can be attributed to the withdrawal from heroin, as can the lack of appetite that she is experiencing. Therefore sleep and food disorders can be ruled out as separate disorders at this time.
Cocaine abuse is noted, but due to low levels in her blood at the time of admittance and the lack withdrawal symptoms, she does not meet the criteria for cocaine dependence or withdrawal (Miller, Gold, & Smith, 1997). Heroin dependence and withdrawal have both been established and Rosa is currently being treated with methadone at the hospital to control the withdrawal symptoms that include elevated hart rate, muscle cramps, insomnia, and nausea (Miller, Gold, & Smith, 1997).
Without knowing how Rosa’s comorbid conditions of poly-substance abuse and her AIDS diagnosis interact, it is important that she be evaluated by a physician to rule out further complications from the interactions of these disorders. In light of the absence of a follow up report from her physician addressing the likely physiological challenges of this comorbidity at the time of this recommendation report, a tentative multi-axial diagnosis is as follows:
Axis I: 304.00 Opioid Dependence
305.60 Cocaine Abuse
Axis II: 301.06 Dependent Personality Disorder
Axis III: AIDS, seizures, short term memory loss
Axis IV: Legal problems, Failure to hold a job and meet basic needs, Lack of
a support system, Lack of education, Live in abject poverty, Is an ethnic minority
Axis V: GAF: 45 (current)
RECOMMENDATIONS: These treatment recommendations are based on the proposed goals for Rosa’s treatment plan. These goals are that: Rosa should be in compliance with continued medical care and adherent to her medical regimen to control the effects of her diagnosis. Rosa should be actively gaining social support from positive family influences who are interested in her continued recovery. Rosa should make every effort to comply with the treatments intended to help her to gain the confidence and skills necessary to function productively in society. Rosa should commit to exercising abstinence, first from heroin and then from methadone. Once clean, commitment should be demonstrated by entering into a maintenance program that expects personal responsibility and accountability while offering guidance through a support network that will enable her to continue her new lifestyle (Dziegielewski, 2005).
Rosa should continue to be under the care of a physician for the management of her physiological problems. The social worker should look into the potential of Rosa’s adult, functioning, children being in charge of both her finances and her housing until such a time that she demonstrates the competency to handle her own affairs. This may require a court order, but her history and recent physical decline should expedite a ruling in the event of her refusal. This might include placing her into an assisted living facility, or a transition house, after her in-residence treatment, to protect her interests in staying clean. This would also act as a preventative measure, or deterrent, of either her further use or her exploitation by her non-functioning children. Also, this will help her establish a positive familial support system during her recovery (King, LLoyd, & Meehan, 2008). For the safety of her grandchildren, alternative placement or the restricted access of addicted members should be implemented.
She should be assisted in obtaining skills and assertiveness training to help her handle the issues related to her remaining addicted children and to teach her how to become an in independent functioning member of society. Ideally, this will facilitate more responsible behavior on Rosa’s part while under the watchful eye of those trying to facilitate her independence. In addition to this, this new found independence will help to reduce the anxiety and fear of being alone and hopefully negate the thoughts that feed her need for codependency (Miller, Gold, & Smith, 1997).
The hospital has already begun methadone management therapy and this should be continued in an inpatient residential program until Rosa can be weaned off the methadone. This has been shown to be the most effective treatment for those suffering with a heroin addiction, as it allows for a gradual cessation that protects the client from withdrawal symptoms while they return to normal functioning (Dziegielewski, 2005). Rosa meets the recommendations for methadone management therapy because she has comorbid health disorders, has demonstrated failure of abstinence, and has used heroin intravenously (Miller, Gold, & Smith, 1997). It is recommended that she do this in residence to protect her from relapse due to the temptation of continued use in her home environment and the associated health complications until she is substance free. It would be helpful for the program to provide incentives for continued abstinence, but regular drug testing should be a requirement.
Upon her release from the resident treatment program, due to her extended history of use, Rosa should be subjected to monthly drug tests for no less than 12 months so that if she relapses it is caught immediately. Her physician should also consider the administration of Naltrexone, or a like drug, during the first year after she is released from the residential facility. While most individuals only use this medication for six months or so, the extended use will prevent her from enjoying the effects of the heroin if she does relapse and help weaken the association between the drug and the associated pleasurable effects that keep her trapped in the cycle of addiction for an extended period of time (Liberty University, 2014). In turn, this will also offer her significant protection during the phase of protracted withdrawal syndrome from weeks 9-30 when she is likely to be the most susceptible to relapse (Miller, Gold, & Smith, 1997). At the minimum, individual maintenance counseling should also be offered more than twice a month during this time (Dziegielewski, 2005).
Finally, Rosa should commit to and religiously attend Narcotics Anonymous, or a similar support group, upon her release from the inpatient residential facility. It has been argued that these groups may present challenges to some women, especially those who have suffered from previous abuse (Doweiko, 2012). However, due to the pervasive nature of Rosa’s addiction, the length of time that she has been addicted, the reality that her addiction is both coupled with her codependent tendencies, and exacerbated by her lack of support, this program, or a like program, offers more potential benefits than potential risks (King, LLoyd, & Meehan, 2008). These groups expect the addict to be independent and accountable for their own use or abstinence, sponsors are available and they do not engage in enabling behaviors. This holds her accountable and enforces the idea of the ability to make her own choices for herself. It will give Rosa an opportunity to surround herself with a strong and successful support network of other people who are struggling to change and face many of the same challenges that she is facing. Also, this type of group will provide her with real life examples and encouragement from those who have managed to get clean and stay clean. Abstinence rates for these programs are better than abstinence rates for those who are not involved in them, 76% versus 49% respectively, of individuals in an Alcoholics Anonymous program, which is considered a sister program of narcotics anonymous (Miller, Gold, & Smith, 1997).
Due to her own inability to get clean and stay clean on her own, these recommendations cover many angles including helping her manage her existing illness and helping her to detox from fist the heroin and then the methadone. They take into account safeguards to help her gain stability in her life and to become successful in functioning at a normal level. Following these recommendations will provide her with support on her journey to a drug free life while emphasizing what can be done to help her avoid the potential pitfalls of relapse. Ideally, when used together, these recommendations will help her break the cycle of addiction while teaching her to use her experiences to safeguard the next generation.
Patricia R. Thakur March 2, 2014 Signature Date
References
Doweiko, H. E. (2012). Concepts of Chemical Dependency, 8th ed. Belmont, CA: Brooks/Cole.
Liberty University. (2014). Addictions and Recovery: An Introduction. Retrieved from Liberty University.
Miller, N. S., Gold, M. S., & Smith, D. E. (1997). Manual of Therapeutics for Addictions. New York, NY: Wiley-Liss Inc.