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  DR. Michael Shery, clinical psycholoGY

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www.carypsychology.com  847 275 8236 (24 Hrs);  drmike@carypsychology.com

  

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Dr. Michael E. Shery, Clinical Psychologist

2615 Three Oaks Rd, Cary, IL 60013, Ph: 847 275 8236

Illinois License #71-1937

 

Alcohol Use Assessment

 

Subject: Jon Doe; Date of Birth: 4-29-1980

Date of Report: June 5, 2010

Because this assessment is based on self-report, its accuracy is dependent on the respondent's ability and willingness to validly respond to questions presented. The interpretations arise from both test data and clinical judgments.

The client is a 31-year-old white male who reports no religious preference. He lives with his wife and children in a house in which they have lived for more than five years; he indicates that his diet is nutritious.

He reports eating lunch, dinner, and snacks and in his spare time, enjoying team sports, artistic, outdoor, mechanical and domestic activities, sporting events, movies, and television.

Situation Leading to Referral 

In 1999 the subject was working for a contractor in Elgin, Il. His employer acquired a drinking problem, eventually causing him to loose his driving privileges.

Once he lost them, the subject not only worked for him as a carpenter, but also became his driver. They would do construction and repair jobs during the day and estimates at night.

They both drank everyday at lunch. The subject got three DUIS in two years, which all hap-pened during work hours. He subsequently quit his job and has been without a drivers license for over eight years.

The subject now has his own successful business. His family has been driving him to work, including pulling a work trailer for him from job to job each day.

In August of 2010, the subject was informed that he must have a current evaluation done assessing his status as an alcohol abuser before he could be considered for reinstatement of his driving privileges. Therefore he requested this report to fulfill that requirement.

DEVELOPMENTAL HISTORY

As a child the client reports being very happy and recalls that he was ill no more often than his peers. As a teenager he reports being happy and healthy. Before age 18 he had a close friend with whom he could discuss nearly anything, however, he has no such friend now.

The client is not aware of childhood problems with toilet training or with learning to sit up, crawl, stand, walk, talk, feed himself or dress himself. He does, however, report a childhood problem with nail biting but no childhood fears or phobias.

He did not have any difficulties with coordination, excitability, or hyperactivity before age 13 and admits to no antisocial or daredevil behavior. Neither does he report any history of being sexually molested, running away from home, having suicidal preoccupations or attempting suicide as a child or teenager.

He recalls physically maturing at roughly the same time as most of his peers. He felt that he could discuss only certain aspects of sex with his parents and began dating before the age of 18.

He usually dated only one person at a time and did so weekly or every other week. His parents usually approved of the individuals he dated and the first time he had sexual intercourse he reports it being a positive experience.

Currently, he reports enjoying heterosexual intercourse and reports no homosexual experiences.

FAMILY OF ORIGIN

The client was raised by his adoptive mother and his adoptive father; his natural mother and father put him up for adoption. The client reports also having an adopted brother.

The client reports that his adoptive mother loved him, gave him enough time and attention and was usually able to talk to her about problems. He further asserts that she accepted him, criticized him when necessary and praised him for his accomplishments.

She was reasonably strict and always wanted to know where he was going and what he would be doing and she usually punished him when he misbehaved. To punish him, behaviorally, she would take away privileges.

He also reports that his adoptive father loved him, gave him enough time and attention also and that he was usually able to talk to him about problems. He also claims that his adoptive father accepted him, criticized him when necessary and praised him for his accomplishments.

His adoptive father was reasonably strict, allowed him a fair amount of freedom and punishment usually resulted if he discovered that the client had misbehaved. To punish him, he also would take away privileges.

EDUCATIONAL HISTORY

The client reports that his elementary school performance was usually good and denies having any serious behavioral problems there. In general, he liked elementary school and describes himself as being popular with most schoolmates.

In high school, however, he received mostly Cs and was placed in special classes for students with behavioral problems. His extracurricular activities included athletics and he reports having no major antisocial problems in high school.

