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BIOPSYCHOSOCIAL ASSESSMENT

Jonel Biopsychosocial & Treatment Plan

D’Corey Sullivan

Department of Social Work, University of Mississippi

SW 687 Substance Use and Addiction

Dr. Fisher

April 12, 2021

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Demographic Information

Name: Jonel

Race: Native American

Residence: Browning, Montana (Reservation)

Age: 24

General Description

Jonel is a Native American female. She lives on an Indian Reservation (Blackfeet), an

underserved community where there are a lack of jobs and resources. Jonel said, “life on the

reservation is hard, there’s nothing but poverty, addiction and alcohol.” She was dressed

appropriately in jeans and a jacket. She wore her hair in a bun. She appeared underweight. Jonel

has 2 children a daughter Joselyn (6) and a son Thunder (14 months). Her first child’s father

(Sotana) is deceased and her second child’s father (unknown) is not currently in the picture.

Medical History

Jonel reported that she is addicted to Suboxone and Methamphetamine.

Jonel has given birth to two children

Any prior diagnoses were not specified.

Psychiatric History

When Jonel was 16 she lost what her family described as “the love of her life” and her first

child’s father Sotana in a tragic car accident. No other previous diagnoses, outpatient and

inpatient treatment, involuntary treatment, or danger assessment were specified.

Family History

When Jonel was born she born into a 2-parent household with her mom Windy and her dad

(unnamed). Growing up she had a normal childhood up until they moved, and her parents began
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to use drugs. Eventually Jonel’s father walked out on them causing Jonel, and mother who was

still an addict at that time to move back to the Reservation. Jonel was raised by her grandmother

Diana until her mother got clean. Her mother is currently still clean and has been raising Joselyn

(6) as her primary guardian since she was a baby. Jonel disclosed that she met the love of her

life, Sotana, at 16. They had been together for only 4 months when she found out she was

pregnant. Sotana unfortunately died in a tragic car accident just 2 days before the birth of their

daughter Joselyn. He was on the passenger side of the vehicle when that same side was struck

killing him upon impact. Jonel also has a son named Thunder who is 14 months old. His dad is

not in the picture. Jonel stated that she got pregnant with Thunder after a one-night stand.

Thunder was born addicted to Suboxone and wasn’t allowed to leave the hospital with Jonel so

her aunt Diana received custody of him. Jonel’s current boyfriend is Brandon. He is also a

substance user, he uses suboxone and methamphetamine. However, when him and Jonel first met

he was clean.

There’s a family history of addiction.

Marital History

Marital information not given. Jonel currently has a live-in boyfriend Brandon

Education

Education history not given.

Work/Military History

Jonel is currently unemployed and is receiving SNAP benefits.

No information on military history or other employment was given.

Legal History
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When Jonel gave birth to Thunder 14 months ago he was born addicted to Suboxone. CPS was

called and would not let Thunder leave to hospital in Jonel’s care. Her Aunt Diana and Uncle

immediately filed to be foster parents and has been Thunder’s primary guardian since he came

home from the hospital. Aunt Diana and her husband disclosed they are currently working on

legally adopting Thunder.

No other history of jail/prison sentencing, probation/parole, DUI’S or other legal charges were

reported.

AOD Current Use and History

Jonel’s family disclosed that after Sotana death, she began to party and drink. Her drinking then

evolved to Suboxone use. Jonel disclosed to taking a quarter of Suboxone daily, “I use my neck

vein because it’s the biggest vein I have on my body,” she said. Jonel also uses

methamphetamine when she cannot get Suboxone however she does in fact state, “I can now say

I’m addicted to both meth and suboxone.” She describes the two drugs as having very different

feelings, “high and low.” Jonel said, “when I take Suboxone it makes me feel tired and sleepy,

but when I want or need energy, I smoke meth.”

AOD Treatment History

There was no information given on previous AOD treatment.

