HomeMy WebLinkAboutMINUTES - 03011994 - H.5A H. 5 a►
TO: Board of Supervisors
FROM: Perfecto Villarreal, Director
Social Service Department
DATE: March 1, 1994
SUBJECT: APPEAL OF GENERAL ASSISTANCE EVIDENTIARY HEARING
D E C I S I O N B Y D E S S J A M E S
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SPECIFIC REQUEST(S) OR RECOMMENDATIONS AND BACKGROUND AND
JUSTIFICATION
RECOMMENDATION:
That the Board deny Jess James' appeal of the General Assistance Hearing decision.
BACKGROUND:
Claimant filed request for Hearing on October 15, 1993. The Hearing was scheduled
for November 23, 1993. The claim was denied.
Signature: (�
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ACTION OF BOARD ON March 1, 1994
APPROVED AS RECOMMENDED x OTHER
This is the time heretofore rescheduled by the Clerk of the Board of
Supervisors for the hearing on the appeal by Jess James from the General
Assistance Evidentiary hearing decision. Jewel Mansapit, General Assis-
tance Program Analyst, presented the staff report. Eleanor Madrigal ,
Contra Costa Legal Services Foundation, representing Mr. James, presented
testimony in support of Mr. James ' appeal . The hearing was closed and
on recommendation of Supervisor Tbrlakson, IT IS BY THE BOARD ORDERED
that the above recommenation is APPROVED; and the appeal by Jess James
is DENIED.
VOTE OF SUPERVISORS
X UNANIMOUS (ABSENT )
AYES: NOES
ABSENT ABSTAIN
Contact: Jewel Mansapit, 313-1601
Original:
cc• Social. Service Dept. I HEREBY CERTIFY THAT THIS IS A
Program Analyst TRUE AND CORRECT COPY OF AN ACTION
Appeals Unit TAKEN AND ENTERED ON THE MINUTES
County Counsel OF THE BOARD OF SUPERVISORS
County Administrator ON THE DATE SHOWN.
Jess James
CCLegal Services Foundation ATTESTED March 1 , 1994
PHIL BATCHELOR, CLERK OF THE
BOARD OF SUPERVISORS AND
C NTY INISTRATOR
BY Aj
D put Jerk
DATE: —/ —9
REQUEST TO SPEAK FORM
(THREE (3) MINUTE LIMIT)
Complete this form and- place it in the box near the speakers' rostrum before
addressingth Board.
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NAE: PHONE:
ADDRESS: CITY: a /
I am speaking formyself OR organization:
NAME OF ORGA!VI7.XTIOti)
Check one:
I wish to speak on Agenda Item #
.
My comments will be: general for _Z, aga-i t
I wish to speak on the s ject of '�
I do not wish to speak bu ea�e a commen or
a Boar to consider.
1
SOCIAL SERVICE DEPARTMENT CONTRA COSTA COUNTY
DATE: March 1, 1994
TO: Board of Supervisors
FROM: Perfecto Villarreal
oy
Director
SUBJECT: Appeal of General Assistance Evidentiary Hearing Decision by Jess
James
The appeal of Jess James was scheduled for February 15, 1994. At that hearing, in'
the absence of testimony by Mr. James, the Board of Supervisors adopted the
recommendation of the Social Service staff, which was to deny the appeal.
Mr. James and his representative, Eleanor Madrigal of Contra Costa Legal Services,
were in the building, but due to some confusion, not in the Board chambers when the
motion was made. The Social Service Department has agreed to request that the
Board reopen the hearing in the matter of Jess James' appeal.
The Department recommends that the Board of Supervisors deny the appeal of Jess
James.
Gen 9c (New 3/86)
CLERK OF THE BOARD
Inter-Office Memo
TO: Social Services Department DATE: February 24, 1994
Appeals and Complaints Division and
Program Analyst
FROM: Jeanne Maglio, Chief Clerk
Ann Cervelli, Deputy Clerk
SUBJECT: Hearing on Appeal from Administrative Decision
Rendered on General Assistance Benefits Filed By
Jess James
Please furnish us with a board order with your recommendations
and a copy of all material filed by both the appellant and the
Social Service Department at the time of the Appeals and
Complaints Division evidentiary hearing by February 25, 1994 plus
any information which your department may wish to file for the
Board appeal which is set for 2 : 00 p.m. on Tuesday, March 1,
1994 .
Attachment
cc: Board members
County Administrator
County Counsel
The Board of Supervisors Contra Phil Batchelor
Clerk of the Board
and
County Administration BuildingCounty Administrator
651 Pine St., Room 106 Costa (510)646-2371
Martinez, California 94553 County
Tom Powers,1st District
Jeff Smith,2nd District
...........
Gayle Bishop.3rd District
Sunne Wright McPeak 4th District
Tom Toriekson,5th District
0..
February 24, 1994 ........
Mr. Jess James
P.O. Box 389
Bethel Island, CA 94511
Appeal to Board of Supervisors
General Assistance Benefits
In response to your request and pursuant to Section 14-4 . 006
of the County Ordinance Code, this is to advise that a hearing on
your appeal from the administrative decision rendered in your
case on General Assistance benefits will be held before the Board
of Supervisors in the Board Chambers, Room 107, County
Administration Building, 651 Pine Street, Martinez, California at
2 :00 p.m., on Tuesday, March 1, 1994 .
In accordance with Board of Supervisor Resolution No.
92/554, your written presentation and all relevant material
pertaining to the appeal must be filed with the Clerk of the
Board (Room 106, County Administration Building, 651 Pine Street,
Martinez) at least one week before the date of the hearing. Your
attention also is directed to the other provisions of said
Resolution (copy enclosed) which set forth the General Assistance
Appeal procedure.
Very truly yours,
PHIL BATCHELOR, Clerk of the Board
of Supervisors and County
Admin'i@trar)ar
(y-
By_ I
-7Vn Cervellt—, Deputy Clerk
Enclosure
CC: Board Members
Social Service Department
Attn: Appeals and Complaints
Program Analyst
County Counsel
County Administrator
CC Legal Services Foundation
191E BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY,CALIFORNIA
Adopted this Order on August 4,1992 by the Wowing vote:
AYES: Supervisors Fanden, Schroder, Torlakson, Weak
NOES: None
ABSENT: Supervisor Powers
ABSTAIN: None
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SUBJECT: General Assistance Hearing } Resolution Number 92/154
and Appeal Procedures }
The Contra Costa County Board of Supervisors RESOLVES that the provisions of Resolutions No.
74/365,75/28, 87/468, and 88/576 which established standards for General Assistance Hearings and
Appeals are hereby superseded effective September 1, 1992:
Part 1
Hearings
101.- General Assistance applicants shall be given written notice of action to deny an application.
102. General Assistance recipients shall be given written notice, mailed at least 10 days prior to the
effective date, of proposed action which will reduce, suspend or terminate his or her General
Assistance grant for cause.Prior notice is not required for action resulting from Board of
Supervisors' changes in grant levels.
103. A General Assistance applicant or recipient shall receive a Social Service Department hearing
upon their timely written request.
(a) The applicant or recipient must deliver or mail a written request for a bearing within fourteen
days of the date the Notice of Action was mailed. Absent evidence to the contrary, the notice is
presumed to have been mailed on the date it bears, and a request for a bearing is presumed to
have been deliver ed on the date it is received and mailed on the date it is postmarked.
104. Where a GA recipient timely requests a bearing challenging a proposed action which will
reduce, suspend or terminate his or her General Assistance grant, the proposed action will be
stayed until a decision is rendered.
(a) Actions implementing Board of Supervisor changes in grant levels are not appealable, and
bearing requests based thereon may be summarily denied.
105. Hearings will be scheduled within thirty days of the date of receipt of a request for a hearing.
The Appeals Unit will mail a written notice of the hearing to the claimant at least ten days in
advance of the Hearing date.
106. When a request for a hearing has been received,the claim may be reviewed and resolved in the.
elaimanfs favor by a pre beating review.
(a) Proposed pre-heating resolutions shall be reviewed and approved by the Appeals Manager and
the General Assistance Policy Manager.
107. If the claimant is unable to attend the hearing at the originally scheduled date and time,and a
timely request for postponement is made,the Hearing Officer will make an evaluation of the
request.The bearing will not be continued beyond the hearing date unless authorized by a
Hearing Officer on one of the following grounds,which require verification:
(a) bearing is continued at request of the Social Service Department,
RESOLUTION NUMBER 92)554..
z
(b) mandatory court appearance which cannot be accommodated by adjusting the hearing time,
i
(c) illness which prevents travel,
(d) death in the immediate faintly,
(e) other substantial and compelling reason. (as approved by the Appeals Manager)
108. Decision
(a) A written decision shall be mailed to the claimant within thirty days after the hearing record is
closed,unless the Department extends the time in writing,for cause.
(b) Proposed decisions shall be reviewed and approved by the Appeals Manager and the General
Assistance Policy Manager prior to notification of the claimant.The Hearing Officer's findings
of fact are not subject to change,but the General Assistance Policy Manager may order re-
hearing for cause.
Part 2
Appeals to the Board
201. The applicant or recipient may appeal an adverse hearing decision to the Board of Supervisors.
202. A written appeal must be received by the C9erk of the Board of Supervisors%%ithin fourteen
days after the decision has been mailed to the claimant Absent evidence showing the contrary,
a hearing decision is presumed to have been mailed on the date it bears.
(a) An appeal to the Board will not stay the implementation of the Heating decision, and the
recipient shall not be entitled to continue to receive assistance pending further hearing.
(b) 71re appeal will be scheduled for the first available Board meeting,but no earlier than the third
meeting following receipt of the appeal.
203. The Administrative Review Panel may review appeals of Hearing decisions and recommend
proposed action to the Director.
(a) If the Director supports the heating decision,the Appeals unit will be notified to proceed with
the presentation to the Board.
(b) U the Director finds in favor of the claimant,the Clerk of the Board will be notified to
withdraw the item from the Board agenda.The appropriate Social Service District office will be
advised to take corrective action.
204: Both the appellant and the Department must file all written materials at least one week before
the date set for she Board hearing.Now material must be served by mail on the opposing party.
205.
(a) Upon bearing the appeal,the Board shall make any required fact determinations based on the
record on appeal and testimony received by the Board This record shall include the
Department's Hearing Officer's fact findings,plus any papers filed with that Officer.
(b) U the facts upon which the appeal is based are not in dispute or if any disputed facts are not.
relevant to the issue ultimately to be decided by the Board,the Board will proceed immediately
to the next step without considering fact questions.The parties may stipulate to an agreed set of
facts.
RESOLUTION NUMBER 92/354
206.
(a) Once the facts are determined,or if there are no fact determinations required by the appeal,
` the Board will consider legal issues presented by the appeal.Legal issues are to be framed,
insofar,as possible,before the Hearing and shalt be based on the Department's Hearing
3
Officer's decision and such other papers as may be filed.
(b) Appealing parties may make legal arguments both by written brief and orally before the Board.
V the issues are susceptible of immediate resolution,the board may immediately decide them at
the appeal bearing. If the County Counsel's advice is needed on legal questions,the Board may
take the matter under submission,reserving its final judgment until it receives such advice.
207. The Board may decide an appeal immediately after bearing or take the appeal under
«submission.
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RE50LunoN NUMBER 92/_n4
LAW OFFICES OF
CONTRA COSTA LEGAL SERVICES FOUNDATION
Main Office Telephone
1017 Macdonald Avenue West County(510)233-9954
P.O.Box 2289 East(510)439-9166
Richmond,California 94802 Central(510)372-8209
Fax(510)236-6846
February 14, 1994
Sent by Fax on 2-14-94 - 646-1059
Original Hand Delivered on 2-15-94 - a.m.
RECEIVED
FEB 1 51994
BEFORE THE BOARD OF SUPERVISORS
CONTRA COSTA COUNTY CLERK BOARD OF SUPERVISORS
CONTRA COSTA CO
In the Matter of:
Jess James Re: Board Hearing on Termination of
GA Benefits and Three Month
Period of Ineligibility
County No. 07-09-437022-C4FD
Date of Hearing Decision:
12-1-93
Board Appeal: 2-15-94
I. STATEMENT OF FACTS
This is an appeal of a hearing decision which found that Mr.
Jess James willfully failed, without good cause, to participate
in Workfare assignments on 9-23-93 and 9-30-93. A Board hearing
in the matter was initially set for 1-18-94. However, County
appeals staff continued the hearing in order to allow time for
Mr. James to undergo a Psychiatric evaluation through County
Mental Health Services in order to determine whether he is
disabled by alcoholism. Mr. James had previously attempted to
get an evaluation through the County Mental Health Services but
was turned away because he was not in a "crisis". Upon
intervention by County Counsel, Mr. James was allowed to a
Psychiatric Evaluation through Cunty Mental Health Services.
. A new Board Hearing in the matter was set for 1-25-94.
However, after review of the Psychiatric Evaluation prepared by
County Mental Health staff, Mr. James Representative asked for
and received, a continuance of the hearing for the purpose of
obtaining a more detailed evaluation of Mr. James disability.
Consequently, a new Board Hearing was scheduled for 2-8-94.
However, by letter to Mr. James dated 2-3-94, the county informed
him that his Board Hearing of 2-8-94 was rescheduled for 2-15-94.
The County Appeals staff allowed until 2-14-94 for submittal of
evidence and a position statement by Mr. James representative.
1.
As presented in a prior statement to the Board of
Supervisors on 1-14-94, by his representative, Mr. James did not
keep the Workfare appointments of 9-23-94 and 9-30-93 because he
had received a notice form the Department of Social Services
(DSS) that his aid was being terminated for a previous alleged
non-compliance. He did not realize that he must continue to
participate in Workfare while his appeal of the termination was
pending. For this reason alone, the hearing decision should be
set aside. In the alternative, the decision should be set aside
because James is disabled by alcoholism and should be exempt from
participation in Workfare. This disability causes Mr. James to
drink to the point of drunkeness each day, resulting in confusion
and lack of concentration, and at times, results in his having
black outs. GAADS has classified Mr. James as chemically
dependent due to his alcoholism.
