Client Name: Melissa

Assessment Date: October 3, 2022

Substance Use History: Drug

First Use: No

Xanax Use: No

Pattern of Use over Time:

• 4 to 5 pills per day

Frequency of Use in Past Month:

• Every day

Date/Amount of Most Recent Use:

• 4 to 5 pills per day

Combination Use:

• Melissa has not used Xanax in combination with any other drugs, to the best of my knowledge from the information provided in the case study.

Consequences

Physical Consequences:

• Melissa has not shown any physical consequences of usage, except feeling good after taking 4 to 5 pills of Xanax per day (Case Study, 2022).

Psychological Consequences:

• Melissa feels the need to hide her use from her parents and school, fearing trouble. She appears defiant towards her parents, feeling neglected due to their divorce. Additionally, she is affected by concealing her sexual orientation, fearing her parents’ reaction due to their religious beliefs.

Medical Concerns:

• Melissa’s mother seeks therapy post-divorce for issues possibly related to depression or anxiety. No other medical concerns related to Xanax use are noted.

Past Treatment History:

• Melissa has not received past treatment for substance use or other related issues. She obtains Xanax by deceiving her doctor.

Environmental Factors

Residential:

• Melissa resides with her mother post-divorce and visits her father every other weekend.

Social Support System:

• Melissa’s parents are preoccupied with the divorce, leading to limited attention towards her and her brother, who has been suspended from high school for marijuana use. Her current friends also use Xanax, often sharing or selling it among themselves.

Family and Family History

Family History of Use:

• Melissa’s parents drink alcohol moderately, and her older brother smokes weed. No other family members have a history of substance use.

Family Mental Health History:

• Melissa’s mother receives therapy for issues linked to the divorce, potentially related to anxiety or depression. No other family history of mental health issues is reported.

Current Additional Status to Consider

Educational:

• Melissa is in her final year of middle school and will be transitioning to high school next year.

Financial:

• No information is available regarding Melissa’s financial or employment situation, likely due to her status as a minor.

Legal:

• There are no reported legal issues faced by Melissa.

Motivation for Treatment:

• Melissa is not actively seeking treatment for substance use. However, she expresses personal issues unrelated to substance use.

Recommended Assessment Measures:

• Further assessment of Melissa’s motives for using Xanax is advised to understand underlying factors contributing to her usage.

Clinical Assessment

Diagnosis:

• Melissa exhibits signs of Xanax abuse, demonstrating dependence based on daily usage of 4 to 5 pills. Her tolerance to the drug suggests a need for intervention. She meets criteria for substance abuse as per DSM-5 (2022), with an ICD-10 code of F19 for anxiolytic drugs.

Prevalence:

• Approximately 0.3% of adolescents aged 13–17 are affected by anxiolytic use (DSM-5, 2022).

Features Supporting Diagnosis:

• Melissa’s tolerance and daily use of Xanax, coupled with environmental stressors like her parents’ divorce, support the diagnosis of substance abuse.

PSYC FPX 4300 Assessment 3 I’ve Got you Pegged Treatment Plan

Treatment Recommendations

Phases of Care:

• Melissa would benefit from therapy and rehabilitation to address her substance abuse. The four phases of care—palliative, stabilization, rehabilitation, and maintenance—offer a framework for treatment (Miller et al., 2019).

Recommended Treatment:

• Therapy would address underlying issues related to the divorce and adolescence stressors. Rehabilitation aims to modify behaviors and coping mechanisms to reduce reliance on Xanax.

Ethical Considerations

Client Confidentiality:

• As a minor, Melissa’s confidentiality is protected, and information disclosure requires her consent, even to her parents.

References

Case Study (2022) Capella University, Melissa.

DSM-5 (2022). Diagnostic And Statistical Manual Of Mental Disorders, Fifth Edition https://doi-org.library.capella.edu/10.1176/appi.books.9780890425596

Miller, W. R., Forcehimes, A. A., & Zweben, A. (2019). Treating Addiction (2nd ed.). Guilford Publications, Inc. https://capella.vitalsource.com/books/9781462542376

PSYC FPX 4300 Assessment 3 I’ve Got you Pegged Treatment Plan