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6-1
1-1
60-10
60
-6
2. Drug & Alcohol History
First
drug
abused:
Age of onset:......................................:
Motivations at onset:..........................................:
...............................................................................................
Drugs used in the ...............................:
...............................................................................................past:
Drug of choice at present:.........................................
Dose:...................:
Duration:.......:
Duration .......:
abuse:
Pleasure
Apathy
Work conditions
Sense of comfort
Boredom
Isolation
Self medication
Peer influence
Family troubles
:
Other:
Negative
consequences
: )
a) psychological :
Suicide
Memory loss
Suspiciousness
Anxiety
Hallucination
Depression
Behavioral changes
Sedation
Flat affect
Psychiatric hospitalization
Others:...............................................................................:
: )
Guilt
Anger
Exciement
felling
&
Shame
nervousness
: )
c) Medical consequence :
Overdose
Severe withdrawal
Loss of consciousness
Seizures
AIDS
Loss of appetite
Liver cirrhosis
Psycho sezual
Tremor
Viral hepatitis
disorders
Chest infections
Peptic ulcer
.................Others................................................................................
..............................................................................
d)
Family
relationships
Divorce
Separation
Family quarrels
Family reputation
Others................................................................................
e)
Interpersonal
relationships
Violent behavior
Isolation
Absence from
Loss of friends
work
Suspiciousness
Fights with work colleagues & superiors
..................Others....................................................................................
.................................................................................
f)
Behavior
changes
:)
after
addiction
Shame
Forgetfulness
Fears
Lying
Aggressiveness
Hesitation
Perplexity
..................Others....................................................................................
.................................................................................
g)
Financial
Loss of property
Debts
..................Others....................................................................................
.................................................................................
h)
Legal
Arrest
Imprisonment
Homicide
Accidents
Drug dealing
Legal judgment
Theft
................................................................................................................
......................................................................................
Effect of legal problems on
relapse
.......................................................................................................................................
.......................................................
In-
No
Out- patient
patient
attempts
to
abstain
Yes
No
for
.......................................................
.................................................................................................abstinence
..
of
Present
stage
dependency
-1
Prodromal
-1
Crucial
-3
Chronic
-1
Recovery
Patients
insight
Got insight
Partial insight
NO
insight
.................Explain....................................................................................
..........................................................................................................
..........................................................................................................
........................................................
-1
3- SOCIAL CONDITION
Economical
level
Present job..........................................................................
......................................................................................
...................................................................................................................
.........................................................................................
.........................................................
Reasons of job
......................................................................................................loss
income
of
Source
Private
Family
Work
Friends
Drug dealing
narcotics
Housing
With
With family
Living alone
Others...................................................................................... friends
Dose he think that his neighborhood may affect his relapse?
Yes
No
residence?
No
Explain ....................................................................................
Family
Family
history
of
.........................................
..................................................................................................dependence
....
Family
situation
Substance use among parents or siblings
Difficulty to express
Jealousy
themselves
Death of a
Superficial relations
Parents
Parents divorce
parent
remarriage
Factors
of
family
cohesion
Psychological support
Understanding
Mutual respect
Financial support
Warm relations
activities
:
Marital
life
Number of wives .........................................................
Wife
....................................................... :
..........................................................................................personality
Males ...........
Disturbed
No.
of
children .......
.....
........................ Females.........
relations
with
..............................................................................................children
Separated
towards his
dependency
Submission
Not understanding
Refusal
Understanding
-1 ..........................................................................................
4- Support Network
( )
Positive
network:
Name .......................... Tel: ............................... :
Address: ..........................................................................
( : )
Negative network
-5
5- Pattern Of Daily Life
:
activity:
Daily
daily
of
Briefing
..................................................................................................................
..........................................................................................
Hobbies
Travel
Work
Club
Self-help group
Prayer
..................................................................................................................
..........................................................................................
( )
No work
Pears effect
Traveling
Family troubles
income Academic failure
Relapsing reasons:
Homeless
No
Religious faith
Others:...............................................................................
...............................................................................................
?Can the family help him to solve these problem
Yes
Explain...............................................................................
No
Explain...............................................................................
No
Why? .................................................................................
...............................................................................................
Yes
How?..................................................................................
...............................................................................................
?Does he want to change his life style
No
Yes
-2
6- Prognosis
His insight ..................................................... :
...................................
Present
.............................................................................................problems
..........................................................................................................
......................................................................................
Family involvement ............................................
..................................
good
with
Factors
............................................................................................prognosis
..................................................................................................
Factors with bad prognosis ....................................
-8
7- Case Summary
..........................................................................................................
..........................................................................................................
..........................................................................................................
..........................................................................................................
..........................................................................................................
..........................................................................................................
.............................
..........................................................................................................
....................................................................................
ASSESSED BY
...........
Date.........
()6
100
. , . , .
-125
( )
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: --------------
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------------------------
( )
17
11
11
13
11
11
14
12
15
19
17
11
11
13
11
11
14
12
18
19
37
31
31
33
31
31
34
32
38
39
17
11
11
13
11
11
14
12
18
19
17
11
11
13
11
11
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12
18
19
47
41
41
43
41
41
44
42
48
49
27
21
21
23
21
21
24
22
28
29
87
81
81
83
81
81
84
55
88
89
97
91
91
93
91
91
94
92
98
99
177
100
. , . , .
:
10
11
16
11
11
15
12
18
16
11
60
61
66
61
61
65
62
68
66
61
10
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11
11
15
12
18
16
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10
11
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11
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12
18
16
11
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51
56
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51
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52
58
56
51
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21
26
21
21
25
22
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81
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85
82
88
86
81
60
60
66
61
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ABSTRACT
Aim of the Study:
The present study investigate the extent of effectiveness of neurolinguistic programming in the relapse prevention through reaching to
the structure of the subjective experiences to substances abusers, that
related to their conscious and unconscious processes, and reframing
these experiences to maintain abstinence as a desired outcome, or the
relapse prevention as long time as possible.
Sample of the Study:
Six cases of substances abusers with mean age 24.17 years old.
Tools of the Study:
1- File of psychological examination for addicted patients.
2- Questionnaire of the relapse situations 100.
3- The strategies of reframing through the model of neurolinguistic programming that involved four stages of application:
1- The first stage: meta model, pacing and identify the
primary representational systems.
2- The second stage: sub- submodalities, six-step reframe and
anchoring.
3- The third stage: Desired outcome: behavioral change.
4- The fourth stage: Reassessment for further work in the first
and second stages: feed back therapist through six months after
follow-up.
Zagazig University
Faculty of Arts
Psychology Department
Prepared By
Prof. Dr.
2006