The hearing officer found that Mr. James had not met his
"burden" of proving that he is disabled and that his testimony
about being confused about a prior hearing request was not
credible. We maintain he failed due to good cause per ADA rules.
II. STATEMENT OF THE LAW
Department Manual Section 49-111,11,G, @, provides that the
reasons which establish good cause for a failure to cooperate or
comply are subject to verification and include, but are not
limited to, the following:
a. The failure has occurred by reason of a disability under
the Americans with Disabilities Act
1. The burden of proof to establish that the
failure occurred because of a disability is on
the applicant or recipient
2. The applicant/recipient's showing may be
rebutted by the Department
b. employment has been obtained,
c. scheduled job interview of testing,
d. mandatory court appearance,
e. incarceration,
f. illness,
g. death in the family,
h. other substantial and compelling reason. These must be
reviewed and approved by the Division Manager.
Department Manual Section 49-111,11,H,1 provides that a willfull
act is one that is intentional or without reasonable excuse or
cause. It need not be done with a specific purpose to violate
program requirements.
a. The burden of proof to establish good cause, which may
include proof that the failure was not willful is on the
applicant/recipient.
b. The Department may rebut a showing of good cause by
proving that the failure to comply was willful, in which
case the Department has the burden of proof.
c. In all cases it is presumed, subject to rebuttal, that
the ordinary consequences of the applicant/receipient's
voluntary acts are intentional are intentional, and thus
willful.
2.
2. Willfulness cannot be be found where the person is mentally
disabled to the extent that s/he does not understand
his/her responsibilities or is incapable of fulfilling
them.
3. Conduct which involves negligence, inadvertence, or
disability may or may not be willful.
a. Three or more acts of negligent failure of the
recipient to follow program requirements, which may
include acts for which the recipient previously has
been discontinued from aid or sanctioned, evidence
willfullness.
Board of Supervisors Resolution #92/857 (Part 7, Section
703) adopted 12-15-92, provides: A recipient who fails or
refuses to comply with General Assistance Program Requirements as
expressed in this resolution or in the Social Service Department
Manual of Policies and Procedures whall be discontinued aid and
sanctions witll be imposed as follows unless the recipient shows
that the failure or refusal to comply was for good cause.
Department Manual Section 49-111,11,B,3,a. provides that
Disability means, with respect to an individual, a physical or
mental impairment that substantially limits one or more of the
major life activities of such individual; a record of such an
impairment; or being regarded a having such impairment.
Depa Department Manual Section 49-111,11,B,3,e. provides that the
phrase major life activities means functions such as caring for
one's self, performing manual tasks, walking, seeing, hearing,
speaking, breathing learning, and working.
42 Usc, Section 12101 states that the Americans With
Disability Act (ADA) is intended "to provide [a] clear and
comprehensive mandate for the elimination of discrimination
against individuals with disabilities". The ADA continues the
three test definition of disability used in the Rehabilitation
ACt of 1973. The tests are:
1. A physical or mental impairment substantially limiting
one or more major life activities (The impairment must
substantially limit a major life activity) .
2. Record of a physical or mental impairment. (this test
provides protection for an individual who previously had an
impairment . . . .
3. Being regarded as having a physicial or mental
impairment that substantially limits a major life activity (this
addresses concerns about attitudes of others, safety, and
liability, etc. ) (Rehabilitation Act of 1973, P.L. 98-112, 29
USC Section 791, et seq.
The third test requires an individual assessment based on
reasonable judgment, relying on current medical knowledge or the
best available objective must be made to ascertain:
a. The nature, duration, and severity of impairment(s) ,
b. the probability of risk of injury,
3
c. Whether risk can be mitigated by reasonable
modifications of policies, practices or procedures.
III. ARGUMENTS
1. The Determination Should Be Reversed or Termed Non-
willfull As the claimant .had good cause.
First, Mr. James had good cause for missing Workfare
appointments on 9-23-93 and 9-30-93 and did not willfully fail
to follow program requirements. As he testified at his hearing,
he believed he no longer had to attend the appointments because
his aid was being terminated for a prior alleged non-compliance.
He stated he did not know that he had to continue to participate
in Workfare while his appeal of that action was pending. The
Hearing Officer's reason for finding that Mr. James willfully
failed to comply with program requirements was that the need to
appear for appointments was reviewed with him on 8-26, before he
filed for his hearing on 9-24 on the prior failure. The hearing
officer failed to consider that although Mr. James filed for a
hearing on the prior failure, he still had a GA termination
looming and for this reason believed that he did not have to keep
future Workfare appointments. The hearing officer stated that
Mr. James explanation regarding his understanding about keeping
future Workfare appointments pending a GA termination, was not
credible. All medical and mental evaluation reports submitted to
date do not indicate that Mr. James is someone who has difficulty
with telling the truth (See enclosed Pittsburg Health Center
records of 3-8-93, 1-24-94 and 1-31-94, Psychiatric Evaluation by
Karen Pratt, M.A MFCC dated 1-24-94, Psychological Evaluation by
Beverly- Ballard Ph.D, dated 2-10-94, ) Additionally, it is
conceivable that due to the effects of alcoholism, Mr. James
didn't understand about keeping future Workfare appointments
pending a termination of GA benefits. For this reason alone the
decision should be set aside.
2. The Determination And Imposition Of A Sanction Should Be
Reversed As The Claimant Lacked Capacity Under The Americans With
Disabilities Act.
Secondly, the decision must be set aside because Mr. James
is disabled and unable to work due to alcoholism. Due to his
continuing disability, Mr. James should be exempt from
participation in Work Programs.
A 1-24-94 psychiatric evaluation of Mr. James by Karen
Pratt, a Marital and Family Counselor with the County Mental
Health Services, fails to fully address the extent of Mr. James
disability due to alcoholism. In addition, the report does not
assess the severity of an existing personality disorder. No
formal testing was performed for the evaluation. Thus, the
evaluation does not adequately assess the severity of Mr. James
disability. In addition, the report does not fully explore Mr.
James past work performance. He told the examiner that he used
drugs and alcohol on all jobs he's had, but there was no
assessment of how his use affected his job performance.
4.
Thus,. it is unclear how Ms. Pratt-'s conclusion that Mr. James
"ability to hold a job seems unaffected even in light of his
current alcohol problems" was arrived at. There is no evidence
to support this conclusion. To the contrary, Mr. James Work
Programs records (see copies of Work Program records attached)
reveal dates when he did not attend, arrived tardy, or arrived
drunk to his appointed job site. In addition, the records
reflect that in one instance, he had a clash with a supervisor
while at a job site, which resulted in her requesting that he not
be not be sent back to that particular job site because of a "Bad
attitude". .
In her 2-10-94 evaluation of Mr. James, Beverly Ballard,
Ph.D, conducted formal tests. In her report, Dr. Ballard states
that although Mr. James falls in the high end of the borderline
intellectual range in verbal and full scale IQ testing, . . . .
"It is likely that he functions in the low average range and
these scales reflect poor aquisitation of verbal skills,
particularly, since he started drinking at age 8. " She further
states that he "exhibits memory problems often associated with
chronic alcohol abuse". She adds that "he falls in the 10th age
percentile on these scores reflecting that 90% of individuals in
his age range do better than he". Upon administration of the
MMPI, a test to determine the existence of a personality
disorder, Dr. Ballard states that the evaluation presented a "cry
for help profile". She further stated that "the profile
evaluations reveal a chronic tendency toward schizoidal
withdrawal, social seclusion, and depression." She added that
"individuals with this profile have poor adaptive skills for
their lack of confidence, insecurity and feelings of social
inadequacy", and she also states that "he managed to work
steadily until age 22 despite his alcohol reliance, but his work
history has been intermittent since that time. " Dr. Ballard
concludes that Mr. James "has a substance abuse disorder,
characterized by regular use of alcohol" Additionally, she
states that "He shows some mild signs of congnitive impairment
based on alcohol use. This is manifested by slow motor
performance, and motor learning tasks, ability to sustain
attention to tasks (distractibility) , decreased ability to learn
complex verbal tasks, and impaired ability to maintain new
information into intermediate memory. She further states that
"he is depressed in mood, has marked restriction of daily
activities of daily living and difficulty maintaining social
functioning", and that Mr. James cognitive deficit along with an
attention deficit disorder and early use of alcohol "are going to
affect his reliability, dependability and performance". With
regard to risk of injury, Dr. Ballard states that "He fell off a
roof in the past, while under the influence of substances, and he
readily admits "being stoned" on all his jobs".
An individual assessment based on reasonable judgment,.
relying on current medical knowledge or the best available
objective must be made to ascertain:
a. The nature, duration, and severity of impairment(s) ,
b. the probability of risk or of injury if Jess James is
required to participate in GA-employable activities, (unlike
GAADS meetings which are unrelated in this case and appeal) , and
5.
r
c. whether his medical and/or mental impairments by
reasonable modification of CCC/DSS GA Workfare policies,
practices or procedures can be provided by auxilliary aides or
services. By this appeal, we formally request that the county
review his records of disabilities for a determination that he is
GA-U.
By conducting an individual assessment as outlined
above, it must be found that Jess James is an unemployable man
due to alcoholism. Mr. James began drinking at age eight. He
admits to drinking "anything" including anywhere from a "six pack
of beer to a pint of hard liquor a day". Medical records from
the Pittsburg Health Clinic and recent mental evaluations support
the a finding of a disabling -impairment due to alcoholism.
claimant's impairment of apparent that Mr. James continued use
of alcohol has affected his ability to maintain steady
employment, and to comply with GA Work Program requirements.
Because of his substance abuse, he is an active participant in
the General Assistance GAADS Program (verified in GAADS records)
However, his participation in the GAADS program in no way implies
that he has the capacity to participate in Work Programs. GAADS
meetings are not comparable to working an eight hour day.
It is apparent that the county cannot accomodate an
"employable" alcoholic such as Mr. James. He is so disabled by
alcoholism that it limits his ability to perform in a work
setting. In addition, Mr. James has a personality disorder,
attention deficit disorder, impaired social functioning,
depression, and memory problems, all compounded by his
alcoholism. Mr. James has applied for Supplemental Security
Income Benefits (SSI) due to his disabling impairment. (For
further reference to vocational implications of alcoholism, see
attached Section on alcoholism from the U.S. Department of
Rehabilitation Services Administration's Handbook of Severe
Disability - 1981 edition - current) .
The risk of injury to Mr. James is serious enough when one
considers the fact that on the days when he does attend Work
Programs appointments, he has already consumed alcohol. He
testified that he drinks every morning. This in itself puts him
at serious risk of injury in his daily performance of work
related activities. His judgment, concentration, and insight are
already impaired upon his arrival to a job site.
It is reasonble to conclude, on the basis of Dr. Ballard's
report, that if Mr. James were to continue in Work Programs, he
is at risk for injury to himself, and possibly those around him.
The evidence supports the claimant's position that he lacks the
capacity to participate in Work Programs due to a disabling
impairment.
6.
r
IV. CONCLUSION
CCLSF requests that the Board of Supervisors comply with
their own Board Order, #92/857, and with county and Federal Law.
RESPECTFULLY SUBMITTED,
CONTRA CO LEGAL SZRVICES FO DATION
E eanor Madi al,
?t1
Paralegal
7.
B IV ca Z>syc�o'Zogfs•t
P.O. BOX 245 PTE. RICHMOND, CA 94807 510-232-7732
February 10, 1994
Contra Costa Legal Services Foundation
1017 Macdonald Avenue
P.O. Box 2289
Richmond, Ca 94802
Attention: Eleanor Madrigal, Paralegal
Re: Jess James
Psychological Evaluation
REASON FOR REFERRAL: Jess James was referred by Eleanor Madrigal who
is processing Mr . James ' appeal for resumption of General Assistance
(GA) . She requested a psychological evaluation with psychological
testing to ascertain the extent, effects, consequences, and prognosis
of his substance use, outlining 10 specific questions which will be
addressed in the body of the report.
PERTINENT DATA: Jess James is a 35 year old male who was terminated
from GA benefits of $300 per month after allegedly failing to attend
two work fare appointments, 9/23 & 9/30/93. Mr . James did not attend
those two sessions because he had reportedly received a termination
notice for a previous alleged noncompliance and because he was
appealing that termination, he thought he was exempt from work fare.
That decision is being appealed on this basis, but in addition, there
is a question about the relationship between his regular alcohol use
and his behavior and how that might affect his participation in GA
work programs . Jess James appeared on time on 2/03/94 and completed a
clinical interview with personal history and six test instruments .
TESTS ADMINISTERED: Trails A & B, from Halstead Neuropsych Battery e
Wechsler Adult Intelligence Scale-Revised (WAIS-R)
Wechsler Memory Scale-Revised (WMS-R)
Controlled Oral Word Association Test (COWAT)
Bender-Gestalt (BG)
Minnesota Multiphasic Personality Inventory, Revised (MMPI-II )
OBSERVATIONS AND TEST BEHAVIOR AND MENTAL STATUS EXAMINATION: Jess
James is a medium-built, 35 year old, caucasian male who dressed in a
flannel shirt, jeans and wore a cap on his head . He was adequately
groomed with a beard, mustache and nape-length curly hair . His
affect was pleasant and honest, and his mood was anxious . His speech
was coherent and there was no evidence of hallucinations, delusions
or a thought disorder . He did not appear under the influence of
intoxicants, although he did report that he had had a "bourbon and
coke and a beer" that morning. There was no evidence of malingering
and he appeared to do his best on the test protocols. He had some
difficulty remembering details of his history, and noted that his
"short-term memory is shot" .
Ab
PSYCHOLOGICAL EVALUATION OF JESS JAMES CONTINUED: 2
His alcohol history includes beginning to drink at age 8, "with my
brother" . He has used most drugs in the distant past, but only
occasionally smokes marijuana now. He has- never been in voluntary
treatment, has no known medical problems, and admits that alcohol
"interferes with my daily life" . His longest sobriety was 45 days,
during an incarceration two years ago for trespassing while
intoxicated. He has never had alcohol-related seizures, but he does
have blackouts and shakes . His fine motor hand coordination was
visibly shaking during pen and pencil tests and reflects the usual
problem .of chronic alcohol users in fine motor control .