Current social functioning

Jonel’s current social functioning with her family members is strained. Jonel’s continued

substance use is negatively affecting her relationship with Joselyn. Joselyn stated while in tears,

“My mommy is a liar, she tells me that she’s going to stay with me then and acts like she never

said it and leaves.” After everything is said and done Windy is left to pick up the pieces of

Joselyn shattered heart which then puts even more strain on her and Jonel’s relationship that is
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struggling because of her addiction. Jonel and Windy have an enabling relationship. Aunt Diana

stated, “If Jonel does go to treatment I’m worried that Windy would go get her if Jonel called

and asked her to.”

Jonel’s relationship with her current boyfriend Brandon is very codependent. They depend on

each to use drugs; they even inject each other with Suboxone. Jonel injects Brandon in a vein in

his arm and he injects her in a vein in her neck. Windy stated that, “Brandon controls my

daughter he doesn’t want her to get clean. The only reason I tolerate him is because I don’t want

Jonel to run off with him.” Jonel’s relationship with her aunt and uncle that are raising her son is

strained too. Her Aunt Diana stated, “we initially thought we would take Thunder in for a couple

of months until Jonel got herself together.” However, it has been 14 months and they are still

taking care of Jonel’s son while she continues to use drugs.

Jonel currently has no relationship with her father (unnamed).

Jonel currently has no relation with Thunder’s father (unnamed).

Current Functioning

Further evaluation would need to occur to rule out depression.

No evidence of suicidal, ideation, threats, plans, or paranoia.

Clinical Impression

I believe Jonel’s abuse of methamphetamine and suboxone stems from unresolved grief of

Sotana’s tragic death. I believe that this unresolved trauma/grief may hinder her from recovering

from substance use and sustaining sobriety. Her drug use negatively affects her relationship with

her family which includes her mother and 2 children. Jonel’s family I believe unknowingly

enables her drug use by caring for her children. I suspect Jonel knows her family will take care

of her children whether she is clean or not and takes advantage of that important aspect. During
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interviews Jonel appeared to have no deficits in memory, speech, and sense of reality. However,

when it comes to her attitude towards her addiction, she didn’t display negative or positive

feelings about it. I do not believe Jonel is at threat to harm others or herself at this time but if not

treated Jonel’s substance use will be fatal.

Diagnosis

o Opioid Use Disorder, Severe 304.00 (F11.20)

Treatment recommendation

I believe that Jonel is in the precontemplation stage of change. There was no information

given that suggest that Jonel wants to stop using drugs. Jonel has made no reported attempts to

get clean despite the negative affects her drug use has on her life including her not having

custody of her 2 children and her last child being born addicted to drugs. I am recommending

Cognitive Behavioral Therapy (CBT) as the modality for treatment; because it is a culturally

competent evidence-based treatment. I think Jonel will benefit from CBT because it will help her

challenge and/or change her thoughts and behaviors, improve her emotional regulation, and

develop healthy coping skills that helps her manage the grief of Sotana death.

Based on ASAM criteria I am recommending Jonel be place in an inpatient treatment center. I

based my decision off her potential withdrawal symptoms ranging from moderate to severe so

she would need to be monitored closely by medical personal. Also, Jonel’s currently living

environment on the reservation isn’t idea for recovery. The reservation has been described as

impoverish and oppressive and there is lack of resources for substance users and recovering

substance users. Jonel also has a current live in boyfriend, Brandon who a substance user.
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Jonel has little awareness on how the unresolve grief she is dealing is affecting her drug use. She

also seems to have little awareness on how much substance use has and continues to negatively

impact her life and will need intervention to make this awareness along with learning coping

strategies to stay in recovery and prevent continued use. CBT will address all of these aspects.

Treatment plan (this should be directly related to your preceding paragraph)

 Problem Statements—

1. Jonel is addicted to methamphetamine and suboxone.

2. Jonel’s currently living environment aids in her addiction and

substance use.

3. Jonel has two children and does not have custody of them because of

substance use.