The client describes himself as being somewhat popular with other students and as being generally happy in high school. He reports graduating from high school and trade/vocational school and attending but not finishing junior college.

MARITAL HISTORY

The client reports his sexual orientation to be heterosexual and he is currently married and living with his first wife and natural children. He lists his wife's race as white, religion as "no preference", and gender as female. She is reported having some college education, being a part-time student and he further reports having no significant relationship problems.

OCCUPATIONAL HISTORY/FINANCIAL STATUS

The client is self-employed, providing skilled labor in construction, has had his present job for approximately eight years, reports being satisfied with his work and is not thinking about changing jobs at this time.

He has been laid off from jobs in the past and resigned from a previous one because he was dissatisfied with it and an opportunity for a better one appeared. Over the past year he reports his business as growing but his income as being barely sufficient to pay for basic necessities because of a significant burden of debt.

LEGAL HISTORY

The client was charged with a criminal offense in the past, however,. there are no charges currently pending against him.

MILITARY HISTORY

He has never served in the United States military.

SYMPTOM SCREEN

The last physical examination the client had was within the last twelve months; he recalls having no problems at that time. His last dental exam was also within the last year and reports currently having some problems with his teeth and gums.

He reports having had surgery on one occasion and believes that he is currently in good health, though he also reports having recently been troubled by back pain. Importantly, this subject reports no longer drinking alcohol.

In the past, his drinking has resulted in traffic accidents and trouble with the law; he has attended AA meetings for his alcohol problem and has used cannabis in the past but does not do so now. No usual diagnostic signs of current pathological drug use were reported. although, in the past, substance abuse has resulted in some legal problems for him.

He reports having no episodes of depressed mood, diminished energy, loss of appetite, sleep disturbance or suicidal ideation lasting two or more weeks. Neither were any periods of elated mood or hyperactivity lasting one week or more reported.

He does not report having experienced psychotic symptoms such as thought broadcasting, thought insertion, or thought withdrawal, auditory distortions, hallucinations, grandiose beliefs, persecutory beliefs or feelings of being controlled.

The client reports having no abnormal anxiety or panic attacks or phobias. He denies having had unwanted repetitive thoughts or having performed repetitive acts.

_____________________________________________________________________

Structure of Assessment:The assessment consisted of 2 in-office interviews and administration of the Alcohol Use Inventory (AUI) and Personal Experience Inventory (PEI).

 

The following are the findings of the testing:

Alcohol Use Inventory (AUI)

Alcoholism includes several distinct conditions of maladjusted and maladaptive alcohol use. This report focuses on these separate conditions rather than simply using the global label of "alcoholic” as a broad brush descriptor.

Profile Trustworthiness and Consistency

Overall, this profile appears to be highly valid. This client's responses appear to be consistent and reliable.

DESCRIPTION AND ASSESSMENT OF ALCOHOL USE CONDITIONS

General Alcohol Involvement

This 31-year-old white male does not show clear preference for any particular type of alcohol consumed (beer, wine, liquor). The largest amount of alcohol consumed in any particular day is reported to be four to six cans of beer and one to three drinks of liquor.

On the last day he drank, he reports consuming four to six cans of beer and acknowledges very little involvement with the use of alcohol.

Manner of Drinking

The subject reports being drug-free and not having used alcohol since his last DUI, so these findings are only a report of his previous drinking behavior.

Individuals differ in the ways they use alcohol. This individual usually drank alone, away from social gatherings and parties. He may have used alcohol to withdraw from interpersonal interactions. He describes himself as having been a periodic drinker who did without alcohol for extended periods of time.

He was possibly a binge-style drinker, with drinking lasting anywhere from only a few hours, to several days. He says his alcohol-free periods extended to more than a month. There may have been a cyclical quality to his pattern of use.

Beliefs About Benefits Associated With Drinking

Alcohol is often used to enhance positive experiences, neutralize the effects of negative experiences, manage interpersonal conflict, alter mood, or reduce psychic or physical pain. It is important to understand how a person rationalizes its use.