He was very anxious about performing the tests, often wanted to know
if he got the correct answer, and actually enjoyed some of the test
tasks, especially those that demonstrate his skill areas . He was
self-denigrating when having difficulty with responses . When given
the 350 question MMPI, where he had to mark true or false, he asked
if he could randomly mark it, "like I did in school", but was asked
to honestly read and answer the questions . The results of this
interview and the test data appear to reflect his current
psychological and cognitive functioning.
INTERVIEW: Jess James reported, unsuredly, that he had not received
General Assistance for December, January or February, although he
does get food stamps . He lives "homeless", sleeping in his non-
operative car and showers at friends ' houses . He repeated that he
had been on appeal for a missed work-fare discontinuance and did not
think he was obligated to attend work-fare while on appeal . Thus his
contact with legal-aid paralegal Ms . Madrigal . He has been on
General Assistance since 1991, after losing his last job as a
maintenance worker for an apartment complex in 1990 . He attends the
GAADS program for substance abusers, but says it is "generally a
hassle", although "there are some good conversations. He would not
attend the once a week, 1 1/2 hour group if not mandatory.
His alcohol use began at age 8, "drinking beer with my brother" . He
prefers 100 proof schnapps, but drinks "anything. He has early
morning shakes, and begins using first thing in the morning to
eliminate the ahakes . He was vague about how much he drinks, saying
he drinks til he "passes out" . He has had numerous blackouts, but no
seizures, and went through a week of sickness, without
hospitalization, when he was incarcerated two years ago. His drug
use includes "everything", and he once was dependent on speed, while
being a dealer . He has been incarcerated once for dealing
methamphetamine, three times for driving under the influence and
again for driving with a suspended license and no insurance. He
shoplifted a candy bar once as a child, and burglared one residence
In his teens, "an event I 'm not proud of" . Criminal activity has not
been a modus operandi for him.
Work History: Jess 's steadiest job was from age 17-22 when he worked
in a warehouse. He acknowledges being a "very good worker", though
he was often loaded. He usually was laid-off from jobs which were
short-term manual labor and he says his bosses always knew he was
loaded, so he is uncertain what role that played in his lay-offs. He
has subsequently worked for oil-refinerys, was a basket tree-trimmer,
shipping and receiving clerk, truck and forklift driver, and
carpentry; he has his own tools . His oldest brother is a carpenter .
PSYCHOLOGICAL EVALUATION OF JESS JAMES CONTINUED: 3
Past History: Jess was born, the youngest son of three boys, to his
father and mother who are still married . His father retired from
civil service for the Air Force because of two heart attacks and lung
problems . His mother 's health is good. Alcohol was "always around"
but he was not aware of either parent being alcoholic. He was
hyperactive as a child and prescribed Ritalin, which he refused .
When Jess was 18, the family moved to California, while he remained
in Texas and Oklahoma, where he had a girlfriend and did carpentry.
He moved here in 1984 and shortly thereafter he fell off a roof,
crushing his heel, and keeping him from employment for about a year .
He said "it has been downhill ever since" .
He has had a few girlfriends, but he has never married and has no
children. He has contact with one brother who has a family in
Oklahoma and is on physical disability for injuries> He has no
contact with his California brother, "whose wife controls him" and
wants nothing to do with Jess . . He occasionally visits his parents,
who always ask about his alcohol use. Both brothers were alcoholics
and his "role models" .
His daily activities include "hanging-out" and fishing with fiiends .
He lives on Bethel Island around other alcoholics and has to hitchike
10 miles to the nearest bus stop. He once had a driver 's license,
but it was long ago suspended; he has never had a California
license. He has driven without a license, but his car is currently
broken-down and he sleeps in it or at friends ' houses . He eats "once
a day—out of a can", or "with friends", not using any food
programs .
He sees his life as a "vicious circle" . He is out of money within 10
days, then borrows and pays back . He does not receive medical care.
He said he was able to get to GAADS and work-fare until about
October . If he missed because he was "too drunk", he usually was
able to get to the Brentwood Clinic to get a medical excuse.
Occasionally, he has gone off General Assistance when he would get
temporary carpentry jobs, so his use has been somewhat sporadic. He
says he is unable to promise that he will keep an appointment because
it is entirely dependent on the effects of his alcohol use.
His sleep is fair, his mood "easy-going", but generally describes
himself in a happy mood, "going with the flow" because there's no
point in worrying. He occasionally gets depressed and "has an
attitude. "
TEST RESULTS: Intellectually, Jess falls in the high end of the
borderline intellectual range in verbal and full scale, and in the
low end of the low average range on visual-motor tasks (VIQ=79;
PIQ=81: FIQ=79 ) . There was no indication of diffuse organic or
localized organicity. It is likely that he functions in the low
average range and these scales reflect poor acquisition of verbal
skills particularly, since he started drinking at age 8.
PSYCHOLOGICAL EVALUATION OF JESS JAMES CONTINUED: 4
The memory indexes reveal comparable scores in the high borderline
range for attention/concentration and visual memory (79 and 78,
respectively) with low borderline ranges in verbal memory, general
memory and delayed memory (70, 70 & 73, respectively) . These latter
scores reflect the memory problems often associated with chronic
alcohol abuse. He falls in the -loth age percentile on these scores,
reflecting that 90% of individuals in his age range do better than
he. He does show ability to learn through visual association tasks,
with a slowed encoding process that does consolidate into long term
storage. Verbal learning tasks are limited to simpler, rather than
complex tasks.
Other tests revealed no frontal lobe impairment (COWAT, Clock Times )
and sequencing tasks revealed mild impairment in motor speed .
Tremulous lines and careless mistakes occured on the BG, which is a
motor copy task, and reflects very soft signs associated with chronic
alcohol use, as does the slowed motor speed.
PERSONALITY: The MMPI is a forced-choice, self-endorsed personality
inventory and this evaluation is based on this instrument solely. He
responded in a valid, typical test-taking manner, indicating balance
between disclosure and openness, and presenting a cry-for-help
profile. The profile elevations reveal a chronic tendency toward
schizoidal withdrawal, social seclusion and depression. Individuals
with this profile have poor adaptive skills for their lack of
confidence, insecurity and feelings of social inadequacy. Although
likely to be a conscientious, hard-worker, such individuals often
have difficulty handling authority issues which affects their job
stability. Angry feelings are not easily expressed and somatic
symptoms and withdrawal may replace them. There appears to be an
underlying ocnflict over dependency needs which is handled by keeping
emotional distance, especially from the opposite sex. Jess does not
have the profile typical of alcoholics, therefore his use may reflect
an early learned and reinforced behavior pattern which interfered
with healthy and normal adolescent development and mastery over the
vissitudes of daily life. He managed to work steadily until aged 22,
despite his alcohol reliance, but his work history has been
intermittent since that time.
RESPONSE TO QUESTIONS AND CONCLUSIONS : 1. Yes, Mr . James has a
substance abuse disorder, characterized by regular use of alcohol .
2. He shows some mild signs of cognitive impairment based on his
alcohol use. This is manifested by slowed motor performance and
motor learning tasks, ability to sustain attention to tasks
(distractability) , decreased ability to learn complex verbal tasks,
and impaired ability to maintain new information into intermediate
memory. He is not disoriented nor does he have hallucinations or a
delusional disorder . He is depressed in mood, has marked restriction
of activities of daily living and difficulty maintaining social
functioning. His attention deficit and distractability is likely to
eventually affect his work performance and reliability.
PSYCHOLOGICAL EVALUATION OF JESS JAMES CONTINUED: 5
3 . Clinically, Mr . James shows a lot of motor tension and
performance anxiety; he was diagnosed with attention deficit disorder
as a child and prescribed Ritalin, which he declined to take. His
personality test (MMPI ) revealed depression and schizoid personality
features, which are withdrawal tendencies into fantasy and avoidance
of social interactions . The early use of alcohol appeared to affect
his developmental maturation, and shaped his personality.
Paradoxically, the inadequacies that he experiences may be self-
medicated through the use of alcohol, and the vicious cycle
continues .
4. Mr . James reports a crisis in living in the fall of 1993, wherein
he lost his usual housing and was forced to retreat to his car and
with friends .
5. He reports ever-increasing interference in his activities of
daily living by his continued use of alcohol . He has not been
motivated to seek treatment or rehabilitation for this problem.
6 . The impairments described in #2 and #3 are going to affect Mr .
James ' reliability, dependability and performance. It appears that
he was able to get medical excuses or make contact until he lost his
abode in the fall of 1993.
7 . On quick perusal of Mr . James ' GAADS records, it appears that he
was valued early on as a hard-worker, but his reliability
deteriorated overtime. This would seem typical behavior of a chronic
alcohol abuser .
B . I am not certain of the risk of injury for Mr . James if he
participates in work programs . He fell off a roof in the past, while
under the influence of substances, and he readily admits "being
stoned" on all his jobs . It appears that the laws of probability are
likely to catch up with him with time and aging, just as his
incarcerations were related to driving under the influence and with
suspended license. Alcohol suspends concern about the consequences
of one's behavior .
9 . Whether risk of injury can be mitigated by provision of
auxilliary aides or services I cannot determine. The use of such .
services would seem to depend on some alcohol-related screen related
to the . level of intoxication. Mr . James is capable of being
reasonable, but alcohol is a disinhibiting contributor to behavior
and judgment .
10 . Mr . James is young enough that if he were motivated to engage in
sobriety, the symptoms he exhibits are mild enough to possibly be
reversed. This can take up to a year of sobriety.
If you have any further questions, please feel free to call 232-7732 .
Respec lly submit ,
Beverly Balla , Ph.D.
Clinical Psychologist
4 .
C23xi3 �� Z Psy�ha2cy�►.i � t
; . P.Q.__ BOX Z45 PTE. RIGHMOND, CA 4807 ( 4151 32-773
WMCATION ANQ,HONQRS:-
1980: PH.D. - CALIFORNIA SCHOOL OF PROFESSIONAL PSYCHOLOGY - BERKELEY
California State Fellow, Clinical Psychology, 1975-1980
1975: B.A. - SAN FRANCISCO STATE UNIVERSITY - Summa Cum laude
Psychology Major - San Francisco, California
SINCEI
1983- CONSULTING CLINICAL PSYCHOLOGIST AND MEDICAL STAFF MEMBER
Mexrithew Memorial Hospital, Martinez, Ca
-DIAGNOSTIC EVALUATIONS -and psychological treatment of
medical patients .
"CONSULTATION AND LIAISON to physicians and inter-
disciplinary staff regarding behavioral management
and therapeutic interventions of medical patients.
"BRIEF PSYCHOTHERAPY with patients and their families with
anxious or depressive adjustments to health disorders,
life-threatening or disabling diagnoses.
'NEUROPSYCHOLOGICAL ASSESSMENTS of braln-injury with
cognitive rehabilitation treatment recommendations;
family and patient interventions and follow-up.
"CHRONIC PAIN CLINIC COORDINATOR providing assessment, multi-
disciplinary group treatment and consultation to primary
physicians .
"GROUP FACILITATOR FOR CHRONIC PAIN, wellness, cancer and
disability and cardiac rehabilitation.
"PSYCHIATRIC EMERGENCY assessments, crisis , intervention,
admissions, involuntary holds, family interventions,
alcohol and drug treatment, community liaison.
"FACULTY MEMBER of Family Practice Medical Residency Program.
"SUPERVISION of doctoral interns . -
1979- PRIVATE PRACTICE 2340 Ward St. , 8105, Berkeley, Ca.
3249 Mt.Diablo Blvd, 210, Lafayette, Ca.
"BRIEF THERAPY with individuals., couples, and families.
"NEUROPSYCHOLOGICAL and psychological assessments .
1980- ADJUNCTIVE FACULTY-CALIFORNIA SCHOOL OF PROFESSIONAL PSYCHOLOGY
"CLINICAL SUPERVISOR of doctoral interns, of first year
Interviewing Techniques students, and team member of
Clinical Proficiency Performance Review evaluators .
1983- CONSULTING EXAMINER- SOCIAL SERVICE ADMINISTRATION
"'DISABILITY EVALUATIONS for Federal social service disability
19$5- COMMISSIONER - PSYCHOLOGICAL EXAMINING COMMITTEE, SACRAMENTO
"ORAL EXAMINER for California State Psychology Licensure
1987- NEUROPSYCHOLOGIST - CONTRA COSTA HEALTH PLAN
BEVERLY BALLARD, PH.D. PAGE 2
PREVIOUS PROFESSION&L EXPERIENCE:
1979-83: CLINICAL PSYCHOLOGIST = ACUTE PSYCHIATRIC SERVICES
"TEAM LEADER with direct clinical caseload and clinical,
and administrative supervision of case assignment/
management/ disposition by teal members .
"DIAGNOSTICS/TREATMENTPLANS on dmission . and discharge.
"BRIEF PSYCHOTHERAPY with individuals/couples/families
with a wide-range of psychiatric diagnoses .
-CONSULTATION for psychophaxmacology, ,and with Community
resources for discharge continuity of care.
"GROUP PSYCHOTHERAPY three times weekly.
"PSYCHOLOGICAL ASSESSMENTS and reports .
"ADMINISTRATIVE reports/program planning/staff development
"SUPERVISION of pre-doctoral interns .
'"FORENSICS for conservatorships, patients ' rights,
legalities of involuntary W & I/jail holds 6 Medi-Cal..
1978-79: PSYCHOLOGY INTERN - COMMUNITY MENTAL HEALTH, MARTINEZ, CA.
"BRIEF AND LONG-TERM THERAPY-individuals/couples/families.
GROUP TREATMENT for weekly women's depression group.
"FAMILY THERAPY of identified high=risk pediatric cases .
"SUPERVISION of medical resident in family co-therapy.
1977-78: PSYCHOLOGY INTERN - PSYCHIATRIC EMERGENCY &' CRISIS SERVICES
COMPREHENSIVE ASSESSMENTS of crisis clients, involuntary
and voluntary, drug/alcohol brain syndiames, organic
and personality disorders, suicidal/homicidal behavior
children through geriatrics in life crises .
