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Case Study: A 21-year-old woman with cocaine dependence, polysubstance abuse, bulimia, and borderline personality disorder

Case Study: A 21-year-old woman with cocaine dependence, polysubstance abuse, bulimia, and borderline personality disorder


OT Treatment Plan

OTAP1316 Psychosocial Occupational Therapy

Due date: week 10

Points and Percent Grade for Assignment: 16 points/25% of grade


The students will review the case study provided and identify pertinent information necessary to develop a treatment plan. The following are elements to include in the treatment plan:

●  Identify client’s abilities and limitations

●  Describe the impact they have on occupation

●  Describe ways in which the social, political, legal, economic and cultural environments impact client’s access to services

●  List any medications and describe potential side effects that could affect treatment

●  Identify a frame of reference on which to base the treatment approach

●  Identify activities for use in treatment, based on treatment approach

●  Identify any liability issues related to the OT treatment

●  Identify all precautions and safety needs

●  Describe the role of the OT, OTA and other professionals involved in this treatment approach

●  Summary

Case Study: A 21-year-old woman with cocaine dependence, polysubstance abuse, bulimia, and borderline personality disorder

Ms. Smith is a 21-year-old woman who sought treatment after the Department of Social Services threatened to take her two children, a boy aged 6 and a girl aged 2. Client stated that her neighbor reported her for leaving her children alone. Client is unemployed and on welfare. She said she couldn’t make enough money working to pay bills and childcare. Client has drunk alcohol and used pot since age 11. She has tried speed and diazepam (Valium) and has used cocaine by snorting, injection, and smoking.

Ms. Smith stated she has used crack for the past 9 months and denies any other drugs since then except an occasional beer. Client admitted to using her welfare check for drugs and selling her food stamps to obtain money. She was never married and did not receive financial support from the father of her children. Client, who is slightly overweight, was observed purging food in the bathroom of the detoxification unit and admitted to episodic purging to control weight.

Ms. Smith described herself as a good student in high school until her drug use became more important than studying. She has a high school diploma but did not attempt college, as she felt she could not afford it. Client’s parents both drank and were physically abusive to one another. Ms. Smith denies physical or sexual abuse of self or siblings by parents. Client reported she cooks, cleans, and takes care of all household chores independently. Ms. Smith stated she has been “out of control” since she took up crack 9 months ago, smoking approximately $200 worth 1 to 2 days per week at friends’ homes or crack houses. She admitted to leaving the children alone twice over the last month and was appalled to have slept with crack dealers to obtain drugs. Client is aware that she must get clean, or she will lose her children. She has never obtained a driver’s license but does have a car of her mother’s that she drives. She has no friends except other users, and other than drug use, her only leisure activity is renting a movie for the children. Ms. Smith stated that she feels depressed much of the time and has no energy.

OT goals identified:

1.  Client will obtain a driver’s license.

2.  Client will identify job and educational training interests.

3.  Client will identify activities to pursue with children at home and in the community.

4.  Client will improve energy level and decrease craving for crack through exercise and proper nutrition.

Papers should be at least one pages and no longer than two pages following the prescribed format.

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