Overall, this person reports that he derived very little psychological or social benefit from the use of alcohol. He says he seldom used it to enhance his social involvement or improve his mental functioning or to change his moods or deal with depression, anxiety, or stress.

Preoccupation With Alcohol

An individual can become preoccupied with thinking about alcohol. This focus can occur in both the sustained and periodic user. This does not seem to have been characteristic of this client however. He did not think obsessively about alcohol. There was no sustained pattern of use; alcohol was used in a periodic manner.

Disruptions

Disruptions can take on different patterns and characteristics which will differ from individual to individual. This particular individual reports having some had signs of life-functioning disruption associated with his previous use of alcohol.

Previous alcohol use has caused some disruption in this subject's social-role functioning. Such social-role dysfunctions include the occurrence of legal consequences for his previous drunken driving.

Concerns

The extent to which a person feels guilty or concerned about his drinking can be identified by the individual's report of feeling remorseful over the use of alcohol.

This client does not seem to be experiencing guilt or anxiety about his drinking, since he is no longer doing so, and also, is not focused on any particular remorse over his past drinking behavior.

Acknowledgment and Awareness

This person does not acknowledge a current alcohol use problem, but does acknowledge a previous one.

Other Drug Involvement

He does not acknowledge the use of alcohol or psychoactive drugs in the past 12 months.

Somatic/Medical Complaints

It is also common for alcohol clients to report medical and physical problems that may or may not be directly associated with alcohol use. This particular client, however, has stopped drinking and, therefore, does not report having any relevant or noticeable, alcohol-related stomach or digestion problems; swelling or puffiness of the hands or feet; numbness in the hands, feet, or toes; coughing up blood or blood in the stools; unsteady balance; or severe problems in swallowing.

SUMMARY OF ASSESSMENT

Summary of Major Conditions

Based on the previous descriptive analysis, this 31-year-old male client has had several alcohol-related conditions in the past which he reports have been successfully addressed. He currently reports that the overall influence and disruptive impact of alcohol use on his life is now non-existent.

A diagnosis of alcohol dependence is appropriate if the individual exhibits three or more of the specified symptoms at any time in the same 12-month period.

This individual's responses on the AUI indicate that he meets none of the diagnostic criteria for alcohol dependence and does not need treatment at this time.

 

____________________________________________________________________

PEI-A

Personal Experience Inventory (PEI)

PSYCHOSOCIAL PROBLEM SCREENS

This instrument is composed of several scales.

 

Part I: Drug Abuse Problem Severity

Based on his responses on the Personal Involvement With Drugs scale, the client reports encountering few, if any, immediate aversive reactions while using drugs. He acknowledges little psychological discomfort and few negative behavioral reactions as a result of drug use.

According to his score the Physiological Dependence scale, the respondent indicates an absence of physical symptoms of withdrawal, and little, if any, evidence of heavy tolerance to drugs.

This result suggests the possibility that he has engaged in little or no drug use.

His score on the Effects of Use scale indicates that this individual experiences few, if any, physiological signs of autonomic arousal in response to drugs.

He indicates that drug-related depression and irritability seldom occur and that paranoid feelings or suicidal thoughts when using are infrequent or nonexistent.

According to his score on the Social Benefits of Use scale, this individual currently derives few if any social benefits from drug use. He finds that drug use rarely improves his self-confidence or social skills. This result is consistent with the absence of drug use.

His score on the Personal Consequences of Use scale indicates that this client probably has few current problems resulting from drug use. He reports having rarely experienced difficulties with friends, relatives, or his spouse/partner because of drug use. It is unlikely that the respondent has committed illegal acts while under the influence of drugs or in order to obtain drugs.

He may, however, have experienced minor drug-related problems at work, and may have experienced personal injury as a result of drug use.

The score on the Recreational Use scale signifies that this client has engaged in drug use as a recreational activity. He has commonly used drugs in social settings, such as at parties, and at home on weekends, holidays, and days off. He may also have used drugs while driving a car or other motorized vehicle.

The client’s score on the Transsituational Use scale indicates that he probably no longer engages in drug use in varied settings. He rarely uses drugs before, during, or after work, if at all. This result may indicate that the person does not currently use drugs at all.