"CRISIS INTERVENTIONS in brief model, and inpatient admits
"PSYCHOLOGICAL TESTING and reports.
1976-77: PSYCHOLOGY MASTERS TRAINEE - Alameda Mental Health Clinic
"INTAKE ASSESSMENTS, drop-in evaluations/telephone intakes
"BRIEF PSYCHOTHERAPY with individuals/couples/families .
-PSYCHOLOGICAL TESTING and reports .
1974-76: AREA COORDINATOR - PARENTAL STRESS SERVICES - OAKLAND
"CHILD ABUSE PREVENTION 24 HOUR CRISIS HOTLINE
"CASEWORK MANAGEMENT of 300 monthly telephone crisis calls
"ADMINISTRATIVE scheduling and case assignment to 40 para-
professionals, with follow-up consultation, training,
and case conferences .
"CRISIS INTERVENTION/BRIEF THERAPY, in-home assessments and
intervention with high-risk families of violence.
"GROUP THERAPY weekly for high-risk parents.
1915-19: GROUP FACILITATOR/INSTRUCTOR - Parenting Class for high-risk
parents funded by Adult School Education and liaisoned
with Alameda Mental Health.
"GROUP FACILITATOR - 4 year weekly group focused on commun-
ication skills, role expectations, value systems,
parent-child conflicts, single-parenting, interpersonal
problem-solving, military tole and community resources .
BEVERLY BALLARD, PH.D. PAGE 3
RROFEssIO,NAL RELATED VOSK Egp .arENC_S
1975-76t ADULT SCHOOL INSTRUCTOR - ,Issuer, Paging Wo en
1974-75: COLLEGE OF ALAMEDA CO-INSTRUCTOR - Lgy„A ADA harri ce
1973--74 : WOHENIS HISTORY RESEARCH CENTER - Berkeley, Ca.
"Compilation/Microfilming of Women's Movement/Bookkeeper
1955-73: FULL-TIME PARENT/PART-TIME SECRETARY
RESIDENTIAL EXPERIENCE IN JAPAN/MIDWEST/SOUTH-URBAN AND RURAL
C0 MUNITY,�RELLATEI,�
1976 "THE BATTERED WIFE" PANEL MEMBER - College of Alameda
'*Collaboration/development of legal diversionary program.
1975 "NON-ADVERSARY DIVORCE PANEL MEMBER - Berkeley Counseling
Center with Judge Avakian/Dr. Gerry Smith/Atty Evlyn nice
1976-77'- ALAMEDA SOCIAL SERVICE BOARD MEMBER
1975-761 ALAMEDA EARLY CHILDHOOD EDUCATION ADVISORY BOARD MEMBER
1975-76: ALAMEDA ADVISORY COMMITTEE-High School Community job--training
1973-84 : H.O.P.E. MEMBER - Housing discrimination advocacy/testcases.
19701 ALAMEDA MASTER PLAN FOR EDUCATION MEMBER
Pre1970i DIRECTOR AND COUNSELOR OF VARIOUS YOUTH CAMPS - Michigan
R ARCCH -EXPER, TENG_ '
1980: DISSERTATION - SaLIM action in Rolm A justment f Si�naie
PaLlat Mo her„a_as LjEunct on of ex Hole _,Qrientati¢nan_d_
Social Networks
1977: MASTER THESIS - Advantages an& D_ i_-addvantaaes of, p ren ina
19751 APA PRESENTATION - AlCohol abuse L, Hien
1976-77: "Piaget Conceptual and Conservation Tasks of 5/6 Year Olds"
"Piaget Interview on Magical Thoughts and Dreams of Children"
"Learning Disabilities of a Six Year Old"
"Dream Analysis of a Five Year Old Child"
HOLAR_sH-IP _AN..AUR .
1975-80: CALIFORNIA STATE GRADUATE FELLOWSHIP
1974: BUSINESS AND PROFESSIONAL WOMEN'S SCHOLARSHIP
1970: HONORS SCHOLARSHIP - Grand Valley State College, Michigan
VALEDICTORIAN - Wayne Memorial High School, Michigan
PRQ—. F..- FSSSIQ L AFFFUATIONNS:
American/California/Contra Costa/Alameda County Psychological
Association Memberships
American Academy of Pain Management
Department of Psychiatry and Psychology - Merrithew Hospital
Medical Staff Member -- Merrithew Hospital, others pending
CRSQ _NT1rALE,
19821 CALIFORNIA PSYCHOLOGY LICENSE PSY 7435
1979: CALIFORNIA MARRIAGE, FAMILY„ CHILD COUNSELING LICENSE M-13712
1977: CALIFORNIA LIFE CREDENTIAL-COMMUNITY COLLEGE COUNSELOR AND
INSTRUCTOR IN PSYCHOLOGY
1975: CALIFORNIA LIFE CREDENTIAL -- ADULT SCHOOL INSTRUCTOR of
English, psychology, Humanities.
DECLARATION OF CUSTODIAN
f Flu OF MEDICAL RECORDS
AND c L I N I c s K. Clevenger, MRT
(CUSTODUW OF MEDICAL RECORDS)
REPLY TO: RE: James, Jess
E] MERRITHEW MEMORIAL MEDICAL RECORD#: 57-00-55-4
HOSPITAL AND
HEALTH CENTER: says as follows:
Medical Records
2500 Alhambra Avenue That the declarant is the duly authorized Custodian of Medical Records of Contra Costa
Martinez,CA 94553 County Health Services and has authority to certify said records and,
r• (510)370-5220
❑ That the Medical Records are all the records described in the subpoena duces
tecum as indicated below and have been released for documentation on microfilm
❑ BRENTWOOD to the deposition notary
HEALTH CENTER:
Medical Records ❑ That the ❑ original ❑ copy of the Medical Records attached to this Declaration
118 Oak Street are all the records described in the subpoena duces tecum as indicated below.
Brentwood,CA 94513
(510)634-1102 ❑ That the Medical Records are all the records described in the request as indicated
below and have been released for documentation on microfilm to the deposition
® PITTSBURG .notary
HEALTH CENTER: ® That the copies of the original Medical Records attached to this declaration are all
Medical Records the records described in the request as indicated below:
550 School Street
Pittsburg,CA 94565 ® no exceptions.
(510)427-8077 ❑ except those portions of the record which come underthe provisions of Section
5328 of the Welfare and Institutions Code.
❑ RICHMOND
HEALTH CENTER: ❑ which by law are permitted to be disclosed.
Medical Records
38th&Bissell ❑ other exceptions.
Richmond,CA 94805 ❑ Billing information will follow under separate cover.
(510)374-3071
❑ X-Rays will follow under separate cover.
❑ CONCORD That the records were completed by the personnel of the Health Services, staff
HEALTH CENTER: physicians, or persons acting under the control of either, in the ordinary course of
Medical Records hospital business at or near the time of the act,condition or event.
3052 Willow Pass Road
Concord,CA 94519 1 declare under penalty of perjury that the foregoing is true and correct
(510)646-5506
❑ OTHER: (SGNATOIE OF
Date: 1/28/94 at RJUsburl ,Califomia.
NOTE:T"report Is strictly Confidential and
Is for the Information only on the person to
whom it Is addressed.No responsibility can be .
accepted If it Is made available to any other
Person,INCLUDING THE PATIENT.
MR 161-6(4/9M , ' - Contra Costa Count
CONTRA iCOUNTY -HEALTH
kEi4O9TAL HOSPITAL
PITTSBURG HEALTHCENTER 03 OF 93
OUTPATIENT NOTES'
Pat ent ID Page
Date
JAMES JESS
MAR 0
M 1
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CONTRA COSTA- COUNTY HEALTH SERVICES - ftM " '•';, —"
llERRTTHEW MEMORIAL HOSPITAL AND CLINICS : . j+E S J E S S
h 10/17/1958 510 684-9572
•. PITTSBURG HEALTH CENTER'
OUTPATIENT NOTES 0 0 510 O S S—4 AO
U.ate.'._ Patient ID P I gT •CE
2 4 1994 141 'IL
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PITTSBURG HEALTH CENTER JAMES D E S S
m 10/17/1958 510 684-95?2
OUTPATIENT N TS
Dos -4� AO Page
Patient ID
Da - Q .�'
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(Side 2)
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CONTRA COSTA COUNTY HEALTH SERVICES
'MERRITIIEW.MEMORIAL HOSPITAL AND CLINICS
• PITTSBURG HEALTH CENTER
OUTPATIENT NOTES
Patient ID Page +E
Date
'Tc-� K.o,- Nom- , �sr A L-r,- JILL t-�
Gb '06
IN rlc_ - I S. N43 4
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-56) (Side 1 SR-I-PHC ( )
�; * 11
r
RUN DATE: 01/25/94 CONTRA COSTA COUNTY HEALTH SERVICES PAGE 1
RUN TIME: 0740 Summary OUT PATIENT Discharge Report
LOCATION
PATIENT: ACCT-:jP:3: M 25673153°.:: : LOCI:;' PHC,: ... 'U i�
s M00570055
:.. .:....:.... :.`''ADE/SS;?::':35/M.::::.:::,:.::.;.;::: ::ROOMi >>.:. °; :.:::REa: - 01%24/94
............
: .:.::;::... ..•;.;::;;
REG DR: :. UNKNOWN..:: :::'.:.;:..::: 'STATUS'-:. EG.:CLI::. °.: ,:. .BED::;:.;:'::'
****xxxxxxxxxxxxxxxxxx*xxxxxxxx*xx*+r+rxxxHEMATOLOGYx*.x*xxxx*.*xx.x**xxx.xxx*xxxx.xxxxxx*+rxxxxxx
... . .. . . .. . .... ...... �:�COMPLETE
Day 1
Date JAN 24
Time 1349 Reference Units
>WBC :;:': >5€'. ' k "F (4.8-10.8). ... TH/CMM
:.:.:...
->RBC4.74 (4.7-6.1) MIL/CMM
......... .........
:. :::
' (14-18)'. G DL
->HCT 44.9 (42-52) $
>MCV =- 4 -( . )
'8:;n; ;> H': $0-94 FL
... ....
>MCH '3f< `f>> :`r :. (27-31) PG
0>HCHC ;':::..34:0;::.::.':::::::'.:. .(33-37) G/DL
->RDW 12.6 (11.5-14.5) $
:... >fi .:v:k:«...
->PLT :. ::.. .= `17<? s`.:, ;:z<;;:j: - TH/C
. :� � .::. ..(130 400) � �:� .� MM
->MPV 8.8 (7.2-11.1) FL
++++.�rwwwwwwww+w+r.wwwwwwww.�wwwwwwwwwwwwwwCkIEMIBTRYwwwww+�www�rw+w+wxwxwww•.rwwxr,�x•wxxwrrxr•+t
:CHEM 13' PROFILE:..
Day 1
Date JAN 24
Time 1349 Reference Units
->GLUCOSE ';x`€ (70-108) MG/DL
->BUN 10 (7.0-22.0) MG/DL
->CREAT
: (0.5-1.2) MG/DL
->CALCIUM 9.9 (8.7-10.7) MG/DL
6>PHOSPHOROUS .......'; ..................:;........ :.;:;::;;:;,::'.': : .:::::::' (2.6-4.9) MG/DL
>T.PROTEIN 7.9 (6.1-8.0) G/DL
>ALBUMIN :. ..: : (I` .> °k}< >'> - 8) G/DL
;....
(3 5 4
->BILI,TOTAL 0.7 (0.3-1.2) MG/DL
>ALK PHOS (30-107) U/L
->AST 37 (8-42) U/L
>URIC ACID :. ..... .. -7.8)(3.9 MG/DL
L
?Patien:t.: JAMES,JESS .'::.' :. :•. Age/Sex::.35/k"' Acct#M025673153 --:-Uriit#M005700554
~ r•. RUN DATE: 01/25/94 CONTRA COSTA COUNTY HEALTH SERVICES PAGE 2
RUN TIME: 0740 Summary OUT PATIENT Discharge Report
. . LOCATION
Patient: JAMES-"JESS''. �`M0256731.53::: : (Coatiiiued).::.:.:. .:
HLIVER•.PROFILE:''
Day 1
Date JAN 24
Time 1349 Reference Units
5 4 L
->LD18hx crH° (94-17 2) U/L
>ALT :. :.:..:.:::: .. 47 .:.:>:: .::::: ;: . : :...(0-55):: U/L
i, 6 :LIPID -PROFILE • . . . . . . . . . . . . . .
Day 1
Date JAN 24
Time 1349 Reference Units
>CHOLESTEROL 191 .'. :.'':: (120-200) MG/DL
Patient: JAMES,JESS :.: :Age/Sex: 35/M Acct#M025673153' Unit#M005700554
MONA
Contra Costa County / Soelal Se VIM Department
,{ MONTH O t '0 x 133 :.WOR. 'ROGRAMS PLACEMENT/ATTENDANCE R: At
PROJECT* SLOT*
:y PARTICIPANT S. CASE NUMBER .) . r:-• W PC
ASSIGNMENT': Show this form to the Hbrk Site Supervisor when you report�t the time and place listed below:
Cd/the Nbrk'S' rvisorif u haveeny probhms. WORK.SCHEDULE -
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WORK BRYICES':..'•.: p1`. DAT/�
E' TIME
WORK SITi Monday . .:r—
AGENCY DEPT
OUTDOOR MAINTENANCE YORKER . Tuesday .: : . . {
POSITION
TITLE C *OT Wednesday
SPECIAL TCEJ SHOES/&RING YOUR uNn) Thursday L!
