Individual Case Notes (3)
S-Subjective O- Objective A - Assessment P - Plan
All names have been changed to preserve the confidentiality of clients.
Number 1
Name: Jonny
S- Jonny states, “I cannot be here with these people. I am not like them. They are crazy. I need to go home.” Jonny worries about being able to find friends who he will relate with. “I could stay a maximum of one month but that’s it,” he tells me. He says he will go crazy if he stays. He complains of being embarrassed to associate with the rest of the group and that he does not deserve to be here. He believes his parents should be sent to a program for help, not him.
O- It is difficult to follow Jonny in conversation. He does not follow through with his sentences clearly. Jonny has been with the group for only an hour and already says he must go home. He stands back away from the other students and does not say much when they try to include him. Records indicate Jonny suffers from oppositional defiance disorder, anxiety, depression and apergers .
A- Jonny does not want to be in our program. He does not understand the impact his behavior has on others but does see how theirs effects him. Jonny does not have a good relationship with his parents, as seen by his comments. Jonny will not go crazy if he stays but rather he does not want to associate with others who have similar emotional and behavioral struggles as he. Jonny struggles with social skills and needs a friend.
P- Introduce Jonny to other students one at a time so he is not overwhelmed. Play a get to know you game with whole group to foster relationship building. Give Jonny two assignment:
1) talk with therapist (Gordon) about his feeling that he must return home.
2) Think of one question that he can ask each person in the group that day and then ask it.
S- Jessica Williamson, BSWI
Number 2
Name: Jim Shoeman
Date: July 6, 2009
S – “My dad is a dick for sending me here. The judge too!” Jim greeted me as I picked him up at the airport for transport to Aspiro. When he was told cigarettes were not allowed in the program he called his dad on the phone and said, “Hey BOSS. You didn’t tell me I can’t have cigarettes here. You’re going to hell. I hope you burn in hell with all those other dam Christians.” Driving to Aspiro Jim told me he was going to smoke in my car. I pulled over and made him get out. While outside the car he yelled at passing cars, “Fuck you! Fuck you all! The economy is going to crash and you’re all going to die!” He proceeded to flip others off and pull his pants down.
Once back in the car I asked when and what he had last had to drink and he responded, “8 shots of Tequila and 3 shots of whiskey about 10 minutes ago.” He had had the drinks between getting off the plane and meeting us in front of the airport. He proceeded to tell me had 30 grams of cocaine on him and offered me some. I put on some music and Jim calmed down. Soon we arrived at the Aspiro offices.
O – Jim mooned people while standing on the street corning smoking his cigarettes. He flipped people off and yelled profanity at them while driving from the window and standing on the corner. He drank and smoked 2 cigarettes within 15 minutes. Jim has just gotten out of state prison. Mom and Dad financially support him (he is 25). He does not stay on one topic in conversation. He is easily distracted. Records show he has previously been in drug rehab and that when drunk becomes violent.
A – Jim was drunk and had drugs in his system. He is addicted to cigarettes and is at Aspiro because of a court order. Because he is at Aspiro his parents will continue to financially support him. At this point, it is difficult to assess possible cognitive issues because of effects from the alcohol and drugs that are in his system. Jim has high impulsivity and aggressive levels. Jim does not understand the consequences of his actions.
P – Remove cigarettes and drugs from Jim’s possession and refer him for both alcohol and drug detoxification. I will also refer him for a psychiatric exam by 7/10/09.
S- Jessica Williamson, BSWI
Number 3
Name: Kirk Johns
Date: July 10, 2009
S- Kirk states, “I want a longer break from hiking.” When encouraged by myself or other students to continue hiking he says, “That’s it, every time someone else says something to me the time goes up that we wait here. I am not moving!” Kirk is refusing to hike, which means the rest of the group cannot continue on. He sees the problem as our fault for talking to him.
O- Kirk is controlling the rest of the group because he wants a longer break from hiking and does not want to be told what to do. When another student said, “Just be a man about it and come on.” Kirk becomes more upset and says we will wait there longer. In past weeks, Kirk has done similar things – refusing to pack, refusing to hike, refusing to eat, refusing to brush his teeth, etc – that cause the group to wait for him. The students are becoming more impatient and at times even hostile to him. Even when he is doing what he should and being helpful, they exclude him in conversation and activities.
A-This is an issue of control. Kirk knows what he wants which is rest and is also pushed around often by others. This is his way of controlling the situation so others will not push him around, even if that means he pushes them around. He struggles with continuity in social skills and in being defiant.
P- Wait out the behavior and not reinforce it. Implement consequences on the trail, and bring in support staff. Make sure therapist is aware of the battles of control. Have a group unity activity aimed at helping him feel more included. Make opportunities for him to show himself in a positive light.
S- Jessica Williamson, BSWI