Based on score on the Psychological Benefits of Use scale, the client has frequently used drugs to reduce emotional discomfort, including feelings of loneliness, depression, boredom, and anxiety. Sometimes he has used them to enhance pleasure and to bring about positive feelings, such as happiness and tranquility. This use of drugs for psychological benefits is slightly below the average for those in drug treatment.

The score on the Preoccupation scale indicates that this individual is not preoccupied with drugs. This score suggests that he may not use drugs at all. If he does use drugs, he does not ruminate about such use, and does not restructure activities in order to promote his drug use.

This individual’s score on the Loss of Control scale suggests that he is not be using any drugs at all.

 

Part II: Psychosocial Adjustment

The client’s score on the Negative Self-Image scale indicates that he is not especially bothered by low self-esteem. He may, however, have some minor personal dissatisfaction or feelings of failure. Sometimes, he may feel guilty or ashamed of himself, and may feel like a failure for brief periods of time.

According to his score on the Psychological Disturbance scale, this client appears to have few perceived psychological problems, which is unusual for an adult being assessed for drug treatment. He is in no immediate emotional distress. In addition, he reports few, if any, disturbances in mood or thinking, and has no notable physical complaints.

The score on the Social Isolation scale suggests that this individual has occasional problems with feelings of social isolation, says social interactions are somewhat awkward for him, and may feel uncomfortable in certain social situations. Nevertheless, he feels that others generally like him.

His score on the Uncontrolled scale indicates that this client has little difficulty limiting or controlling his anger and aggressiveness, and rarely displays anger in public. He is respectful of authority figures and rules, and tends to be cooperative and conscientious.

He received a score on the Absence of Goals scale, which suggests that he feels hopeful about the future. He is aware of future plans and expectations, and is working toward his goals. This individual cares about how his life turns out and is intent on pursuing a career. He values education highly.

His score on the Rejecting Convention scale suggests that this individual maintains some traditional moral beliefs, although he also endorses some beliefs about right and wrong that may mark him as somewhat oppositional.

Based on the client’s score of on the Deviant Behavior scale, he rarely engages in oppositional or illegal behavior. However, he does have a history of minor trouble with the law, and must be conscious of the necessity of impulse control.

The client received a score of on the Absence of Goals scale, which suggests that he feels hopeful about the future. He is aware of future plans and expectations, and is working toward his goals.

This individual cares about how his life turns out and is intent on pursuing a career and values education highly.

According to his score on the Spiritual Isolation scale, the client has mild beliefs in a spiritual life or force, and occasionally uses prayer or meditation in times of stress. He may consider himself to be slightly or mildly religious.

The Peer Drug Use score indicates that the client used to have a group of friends who were moderately involved with alcohol and drugs. Some of them probably had trouble at home or work as a result of using alcohol or drugs. However, the subject appears to no longer have problems with this sub-group.

Based on his Interpersonal Pathology score, this individual reports no widespread family dysfunction, however, there may be an intermittent atmosphere of minor anger and hostility at times.

The client’s Estrangement in the Home score indicates family solidarity and closeness, and an absence of substantive conflict between him and his spouse.

Drug Abuse Treatment Recommendation

Overall, the client’s scores on the Problem Severity scales suggest that he does not require drug treatment at this time.

 

__________________________________________________________________

.

Diagnostic Impression:

According to DSM-IV, a diagnosis of substance dependence is appropriate if the individual exhibits three or more of the specified symptoms at any time in the same 12-month period.

SUMMARY

This individual's responses on the AUI and PEI indicate that he meets none of the DSM-IV criteria for substance or alcohol dependence and does not require treatment at this time. In sum, the subject appears acutely aware of the risks associated with using alcohol and drugs inappropriately in social situations and while driving and is very unlikelyto repeat his mistakes, particularly after undergoing all the consequences his previous alcohol abuse has entailed.

 

Respectfully Submitted,_________________________;________

Dr. Michael Shery, Psychologist Date

__________________________________________________

 

 

 

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