REOUIREMENFE
Friday
REPORT TO �ephone
Monday- - -
. -4545 Det"er�1wNorBLYO-. ANTI _� _ -
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LOCATION Tuesday 7-0( ,•,ti;
Worksite Address
NEXT WORK PROGRAMS Wed nesda 1 r,
APPOINTMENTDay.. 4- Date • /�Iy , Thu�y � 7 iJ
1905 Macdonal Ave. 0 30 Muir Road Qtq'�+ ase5 Deka f air Blvd. �^ Friday .. r., - _ '••:
a';,, RkhnwW 374-3791 Martinez 439.2022" Ant+och4PPMli@
1 adCnowledge ascalpt of nay assignment �f /'• fl t1WERE
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* Participawsr'Signature * Date
tl'�m�tilrlg�rl�Ru?um�a�:..Rt10LCOJ1Tz�.�i•8-�;7 vyr,�i .
r:. �Ttsaspurtmdbn to the job site or pick up point IS YOUR RESPONSIBILITY. If you need .lu>OuauMtmnnno�un��trpo�tJz4^R�'
help with your transpoMrion expenses,contact your Work Prbgnuns Representative a
:._...jb?ek before ybur work schedule begins.. p•1:ti1!9'11!•1u•
ATTENDANCE RECORD s:
t bmpledbn Instructions.On Reverse.
TIME IN TIME OUT Tot.Hr.. PARTICIPANT'S SIGNATURE WORKSITE COMMENTS
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:t ev.•9/881 ti: . ...:. :.�:: :r:qopy4; Worksite.File!
+ Contra Costa County ±r- r :' Sot Service Dopa.
WORK-PROGRAMS PLACEMENT/ATTENDANCE RECORD -PROJECT*�SLOT*—
a MONTH ❑ t D z ❑3 , -
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AG NCVVE FRAL SERVICES DEPT Monday y• Z U*
1. Tuesday t, .
PosiTIONOUTOCOR NAINTENANCE k'ORICER f
TITLE Wednesday ZS
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-: REPORT Worksite Supervisor Telephone Monday
9 L944w-
'#''` 4545" OELTA -FAIR BLYD
LOCATION Tuesday i
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=` c: Wednesday
NEXT WORK PROGRAMS z, tQ'
APPOINTMENT Day- Data-. Time ThursWY
13 1305 Macdonai Ave. D 301AW Road 4545 Delve Fa'ar Blvd. Friday
RicM�ond3743791 Maruner439.2029 Anft=h427-03S
-101* of my mignment-. $+OWERE UD UNA TRADIICCIDII EN ESPANOL DE �
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4545 DELTA FAIR BL,Y'De ANT10CN Tuesday `oZ-' ►� '7 g:()(�-4353
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NEXT WORK PROGRAMS
3 9 i "waNra'y
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TIME IN TIME OUT ToLHre PARTICIPANTS SIGNATURE WORKSITE COMMENTS
DAY 1 -
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DAY?
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ADDITIONAL COMMENTS TOTAL HOURS WORKED FOR THE MONTH OF
Copy t:Chent I PanKtpant
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ENERAL BERYICES •
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OUTDOOR MA111TIVANCE NORM � � tti�.Lry � •'�Ga-
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DAY t
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SPECIAL-' CLOTHES FOR TARD VORK/NO OPEN 4e�ady - ^
REGUIRE 'No YOUR MINCH
MEIIL
REPORTT SREV LEADER 42 5 P•�y
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Worlolb Superview Telephone Monday .•
4545 DELTA FAIR OL a ANTIIOCH
LOCATION Tuesday — 1 .—U'.;;
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APPOINTMENT Day Date'
Tyyyiime `nursday –
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J : . Sae On Rowney ATTENDANCE RECORD
TIME IN TIME OUT ToLHm PART CIPANT•S SIGNATURE WORKSITE COMMENTS
DAY
d0
DAYS
DAY 7
DAYS '
DAYS
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DAY TO
ADDITIONAL:COMMENTS TOTAL HOURS WORKED FOR THE MONTH OF hL
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Copy 1:Client i PartK,pant
KSI S U VIS 1 NATURE D A E Copy 2:Work Programs(con:'
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RECORD OF CONTACTS
,. CA NAME CASE NUMBER WORKER NAME
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:.+ CONTACTr Comments/Explanation of Contact.plus Initials.PCN and Date You Entered Documentation
DATE TYPE
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f EM. C.YMENT SERVICES APPOIN'. C. HIT SLIP
4545 Delta Fair Blvd. ❑ 1305 Macdonald Ave.
Antioch,CA 94509 r ` Richmond,CA 94805
427-8535 374-3791
..errT1
YOUR NEXT EMPLOYMENT SERVICES APPOINTMENT WIAEi f,,f„3'�'„� at J zS""_pin
AT THE OFFICE CHECKED ABOVE. day/date Vtime
Failure to appear for this appointment may result in your aid being discontinued and a period of ineligibility. Your must call
in advance if you are unable to keep this appointment. Lack of transportation and being out of town are NOT valid excuses.
Please arrive at least 10 minutes before your scheduled appointment.
Your appointment is for a: J5-GROUP MEETING ❑ INDIVIDUAL MEETING
SPECIAL ASSIGNMENT/COMMENTS- ,t
❑ I pckrowledge receipt of Chis apprvbrSlrat/assig'riir�i�/(rt. 1-un
deWtUd that failure to appear without good cause may
Ir.0 1(jm
t y aid bein t¢ p .. �1 U qt,' _ p
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NAME/f?rint)` i ",^� tsIGN EI T _i !+ ,t DATE �1
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WP 30(Rev.t192) // , r' .y - �,' Copy 3: IM Case
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Contra Costa County Sotial5ervlee DeDartme
MONTH 1 s s : -,,•`,-WORK PROGRAMS.PLACEMENT/ATTENDAhyt:RECOR: PRaecrw SLOT*
A 1 A UEW PCN
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ADDRESS _EPHOINE NUMBER
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ASS/GNAIENT: Wow this form to the Abrk She Supervisor when you report at die trine and plea listed /ow:
•. LyI/the lbrrk Site S/�rubor if you have env problems. .. WORK SCHEDULE""
.�,.. DATE TIME
WORK SITEAT •Y•INCENT DE •PAULAGENCY: DEPT 30f Mond G 8 .
.-... .
PosITION -ARO/GENERAL HA I NTENANCE WRKR Tuesday
TITLE Wednesday
SPECIAL 9-430
/
REQUIREMENTS Thursday
634-0473 F.Id.Y
REPORT TO
H toTRElmo 0 D Telephone Monday G G
7 .
LOCATION 1 _ • 4.. Tetchy,.i..
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NEXT WORK PROGRAMS . Wednesday.
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❑ t9bsss�odwnlAve: (] MMir:aoad Q�vsasoe>r.f.ir.wa. Friday:
akaeiad 97a-371r:�'.•`�iilartiner a.94�mt! . anuo0�v7is9s ••''"',.•'': �: e� ��tt
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ESTE PAPEL.LLAME A w TRASAJADGR(A) DE .
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ova n notaure •Ie1�tYlelg�l� uo'las'l...dtia`ueann_CfIR>fi opm V72H
ft t/on to the jobs/teorplekup.point IS.YOURRESPONWILITY,-Ifyou need o.iuOueJuw�ttMelrun�•Itioo�elK4�a9
help with your tremportetion expenses,contact your Work Proprems Representative a
week before your work sdiedule begins. c P'►;,00'frl�L•
See Completion hver
atructions On Rese. ATTENDANCE RECORD :: ..,.
TIME IN- TIME OUT: Tot.Hm 'PARTICIPANT'S.SIGNATURE KS COMMENTS
DAY t
I DAY 2 AA A
1 DAY 3
I
DAY4 .
DAY b
A Hv
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DAY 7I flV
I
DAYS
DAY
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DAY 10'
ADDITIONAL COMMENTS TOTAL HOURS WORKED FOR THE MONTH OF
Vq :.. .
' - - �•'. � Copy t: Client/Participant
WORKS 1 T E S U P E R V 1 R S I O N A T R E - . 7 DATE :Copy 2: Work Programs(contro
:. : •. ... : : .•.: :::: Copy 3• Work Programs(compl
(Rev:9/SS) ..;...:.:.,,:::: : :%; - Copy 4: Worksite File
Hill! ii IIIIMI
NMI
.I
17 ALCOHOLISM
Vemelle Fox, M.D.
James P. Conway, M.S.
Jeri Schweigler, M.S.
DISEASE DESCRIPTION disabilities and does not always refer to the disease
Alcoholism, with or without a simultaneous drug "alcohol addiction." Much of the confusion and ;
abuse problem,is one of the most prevalent disabilities pessimism surrounding this illness is due to the fact
in the United States. More often than not, the that we label abusive drinking as alcoholism without
alcoholic client's stated reason for seeking vocational trying to differentially diagnose the mechanism by
rehabilitation services will not be a candid declaration which the individual developed the alcohol addiction or
of alcoholism, but this disease will be the major the specific manifestations and prognosis for that i
disability after the client has been adequately individual. Prior to the mid-1950's, alcoholism was -
evaluated. If the alcoholism is not diagnosed and only regarded as willful misconduct rather than as a
realistically dealt with, as opposed to simply treating disease, and alcoholics were handled punitively by the
the complications or presenting symptoms, there is legal system. The individual was blamed for his lack of
virtually no chance of the individual being will power, and medical treatment was only available
rehabilitated. for the advanced complications of alcoholism.
Alcoholism occurs in all ethnic, socioeconomic, and In this chapter, the terms "alcoholism," "alcohol
age groups. However, the incidence of the disease is abuse" and "alcohol addiction," and the terms
higher in some groups (for example, Irish and native "alcoholic" and "alcohol addict" are synonymous.
Americans)and lower in others(for example,Jews and The National Council on Alcoholism (NCA) and the
Chinese), and is reported three times more often in American Medical Society on Alcoholism (AMSA)
men than in women. It has been estimated that one- have defined alcoholism as "a chronic, progressive I
quarter to one-third of the persons who have and potentially fatal disease . . . characterized by: ii 7-
alcoholism
alcoholism also abuse other drugs, usually sedatives or tolerance, physical dependency and/or pathological
tranquilizers prescribed for them in an attempt to organ changes, all of which are the direct or indirect
control their alcoholism.The disease is seen in persons consequences of the alcohol ingested." a,
of all occupations, but tends to be higher in some Tolerance is that phenomenon whereby a much
occupational groups, such as physicians, career and greater and more toxic amount of alcohol(or any drug) �.
service personnel, painters, and short-order cooks. is required to produce the same subjective effects that a
Although speculations have been made, the reason for smaller amount originally produced. The exact
higher incidence in persons in these vocational areas is mechanism for tolerance is not proven,but it is known _
not known. that certain changes occur in the liver and that persons -_
The total number of alcoholics in the United States develop central nervous system adaptation to the
is estimated to be nine million. About 5 percent of all sedative effects of alcohol. How much tolerance is due
employed persons are thought to have the disease, to altered liver metabolism and how much to central -
while the "skid row" or homeless male with frequent nervous system adaptation is not yet known. 1 -
arrests,often thought of as"the alcoholic,"constitutes Alcohol addicts usually develop cross tolerance to other
only 3-5 percent of the alcoholic population. During sedative drugs and sometimes to narcotics. The -
recent years,there has been an increased prevalence of individual who develops a high tolerance for one ' :-
alcoholism among women and youth. sedative drug will subsequently nearly always have a ! --
higher tolerance.from the beginning,for related drugs. _
7efinition For example, an individual whose metabolism is so
changed that it takes a fifth of whiskey to make him
Alcoholism can be the person's only disability, or it drunk will also probably require two or three sleeping --:an occur with one or more other physical or pills to put him to sleep, more morphine to kill pain, __-
)sychiatric disabilities. The label "alcoholism" is and more anesthetic to induce unconsciousness than a -
requently loosely applied to 'several groups of person with normal metabolism. Also, a person
231 _-
282 Fox, Conway, and Schweigler =
addicted to one drug obviously has a much higher risk A great deal of sociological research has been done
of becoming addicted to other drugs. regarding drinking habits and other behavioral
Withdrawal symptoms begin to occur 6 to 12 hours patterns of subcultures. Drinking patterns are so - :
after the long-term heavy intake of alcohol has ceased. influenced by peer pressure and cultural value systems
The symptoms reach their peak in 1 to 2.days and that it is impossible to answer such pertinent questions ;
gradually subside after 3 to 6 days. The symptoms of as whether children who are taught responsible -
withdrawal can be quite mild, such as lack of appetite, drinking, such as wine with meals or an occasional
sweating, and nervousness, or they can be very severe cocktail,are less likely to develop alcoholism than those ^`
and potentially fatal, such as severe tremors, who are taught total abstinence. Although it is known
hallucinations, convulsions, cardiac irregularity, and that the incidence of alcoholism is very high in
shock. environments where drunkenness is "normal" and
Physical d*mdency on alcohol is defined by the sobriety "abnormal," not all individuals who live in _
appearance of some withdrawal symptoms when the these environments become alcoholics. There is l
individual decreases or ceases alcohol consumption. In obviously a great deal yet to be learned about the
addition, an alcoholic is generally a person whose influence of the environment in the development of t :
drinking repeatedly and seriously interferes with one alcoholism.
or more major spheres of his life,such as work,health, Reality avoidance. Some persons develop their high
or interpersonal relationships. exposure to alcohol by learning to use the drug as a :'
The NCA has developed groupings of signs, tranquilizer, a means to avoid reality. They control *
- symptoms,and criteria for the diagnosis of this disease. their anxiety or depression by drinking, and alcohol
Duringthe earl stages of the disease the individual increasingly becomes their most effective coping skill. -
Y ge 8 Y P g
often drinks increasing amounts to feel a "glow," Gradually, as their tolerance develops, they stay in a
gulps and sneaks drinks, looks for more occasions to state of low-grade chronic withdrawal,with aresultant
drink, lies about the amount consumed, misses more craving for the drug. They drink in order to-avoid
work and shows decreased performance when at work, withdrawal symptoms and to be able to maintain
has morning shakes, and shows a loss of appetite. In routine functions.Eventually,alcohol may become the ='
the later stages, the alcoholic typically stays drunk for most important thing in their lives and they frequently
weeks at a time,is unable to go a day without drinking, become preoccupied with getting a drink, stopping "=
tr
displays severe withdrawal symptoms lasting for days drinking, or staying sober.
(sometimes including convulsions and hallucinations),
and shows physical damage to the liver,nerves,heart, . .