4. Jonel has unresolved grief.

 Long Term Goals

1. Jonel will safely withdraw from using methamphetamine and suboxone.

(PS 1, PS 3)
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2. Jonel will learn how to utilize behavioral and cognitive coping skills to

help maintain sobriety outside an inpatient facility (real world). (PS 2, PS

4)

 Short Term Objectives (SMART)

1. Jonel will report withdrawal symptoms every three hours for the first two

weeks to medical staff. (LTG 1)

2. Within the last 30 days of treatment Jonel, in individual therapy, will learn

about triggers and trauma and implement relapse prevention strategies for

managing possible future situations with high risk for relapse. (LTG2 )

 Interventions

1. Medical staff will closely monitor Jonel and assess her need for

medication for withdrawal symptoms. (STO 1)

2. Use instruction, modeling, imaginal rehearsal, role play, and CBT to teach

the client cognitive behavioral skills for managing urges and other high-

risk situations. (STO 2)

Proposed method of evaluation of effectiveness of intervention


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1. Short Opiate Withdrawal Scale (SOWS) will be used to ensure Jonel is

safely moving through the withdrawal stages by monitoring her

symptom which is vital in her treatment. The SOWS will consist of 10

items and will be rated on a 4-point scale ranging from 0-none, 1-mild,

2-moderate, 3-severe. (STO 1)

2. Assess how Jonel rates her ability to use skills learned on relapse

prevention strategies and began to think of ways to apply these

strategies to her home life by using The New General Self-Efficacy

scale. The scale will consist of 8 items and will be rated on a 5-point

scale. 1-strongly disagree, 2- disagree, 3-neither agree nor disagree, 4-

agree, 5-strongly agree. (STO 2)

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References

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders

(5th ed.). Arlington, VA: American Psychiatric Association.

American Society of Addiction Medicine. ASAM Magellan Behavioral Health Checklist for

ASAM Adult Patient Placement Criteria-Second Edition Revised.

Bramble, K. (Writer), & Igoe, S. (Director). (2016, July 24). Jonel [Television series episode] In

M. Branton & G. R. Benz (Producers), Intervention. Arts & Entertainment Network.

Novins, D. K., Boyd, M. L., Brotherton, D. T., Fickenscher, A., Moore, L., & Spicer, P. (2012).

Walking On: Celebrating the journeys of Native American adolescents with substance

use problems on the winding road to healing. Journal of Psychoactive Drugs, 44(2), 153–

159. https://doi-org.umiss.idm.oclc.org/10.1080/02791072.2012.684628

Perkinson, R. R., Jongsma, A. E., Jr, Bruce, T. J., (2014). The addiction treatment planner (5th

ed.). Hoboken, New Jersey: Wiley

Short opiate withdrawal scale (sows). (n.d.). https://conductscience.com/portfolio/short-opiate-

withdrawal-scale-sows/.
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Appendix A
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Appendix B

According to ASAM six criteria, Jonel meets the criteria for Acute Intoxication

and/or Withdrawal Potential because she uses Suboxone on a daily basis and when can’t get that

she uses Meth. Jonel stated that when she takes Suboxone she is high for 8 hours of her day.

Jonel also meets the criteria for Biomedical Conditions/Complications, she is physically

underweight. Jonel’s Aunt Diana stated, “Jonel is so thin you can see the outline of her skull.”

In regards of Emotional/Behavioral/Cognitive Conditions and Complications Jonel meets the

criteria because has ACE’S. Jonel lost the love of her life , Sotana at 16 and has be living and

coping the best way she knows how with unresolved grief.

With criteria four Jonel appears to be in the precontemplation stage there was no information

given that suggest that Jonel wants to stop using drugs. She feels as if she needs it to stay well.

In criteria five I do have concerns about Jonel's continued drug use and possible relapse. Her

continued relationship with Brandon worries me that she won’t stay clean if they stay together.

Jonel also meets criteria 6, Recovery Environment. Jonel’s home on the reservation is very

oppressive and there is a lack of resources for recovering addicts. Holding all of this information

in mind, I am recommending Jonel to an inpatient treatment facility.