Complications
gastrointestinal tract, and other major organs. °'
Alcohol is a relatively short-acting drug that is
Etiology rapidly absorbed and circulates unchanged in the
blood stream and cerebrospinal fluid. The most
There are three distinct ways a person can develop common acute complications of alcoholism are falling
alcoholism. Most commonly, however, a combination and driving accidents causing bruises, broken bones,
of these mechanisms is present. and other injuries.
Physiological susceptibility. A certain portion of the Every organ system in the body is•affected to some ";w• .
alcoholic population appears to be biologically degree by alcohol, and prolonged heavy usage often
abnormal in their physiologic response- to alcohol. causes pathological changes in the brain, liver,
They appear to have a potential at birth for developing stomach, pancreas, peripheral nerves, and heart.
abnormal metabolism and tolerance to alcohol if they Anemia, gastritis, pancreatitis, neuritis, and fatty
R5
.
are exposed to it. Persons with high susceptibility may changes of the liver can occur. There can also be L'..
develop gross tolerance and withdrawal symptoms impaired brain function, resulting.in confusion and
after only brief exposure, while those with only slight memory loss. Cirrhosis of the liver, a devastating,
susceptibility would take longer exposure to develop destructive disease, is not as common as it was once YTS
the same set of clinical symptoms that we call thought to be.
alcoholism. There is substantial evidence that this individuals have great variance in their organ -
physiological susceptibility to alcoholism is familial. susceptibility to alcohol damage. It is not known why
Par group pressure. The drinking culture in which two alcoholics drinking approximately the sarr.
the individual lives has a substantial influence on the amount over the same number of years will develop
development of and recovery from alcoholism-In some different complications. For example, one individual ' s^
subcultures in the United States,drinking is so much a may have severe gastritis or ulcers, while another
way of life that the abstinent individual is viewed as a develops some level of brain damage and associated
social deviant and regarded with suspicion by his symptoms, such as impaired judgment, loss of recent —
peers. memory, irritability, or emotional instability. Organs
' Sf,
is
Alcoholism 288
are not affected in any specific pattern, nor is there a Some persons "mature out" and virtually stop
specific relationship between the amount or duration of drinking unassisted,while others have variable periods
drinking and the development of organ damage. of spontaneous remissions. Since there are no reliable !
Undoubtedly, the degree of malnutrition and vitamin indicators or characteristics to predict the natural ;!
deficiency that the person suffers to some extent course of the disease, remission should never be relied
governs the severity of organic pathology that will upon for the individual's recovery. However, the
develop. majority of alcoholics can show improvement or
Since the complications of alcoholism can mimic completely recover with abstinence and appropriate
almost any disease, it would require several textbooks treatment over a sufficient period of time.
of medicine to completely describe all the organ
damage that can be caused. If a client reports high
levels of alcohol ingestion and has multiple other FUNCTIONAL DISABILITIES
diagnoses,the counselor should suspect alcoholism and physical Disabilities
request a thorough medical evaluation.
Although major complications and organ changes The degree of physical disability may be severe for
usually develop in the later stages of alcohol addiction, the alcoholic even in the early stages of the disease.
work problems can be diagnosed much earlier. With During drinking episodes, motor functions, such as
earlier recognition and appropriate treatment leading memory and judgment, will obviously be affected. As
to abstinence, these complications are usually organ involvement becomes more pronounced, the '
preventable or easily reversible. The majority of magnitude of symptoms and resultant impairment of
physical complications are reversible -with long functional abilities increases.
abstinence and .good nutrition, even in the more Impairment of fine or even gross forms of motor
advanced stages. coordination generally do not interfere with activities s
In addition to these medical complications,the social of daily living. In the first 6 to 12 months of recovery, !;
and economic costs of alcoholism are awesome. The clients may have tremors which interfere with their {
NCA estimates that 50 percent of all fatal accidents ability to write,or they may experience lapses in short-
involve the use of alcohol, with two-thirds related term memory and the ability to concentrate.
directly to the actions of alcoholics. In addition, a Physical restoration will be gradual and is predicated
conservative estimate of the cost of alcoholism to on the client's ability to remain abstinent. Milder ?
- industry is 25 percent of each employed alcoholic's forms of dysfunction will reverse within a few months
salary when such factors as absenteeism, tardiness, after abstinence, while more pronounced dysfunction
spoiled materials, decreased efficiency, on-the-job may require 6 to 12 months. Although uninterrupted
accidents,and medical benefits are taken into account. alcoholism over a long period of time can result in
irreversible organ damage and physical disability, in i
prognosis most cases these are fairly temporary in nature if the
individual can achieve and maintain abstinence. If the
Alcoholism is a slowly progressive disease. The client has impairment in self-care, ambulation, and
typical male alcoholic has been drinking abusively for 8 gross motor performance after several weeks of proven
-to 12 years before he develops complications or abstinence, advanced complications 'or another
otherwise deteriorates sufficiently to seek help. For disability must be suspected. In these cases, the
women, the time period is usually somewhat shorter. counselor should refer the client for complete medical
Individuals with serious psychiatric disorders who evaluation.
become more disturbed when they drink and
individuals who have previously been, or currently p chosocial Disabilities '
are, addicted to other sedative or narcotic drugs also ry
require a shorter exposure time to develop alcoholism. Long-term combined alcohol/sedative addiction can
For example, the former heroin abuser or the produce manifestations of severe psychopathology
methadone maintenance patient is virtually an instant during the addiction and for as much as 6 months
alcoholic if he begins to drink any appreciable amount. afterwards. When these manifestations. occur, they
This is due, at least in part, to cross tolerance. but may be suggestive of severe debilitating mental illness
there may also be specific biochemical alterations that and may possibly even require acute temporary
result in this difference. intervention.The severity of the symptoms,sometimes
The natural course of addiction is quite variable accompanied by a self-destructive component, may
across individuals. Although it is commonly believed lead the counselor to assume that an underlying
that, once developed, addiction is steadily progressive chronic psychiatric disability is surfacing. This
and the individual's condition worsens in an determination cannot accurately be made until all the
uninterrupted fashion, this is not necessarily true. organic brain syndrome secondary to alcohol and drug
284 Fox, Conway, and Schweigler
:,
abuse has reversed. The vast majority of alcoholics around him and of relieving the pain caused, in part,
• who come for services have the potential for becoming by lack of meaningful communication. He may have :M.
emotionally adjusted and functioning adequately in established his entire social life around alcohol
their environments. consumption and find that, in recovery, his ability to
Other psychosocial disabilities are often observed in maintain old contacts or develop new relationships and
the untreated alcoholic and often also extend into the communicate meaningfully with others is impaired or
early stages of recovery(0-12 months). These include lost. =_
pathological • dependency, marked anxiety, The recovering alcoholic has often been given
pathological isolation, denial, and decreased ability to ponderous amounts of unsolicited critical advice which
establish long-term goals, proceed in a step-wise he has generally learned to ignore effectively.
manner, and handle responsibility. Typically, he doesn't trust people and seemingly is
D*endemry. Alcoholism reduces the person's ability more concerned with getting something from them
to act effectively in his own behalf. As a result, than in genuinely relating to them. This is often
alcoholics become increasingly dependent on others for misinterpreted by the counselor or consultants to be _
both economic and physical support.They may expect indicative of surfacing psychopathology. Both the
to have their dependency needs met in all their client and the counselor should recognize'that it takes
relationships -and may attempt to develop new time to develop new avenues for social contact and
relationships -for this purpose. Accompanying the meaningful interpersonal relationships.
dependency is often a feeling of resentment toward Denial. The alcoholic can be particularly adept at =
those who are viewed as having power or authority denying reality. Misperceptions of reality can be an
L:•
- over them. Even after abstinence begins, many effective tool in defending himself against pain and 51,
alcoholics will continue to seek the same sort of avoiding some of the unpleasant aspects of the
dependent relationships with'people or institutions, alcoholic life style. For example, he may have
often including the counselor and rehabilitation convinced himself that if he stops drinking,everything
agency.The client may want the counselor to do things will be rectified, the pain he has inflicted and sufferedz;.
that he could do for himself, such as make contacts will be healed, and his life will automatically readjust
with agencies and communicate with family members. to normal. This type of oversimplification can often
Since reduction of dependency is nearly: always hamper his commitment to a total treatment plan.
desirable, the counselor should avoid doing things for Inaccurate self-appraisal. The alcoholic is often
the client that he honestly believes the client could do unrealistic in assessing his own aptitudes and skills and
himself. in setting suitable goals for himself. He may -
In many instances, the client's family may overestimate his abilities and have unrealistically high
contribute to his alcoholism. Often in their effort to achievement expectations. Further, his level of
help; family members perpetuate the alcoholic's functioning is often not congruent with his potential as
dependency and lack of responsibility by rescuing him measured by psychometric instruments. It is not �5 `
from the consequences of his drinking behavior. uncommon for trained and experienced professionals
Examples of rescuing behavior include making excuses to be misled by the apparent abilities of an alcoholic. It
to employers, bailing the. alcoholic out of jail, is important for the professionals evaluating the client
providing money, and covering bad checks. to guard against overestimating the. alcoholic's
Anxiety. The tension-reducing properties of alcohol functional abilities.
also deplete the alcoholic's natural coping abilities and Impatience. In addition to his unrealistic expectations,
leave the recovering person vulnerable and prone to the alcoholic is impatient and seeks immediate rewards
crisis. 'Anxiety states may render the person for his efforts. He is not only likely to have a firm:a
temporarily dysfunctional and interrupt his ability to concept of what he wants but also.will demand
Po Y Y P tY p
perform in a job or training setting. Often the anxiety immediate action. Although the recovering alcoholic
will be cyclic and related to trying to remain sober. At has begun to live without alcohol, he usually does not
other times the anxiety will be related to new situations simultaneously give up his need for quick solutions. In 17
and responsibilities resulting from sobriety. Whenever fact, in giving up alcohol, his attention may be drawn
the client is undergoing some type of change, stress even more acutely to other needs which he may - r
and anxiety are likely to increase. honestly feel must be satisfied without delay if he is to _
Isolation. Alcohol is widely regarded as a social remain sober. He may have great difficulty :N�>
"lubricant" that facilitates communication and understanding why others do not respond immediately ;
personal contact. Often the alcoholic has learned to to his needs.The amount of pressure that such a client T'
depend on alcohol as an aid either in making social can exert on the counselor can be appreciated only b
p g PP Y Y ::'•,•y s
contacts or tolerating a dearth of social contacts. those who have encountered this force. All too often,
Alcohol consumption is frequently the alcoholic's these pressures can result in the counselor either giving =^
most effective way of communicating with persons what is being requested without proper evaluation or
"x'
r ! �
Alcoholism 235 I �
rejecting the request, and possibly the client, entirely. meaningful evaluation and planning. No one has yet j
Both these extremes should obviously be avoided. learned how to maks an alcoholic stay sober. In fact, it li
To complicate matters, drinking is not always the seems that the harder people try to keep him away I{
worst possible course of action for the alcoholic to from alcohol, the more intent he becomes on asserting i
follow. He may have reached a point of crisis in his life his independence by drinking.
when his alternatives are reduced to three perceived Drinking can occasionally serve a kind of
courses: (a) become openly psychotic and require therapeutic purpose for the client. An occasional I!.
hospitalization;(b)kill himself someone else;or "slip" can help to convince an addicted person who
(c) drink. In such a context, the client may view has been sober for a relatively long time that he still has
drinking as the only choice by which he can retain a problem with alcohol, and that there is no "cure"
some degree of control over himself and his that will allow him to drink with impunity or without
environment. It is easy for the professional to see destructive consequences. The counselor has the task I:
treatment as a preferred course and to encourage the of deciphering the reasons for any drinking episode
client to seek help. But while this seems an acceptable and relating the episode to the other observations by
alternative to someone else, it may be completely which he is determining the feasibility or prognosis.
impossible for the client. Many reach a point in their The rehabilitation .potential of an alcoholic is i
recovery when their feelings toward the treatment affected more by his psychosocial disabilities than by ,
li
person or group are so intense that contact with these his physical disabilities. This is particularly true of the I ,t
"helpers" is the least tolerable thing they can imagine. Impatience, lack of realistic self-appraisal, and limited.
From the alcoholic's perception, then, drinking ability to handle stress so often characteristic of I!
becomes not just a "good" choice, but the only choice alcoholics. Prior to recovery, the practicing alcoholic
available. lived a life marked by increasing irresponsibility and R
Any of these psychosocial disabilities can contribute impulsive behavior,and a decreased ability to set long- J+
to the occurrence of a relapse in which the recovering term goals.In early sobriety,he may wish to"make up
alcoholic returns to the use of alcohol. As such, they for lost time" by resuming a job or career at a •I
should not be regarded as isolated from the disease previously achieved level. Also, as a rehabilitation II
itself.The counselor should anticipate the possibility of client, he may wish to establish vocational goals with
their' occurrence, develop the rehabilitation plan quite unrealistic time frames.
accordingly, and integrate his planning with other The counselor should be prepared to deal with such
treatment resources in the community. expectations and to regard them as natural for a
recovering person in the first year. He should guard
Rehabilitation Potential against either (a) considering the client as unfeasible, 1
n I'
or (b) being manipulated into poor planning and .
The stage of the client's alcoholism or treatment potential crises. Agencies with short-term rehabilitation
must be taken into account to accurately appraise an production goals are especially vulnerable. The
individual's feasibility for rehabilitation services. For alcoholic may be able to exert heroic efforts for short
the vast majority of clients, the ability to achieve and periods of time while pressures are simultaneously I
maintain abstinence is the critical difference between building up toward a relapse.It is extremely important j
success and failure. Major clues in determining the that counselors and agencies not encourage the
probability of success are to be found in the client's recovering alcoholic to achieve too rapid a"success."
response to general interview questions and specific The recovering alcoholic needs both long-and short-
treatment elements. Amon questions the counselor term goals, a sense of the long-range process of his '
8 q 80 � 8 8e P i
should ask are: rehabilitation, and a continued source of ongoing
1. Does the client accept the fact that he has a reinforcement. The longer the alcoholic continues his
serious drinking problem? involvement in a total treatment process, the more
2. Is the client able to accept the need for a long- stability he gains in all areas of functioning. This ,
term recovery plan which includes a new peer stability is accompanied by increasing capacity to make '
group identity? long-range plans and to handle emotional stress.
3. Is the client willing to take deterrent medication? During the course of treatment, the counselor should `
4. Can significant others be involved in the client's regularly reassess the client's changing ability to
recovery process? assume more responsibility and independence and
If most of the above are answered positively,the client plan the next phase of vocational rehabilitation I
has a relatively good prognosis for success. However, accordingly. '
the counselor should be wary of too rapid acceptance of
the total treatment plan and anticipate a certain STANDARDS OF EVALUATION
amount of limit testing and acting out.
The initial struggle for the alcoholic is maintaining Behavioral impairment and the development of
sobriety, which is a prerequisite of any realistic and physical organ damage are usually viewed as the major
236 Fox, Conway, and Schweigler
criteria for diagnosis of alcoholism. Evaluation should through routine interviews is usually sufficiently
consist of a complete general medical examination accurate to serve his practical needs in developing a
including standard blood tests, urinalysis, and liver preliminary rehabilitation plan. In fact, the client's
function studies. In addition, an electrocardiogram ability to function in t e environment, especially the
should be included if the client is over 40 years of age. vocational environmer is usually a more significant
Although nearly all physicians can be expected to indicator of impairme- t than either .the physical or
perform an accurate appraisal of physical status, most psychiatric pathologies. This environment may be the
will not be equipped to provide long-range treatment client's job, if he has r, mined employed, or a variety
for the client with alcoholism. The counselor should of work evaluation/adjustment settings, depending on
identify specifically trained and interested physicians the individual needs of the client and the community
in the community and encourage them to become resources available.
involved in the treatment plan. Unfortunately, there is if an individual is referred for evaluation and
not yet a board or certified specialty in the area of services immediately after entering alcoholism
addictions. Although this may evolve, at present the treatment for the first time, it is virtually impossible to
counselor must personally inquire about the make an accurate evaluation in a brief period. In most
physician's training and interest in this field. Reliable instances, a period of several months to observe the
indicators are membership in the American Medical client's response to alcoholism treatment is the preferred
Society on Alcoholism and recent attendance at any course of action. Data obtained during this period
alcohol and drug abuse conferences.These conferences should include feedback from clinical staff regarding
are often sponsored by organizations such as the his attendance and level of active participation in the
Alcohol and Drug Abuse Problems Association- of treatment program. If the client has a sponsor for
North America, the National C uncil on Alcoholism, Alcoholics Anonymous, or if contact can be made with
and the National Drug Abuse( onference. close family members, these lines of information
Each state has a special -gency dealing with should also be established. In addition, the counselor
alcoholism information and tre. ment referral. These should make direct observations by.attending open
agencies are partially funded 'cough the National Alcoholics Anonymous and treatment staff meetings
Institute for Alcohol Abuse and %lcoholism(NIAAA). with the client. Taken together, these behavioral
The State agencies, in turn, support organized factors can provide meaningful evaluative material for
community alcoholism treatment programs, and can timing of rehabilitation r:forts and establishment of
provide the counselor with a directory of State and vocational goals.
local resources. Research directed toward the
development of improved alcoholism treatment 4V71
techniques is also supported by NIAAA. The coun-
TOTAL TREATMENT
selor should be aware of all these resources and Alcoholism treatment is an ongoing process rather
establish a working relationship with the staff of these than a single act. The alcoholic has many obstacles to
programs• overcome and a total process is the key to gaining
If gross psychiatric and behavioral symptoms are stability in all areas of functioning.. It is important that
manifested, a psychiatric evaluation, with or without the rehabilitation counselor have a full understanding
psychological testing, can provide valuable treatment of this concept and of his role in the multistaged
and prognostic information. However, it is essential process. Without this base, he is likely to respond to
that the client be recovered from the organic brain the client's instant solutions, fantasies, and
syndrome associated with alcohol and drug abuse overinvestments. If this happens, the counselor may
before Interpreting tests or psychiatric evaluations. subsequently become disillusioned and reject the client.
Experience has shown that routine or extensive he is trying hardest to help. The counselor can be
psychological testing frequently offers little useful instrumental in the client's rehabilitation by
information. For example, intelligence tests or recognizing the many facets of the problem and being
aptitude batteries can be so responsive to the willing to help the client organize and integrate a !
temporary intellectual impairment associated with an recovery process.
acute or intermediate brain syndrome that they give an A continuum of services is essential, and each client
inaccurate and misleading indication of the real needs a different combination of services at the various
aptitudes of the recovering alcoholic. Similarly, stages of recovery. The rehabilitation counselor can
personality inventories such as the Minnestoa play a critical role in the delivery of services at any
Multiphasic Personality Inventory (MMPI) can often stage by serving as the client's advocate and/or case
give an erroneous prediction of the recovering manager. Almost never is it desirable for the counselor
alcoholic's stability. to assume a solitary or prime therapist relationship with
A trained counselor's clinical evaluation of the the recovering alcoholic client. This may be difficult
client's attitudes and intellectual functioning obtained since it is not uncommon for-the alcoholic to seek out
Alcoholism 237 j+I
one thing or one person to solve all his problems.When After detoxification, the client is best served by a
the counselor avoids solving all the diem's problems, it thorough evaluation of his indivii sal needs and
decreases the client's dependency and supports his selection of the appropriate services to meet those
efforts to solve problems and take responsibility for his needs. There are many approaches to the treatment of
own behavior. alcoholism; for example, medical, psychological, and
The critical first step of treatment is early diagnosis social. Most alcoholics will benefit from a combination
and motivation by the client to seek help to change. of these services, which will be avail able in different
For a great many years, alcoholism was only forms in different communities. In general, the T
acknowledged in its terminal stages, as manifested by following are the major components of alcoholism
repeated legal problems or advanced medical treatment which can be combined, as appropriate, for
complications. In the past two decades, however, an individual client.
industrial, drunk driving, and armed services Environmental manipulation in varying degrees may be
alcoholism programs have sprung up across the needed, depending upon the individual circumstances ° li
country. These programs have made a great deal of of the client. When the alcoholic comes for
progress in the development of effective techniques of rehabilitation services, he is often-immersed in a
early diagnosis based on performance factors, such as variety of life crises, such as divorce, dental problems,
tardiness, absenteeism, and decreased productivity on legal actions, overdue bills, and revoked driver's j
the job, rather than on complications. 'In these license. The client can be helped to solve these
programs, emphasis is placed upon identifying the -problems and thereby create an environment more
troubled employee and providing early intervention conducive to abstinence. I
and treatment. Internal change therapy may be provided through a I'
The rehabilitation counselor has a great deal to wide range of psychotherapeutic techniques aimed at i
contribute in this area by helping to establish such the development of insight and the modification of
detection programs, by working closely with the behavior. These treatment modalities are not required
industrial counselor, and by being a source of by the majority of clients and are inappropriate for a ;
counseling for the disabled employee. It is desirable large number at the beginining of recovery. An I
that counselors become familiar with industrial except;on is those programs designed to prepare the j
"troubled employee"'programs and the activities and alcoh, .c to enter a regular treatment program. i
materials of local branches of the National Council on Inv cement in the treatment plan of sign fmni other persons,
Alcoholism and local Alcohol Safety Action Programs. such s spouse, children, probation officer, sexual
When diagnosed early, a great many persons with partrn •, or anyone else in a position to contribute
uncomplicated alcoholism may recover with the help of positively or negatively to the client's recovery, is
their industrial counselor and a self-help group. essential. Often these persons also need treatment in
For clients who have been drinking recently,the first order to increase the prospects of the client's success.If
stage of any treatment program is acute detoxication. the client has a family, alcoholism and its treatment is a
This refers to the treatment .of the withdrawal family matter.
syndrome. Mild withdrawal symptoms are sometimes Antabuse(disulfiram)is a drug that interferes with the
treated on an outpatient basis in a medical facility or in normal metabolism of alcohol, thereby causing acute I
a nonmedical detoxification facility. More severe gastrointestinal distress. When taken daily, it acts as a
withdrawal symptoms, however, do require medical deterrent to alcoholism because ingestion of alcohol
.supervision and usually hospitalization. Tranquilizers will producethe unpleasant reaction. It can be
are commonly administered to reduce the symptoms extremely helpful in support of other. program. I
and prevent the development of delirium tremens. elements. The courts may require individuals to take
Medical management usually also includes the Antabuse regularly in order to retain or get back their
administration of fluids, electrolytes, and vitamins. driver's licenses. In some cases, it may be appropriate
Individuals with more severe withdrawal symptoms for the counselor to require Antabuse maintenance
and greater organic damage will require chronic to help alcoholic clients keep their jobs, stay in school, I
ddoxi,fication for 3 to 6 months.Medical monitoring will and the like. '
be needed intermittently to counter the adverse effects Modification of peer group identity may be achieved
of alcohol on the digestive, nervous, and endocrine through membership in a self-help group which, for
systems. The physician may prescribe vitamins, many alcoholics, will be the mainstay of treatment. In
special diets, and specific drugs. this country, the established, effective, and available
In addition,alcoholics may have associated illnesses, self-help group is Alcoholics Anonymous (AA). This
such as psychiatric disorders or emphysema, which group is based on the philosophy that alcoholics can
require appropriate treatment. Because the needs of gather together and provide each other with support j 11
clients will vary so widely, it is important that the for sobriety and recovery. The principles and methods I j
counselor identify at least one physician he can rely for recovery am incorporated in a 12-step program. I�
upon for this aspect of the total treatment plan. Alcoholics Anonymous and its companion
288 Fox, Conway, and Schweigler
organizations, Alanon for adult family members and vocational training. The applicant makes these
Alateen and Alatot for their offspring, are highly requests quite firmly and expects the counselor to make
available, virtually free, and indisputedly effective for a decision immediately. .Any attempt on the
a great many alcoholics and their families. Especially counselor's part to evaluate such requests against the
when family members are inadvertently contributing applicant's vocational, social, educational, and
to the client's alcoholism and dependency,they should medical background is apt to be met with bewilderment
be strongly encouraged to become involved in the or anger.
Alanon and Alateen programs to help ' them Vocational planning is dependent upon first, a i
understand their role in the total treatment program to reasonable amount of sobriety, and second, the
the greatest degree possible. assessment of individual strengths and problem areas.
Any counselor who is going to accept even one client It is essential that the counselor help the client
a year with alcoholism is grossly negligent if he does recognize that entering and maintaining a program
not develop a working knowledge of, and relationship designed to help .him remain abstinent must be
with, Alcoholics Anonymous. This can be simply accomplished before any job seeking or retraining is
and pleasantly accomplished. Local chapters usually undertaken. The counselor must then determine what :
have at least one open meeting a week to which the individual client's past job difficulties were.
most members would be delighted to invite a Common problems include inability to tolerate stress,
counselor. AA literature is easily available, lack of job skills, or attempting to achieve beyond
inexpensive,and quite readable,and every community ability level. With this information, the counselor and
— has many stable members who would be most willing client should develop rehabilitationplans.
to sponsor an appropriate new member. Groups have There is great variance in individual client's responses
their own traditions and procedures which they adhere to different situations. Some are more successful-working
to quite rigidly. If the counselor becomes familiar with with people,and others are more successful working with _
these traditions and procedures and respects them,the data and things.Careful work history,vocational assess-
AA group will be an excellent ally for his client's ment,and individual evaluation are critical.Consultation
recovery. with other members of the client's treatment team is
Some clients, for physical, psychological, or other most important in making these determinations.
reasons, are not able to use Alcoholics Anonymous as In general, alcoholics must be helped to avoid three
their recovery mainstay. This is especially likely to be common pitfalls: (a) believing that an appropriate job
true early in the recovery process. These individuals will "cure" their alcoholism; (b) overcommitting
may need various levels of professional treatment themselves by working too many hours or too many
directed toward preparing them for entry into a regular days; and (c) taking on more responsibility than they
alcoholism treatment program. This preparation are stable enough to handle. Usually the alcoholic
usually takes 1 to 4 months, and can be provided by should not be encouraged to'undertake retraining or a
some combination of medical, psychological, spiritual, new type of job until he has achieved sobriety for 6 to
and social service. Usually a combination of hospital, 12 months. Planning must be directed toward helping
day care, outpatient, and residential settings is needed the individual establish an environment of low
for this type of preparatory treatment. pressure. Continued observation and supervision by
the counselor while the client participates in treatment
VOCATIONAL IMPLICATIONS and retains an easily managed job can be a most
useful technique.
Progressive loss of work skills or inability to develop The client's potential skills frequently exceed his
new skills is often the best early indication of alcohol ability to tolerate stress. It is important to remember
addiction. Industry leaders have estimated that 6040 that stress tolerance is usually lowest early in treatment
percent of persistent job performance problems aie a but can be expected to improve slowly over the next 3
direct result of alcoholism. Although the disease is years.Often the client does not adequately perceive his
more prevalent in certain occupations, virtually no low stress tolerance and the counselor must
group is immune.Actual or impending job loss is quite continuously monitor the client's tendency to
frequently the reason individuals seek treatment for overextend. The stressfulness of the client's
their alcoholism. The counselor can often intervene at environment can be increased gradually as his
this point to help the client retain his job while he tolerance increases. A series of short-term, easily
participates in a treatment program. latainable goals is the best way to achieve this.
During the early phases of recovery, the alcoholic is The counselor should be aware that stress and
unrealistic in assessing his readiness and capability to anxiety are likely to increase whenever the client is
re-establish ocational, social, and emotional undergoing some type of change and he should be
involvement. A great many alcoholics bring only one prepared to offer greater structure and support during
or two commonly heard requests to a rehabilitation these periods. Repeated crisis counseling regarding
counselor: (a) help me get a job, or (b) help me get work relationships and job stresses can be a mainstay
a �
Alcoholism 239
of the client's recovery. Practicing and recovering The clearinghouse is a major source of current information
alcoholics are excellent in short-term employment or in all area of alcoholism. The annotated bibliographies
training situations. Many have excellent job-finding (Grouped Interest Guides) are periodically updated, and
skills,
and it is not atypical to encounter an alcoholic the one entitled Rehabilitation Strategies for Alcohol
who is able to get one or more jobs per month. Abusers is particularly valuable. In addition, the
However, poor long-term job performance patterns clearinghouse provides an ongoing awareness service to its
subscribers. This resource is free.
can be National Council on Alcoholism Criteria Committee:
The vocational counselor is an essential component Criteria for the diagnosing of alcoholism. AM J Psychiatry
of the comprehensive alcoholic treatment team. In the 192:127-135, 1972.
preventive maintenance period of recovery, the This effort by the council expands the basis for the
counselor-client relationship will be most critical. The diagnosis of alcoholism,which commonly has been delayed
vocational counselor is most able to relate to the until the late stages when body organs are damaged.The
recovering person during the early period of re- criteria include behavioral, social, and physical trends in
employment and is therefore in a key position to the patient which can aid in the early recognition of the
positively influence the final rehabilitation outcome. illness''
Rowntree GR, Brand J: The employee with alcohol, drug,
and emotional problems. A Kentucky occupational
BIBLIOGRAPHY program.J Occup Med 17:829-882, 1975.
This article describes a program designed to identify
Alcoholics Anonymous World Services, Inc. Alcoholics "troubled employees," 50 percent of whom will have
Anonymous,Box 459,Grand Central Station,New York, alcoholism,on the basis of deteriorating job performance.
NY 10017 Early intervention and referral are discussed.
Commonly referred to as "The Big Book," this is the Seixas PA Cadoret R, Eggleston S (eds): The Persons with
basic text and description of the AA program. As AA is Akoholirm. Ann NY Acad Sci 298, 15 Apr. 1974.
the most widely available and inexpensive resource for The issue is devoted to the psychiatric aspects of
the recovering person,it is incumbent upon the counselor
to be familiar with it. alcoholism. There are articles on various psychological
C to be a RJ: General aspects of treatment. la characteristics and problems of alcoholics and on various
Canta ro : (ed): Alcoholism: The Total treatment.
Treatment Psychotherapeutic approaches to alcoholism treatment.
Wiseman JP: Stations
Approach, Thomas, Springfield, IL, 1968. Stations of the Lost: The Treatment of &d
overview of the multidisciplinary, multiphased Row Alcoholics. Prentice-Hall,Englewood Cliffs,NJ,1970.
An
approach alcoholism treatment. The counselor can Dr. Wiseman offers two views, often contradictory, of
rehabilitation; namely, the view of the providers and the
find important information on the acute phase, family
view of the consumers of services in the Skid Row
involvement, and AA in the total treatment approach.
Estes NJ, Hanson KJ: Sobriety: Problems, challenges and thesesubpseparate
Chapters 1 and 9 provide desolations of
solutions. Am J Psychother 30(2):256-66, 1976. �� separate perspectives, which can be generalized to
other alcoholic populations seeking services.
Ten wives of alcoholics participated in group therapy for 2
years. The new problems they encountered as a result of
their husbands' sobriety are described in this article.
Hough GS:A behavioral approach to alcoholism. Nurs Clin
North Am 11: 507-516, 1976.
This article describes a behavioral approach used in the
treatment of alcoholism.The goals of the program include
either abstinence or controlled drinking for problem
drinkers who do not have any medical reason for
abstinence.
Lowe WC,Thomas SD:Assessing alcoholism treatment effec-
tiveness.A comparison of three evaluative measures.J Said
Alcohol 37:883-889, 1976.
This article describes three criteria which were used to
evaluate the success rate of an alcoholism treatment
program: vocational rehabilitation, abstinence, and
behavior(such as number of drinking episodes,family and
marital adjustment, 'and participation in outpatient
program).
Mullan H: Vocational counseling with the alcoholic. In
Mullan H, Sanguiliano I: Alcoholism: Group Prychothmpy
and Rdk&itttad*N Springfield, IL, 175-204. Thomas, 1966.
This chapter offers a comparative analysis of the vocational
counselor's role and approach and that of the psycho-
therapist.
National Clearinghouse for Alcohol Information-(NCALI),
PO Box 2345 Rockville, MD 20850.
m 'R 7'
LAW OFFICES OF
CONTRA COSTA LEGAL SERVICES FOUNDATION
Main office. Te-lisphans
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LAW OFFICES OF
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Fax(510)236-6846
February 25, 1994
Kevin Kerr, county counsel
CONTRA COSTA COUNTY
651 Pine Street
Martinez, CA 94553
Re: Jess James
Confirmation of new Board
Bearing date of March 1, 1994
Dear Mr. Kerr:
This is to confirm. yestardayfe message from you on my voice
mail box that Jess James CA Board Hearing has been rescheduled
for Tuesday, March 1, 1994 at 2:00 p.m. l sincerely appreciate
your efforts in having Mr. James Board Hearing rescheduled. Mr.
James is grateful and sends his thanks.
Your courtesy and cooperation is greatly appreciated. I
look forward to working with you.
You iirigal
rulanor ,
Paralegal t
cc: Jewell Mansapit
Clerk of the Boardi.;.
a t{
o
4r:-
LAW OFFICES OF
• CONTRA COSTA LEGAL SERVICES FOUNDATION
Main Office Telephone
1017 Macdonald Avenue West County(510)233-9954
P.O.Box 2289 East(510)439-9166
Richmond,Califomia 94802 Central(510)372-8209
Fax(510)236-6846
February 14, 1994
Sent by Fax on 2-14-94 - 646-1059
Original Hand Delivered on 2-15-94 - a.m.
RECEIVED
FEB 1 51994
BEFORE THE BOARD OF SUPERVISORS
CONTRA COSTA COUNTY CLERK BOARD OF SUPERVISORS
CONTRA COSTA CO.
In the Matter of:
Jess James Re: Board Hearing on Termination of
GA Benefits and Three Month
Period of Ineligibility
County No. 07-09-437022-C4FD
Date bf Hearing Decision:
12-1-93
Board Appeal: 2-15-94
I. STATEMENT OF FACTS
This is an appeal of a hearing decision which found that Mr.
Jess James willfully failed, without good cause, to participate
in Workfare assignments on 9-23-93 and 9-30-93. A Board hearing
in the matter was initially set for 1-18-94. However, County
appeals staff continued the hearing in order to allow time for
Mr. James to undergo a Psychiatric evaluation through County
Mental Health Services in order to determine whether he is
disabled by alcoholism. Mr. James had previously attempted to
get an evaluation through the County Mental Health Services but
was turned away because he was not in a "crisis" . Upon
intervention by County Counsel, Mr. James was allowed to a
Psychiatric Evaluation through Cunty Mental Health Services.
A new Board Hearing in the matter was set for 1-25-94.
However, after review of the Psychiatric Evaluation prepared by
County Mental Health staff, Mr. James Representative asked for
and received, a continuance of the hearing for the purpose of
obtaining a more detailed evaluation of Mr. James disability.
Consequently, a new Board Hearing was scheduled for 2-8-94.
However, by letter to Mr. James dated 2-3-94, the county informed
him that his Board Hearing of 2-8-94 was rescheduled for 2-15-94.
The County Appeals staff allowed until 2-14-94 for submittal of
evidence and a position statement by Mr. James representative.
:. 1.
As presented in a prior sffitement to the Board of
Supervisors on 1-14-94, by his representative, Mr. James did not
keep the Workfare appointments of 9-23-94 and 9-30-93 because he
had received a notice form the Department of Social Services
(DSS) that his aid was being terminated for a previous alleged
non-compliance. He did not realize that he must continue to
participate in Workfare while his appeal of the termination was
pending. For this reason alone, the hearing decision should be
set aside. In the alternative, the decision should be set aside
because James is disabled by alcoholism and should be exempt from
participation in Workfare. This disability causes Mr. James to
drink to the point of drunkeness each day, resulting in confusion
and lack of concentration, and at times, results in his having
black outs. GAADS has classified Mr. James as chemically
dependent due to his alcoholism.
The hearing officer found that Mr. James had not met his
"burden" of proving that he is, disabled and that his testimony
about being confused about a prior hearing request was not
credible. We maintain he failed due to good cause per ADA rules.
II. STATEMENT OF THE LAW
Department Manual Section 49-111, 11,G,@, provides that the
reasons which establish good cause for a failure to cooperate or
comply are subject to verification and include, but are not
limited to, the following:
a. The failure has occurred by reason of a disability under
the Americans with Disabilities Act
1. The burden of proof to establish that the
failure occurred because of a disability is on
the applicant or recipient
2. The applicant/recipient's showing may be
rebutted by the Department
b. employment has been obtained,
C. scheduled job interview of testing,
d. mandatory court appearance,
e. incarceration,
f. illness,
g. death in the family,
h. other substantial and compelling reason. These must be
reviewed and approved by the Division Manager.
Department Manual Section 49-111, 11,H, 1 provides that a willfull
act is one that is intentional or without reasonable excuse or
cause. It need not be done with a specific purpose to violate
program requirements.
a. The burden of proof to establish good cause, which may
include proof that the failure was not willful is on the
applicant/recipient.
b. The Department may rebut a showing of good cause by
proving that the failure to comply was willful, in which
case the Department has the burden of proof.
c. In all cases it is presumed, subject to rebuttal, that
the ordinary consequences of the applicant/receipient's
voluntary acts are intentional are intentional, and thus
willful.
2.
2. Willfulness cannot be be found where the person is mentally
disabled to the extent that s/he does not understand
his/her responsibilities or is incapable of fulfilling
them.
3. Conduct which involves negligence, inadvertence, or
disability may or may not be willful.
a. Three or more acts of negligent failure of the
recipient to follow program requirements, which may
include acts for which the recipient previously has
been discontinued from aid or sanctioned, evidence
willfullness.
Board of Supervisors Resolution #92/857 (Part 7, Section
703) adopted 12-15-92, provides: A recipient who fails or
refuses to comply with General Assistance Program Requirements as
expressed in this resolution or in the Social Service Department
Manual of Policies and Procedures whall be discontinued aid and
sanctions witll be imposed as follows unless the recipient shows
that the failure or refusal to comply was for good cause.
Department Manual Section 49-111, 11,B, 3,a. provides that
Disability means, with respect to an individual, a physical or
mental impairment that substantially limits one or more of the
major life activities of such individual; a record of such an
impairment; or being regarded a having such impairment.
Depa Department Manual Section 49-111, 11,B, 3,e. provides that the
phrase major life activities means functions such as caring for
one's self, performing manual tasks, walking, seeing, hearing,
speaking, breathing learning, and working.
42 Usc, Section 12101 states that the Americans With
Disability Act (ADA) is intended "to provide (a] clear and
comprehensive mandate for the elimination of discrimination
against individuals with disabilities". The ADA continues the
three test definition of disability used in the Rehabilitation
ACt of 1973. The tests are:
1. A physical or mental impairment substantially limiting
one or more major life activities (The impairment must
substantially limit a major life activity) .
2. Record of a physical or mental impairment. (this test
provides protection for an individual who previously had an
impairment . . . .
3. Being regarded as having a physicial or mental
impairment that substantially limits a major life activity (this
addresses concerns about attitudes of others, safety, and
liability, etc. ) (Rehabilitation Act of 1973, P.L. 98-112, 29
USC Section 791, et seq.
The third test requires an individual assessment based on
reasonable judgment, relying on current medical knowledge or the
best available objective must be made to ascertain:
a. The nature, duration, and severity of impairment(s) ,
b. the probability of risk of injury,
3
c. Whether risk can be mitigated by reasonable
modifications of policies, practices or procedures.
III. ARGUMENTS
1. The Determination Should Be Reversed or Termed Non-
willfull As the claimant had good cause.
First, Mr. James had good cause for missing Workfare
appointments on 9-23-93 and 9-30-93 and did not willfully fail
to follow program requirements. As he testified at his hearing,
he believed he no longer had to attend the appointments because
his aid was being terminated for a prior alleged non-compliance.
He stated he did not know that he had to continue to participate
in Workfare while his appeal of that action was pending. The
Hearing Officer's reason for finding that Mr. James willfully
failed to comply with program requirements was that the need to
appear for appointments was reviewed with him on 8-26, before he
filed for his hearing on 9-24 on the prior failure. The hearing
officer failed to consider that although Mr. James filed for a
hearing on the prior failure, he still had a GA termination
looming and for this reason believed that he did not have to keep
future Workfare appointments. The hearing officer stated that
Mr. James explanation regarding his understanding about keeping
future Workfare appointments pending a GA termination, was not
credible. All medical and mental evaluation reports submitted to
date do not indicate that Mr. James is someone who has difficulty
with telling the truth (See enclosed Pittsburg Health Center
records of 3-8-93, 1-24-94 and 1-31-94, Psychiatric Evaluation by
Karen Pratt, M.A MFCC dated 1-24-94, Psychological Evaluation by
Beverly- Ballard Ph.D, dated 2-10-94, ) Additionally, it is
conceivable that due to the effects of alcoholism, Mr. James
didn't understand about keeping future Workfare appointments
pending a termination of GA benefits. For this reason alone the
decision should be set aside.
2 . The Determination And Imposition Of A Sanction Should Be
Reversed As The Claimant Lacked Capacity Under The Americans With
Disabilities Act.
Secondly, the decision must be set aside because Mr. James
is disabled and unable to work due to alcoholism. Due to his
continuing disability, Mr. James should be exempt from
participation in Work Programs.
A 1-24-94 psychiatric evaluation of Mr. James by Karen
Pratt, a Marital and Family Counselor with the County Mental
Health Services, fails to fully address the extent of Mr. James
disability due to alcoholism. In addition, the report does not
assess the severity of an existing personality disorder. No
formal testing was performed for the evaluation. Thus, the
evaluation does not adequately assess the severity of Mr. James
disability. In addition, the report does not fully explore Mr.
James past work performance. He told the examiner that he used
drugs and alcohol on all jobs he's had, but there was no
assessment of how his use affected his job performance.
4.
Thus, it is unclear how Ms. Pratt's conclusion that Mr. James
"ability to hold a job seems unaffected even in light of his
current alcohol problems" was arrived at. There is no evidence
to support this conclusion. To the contrary, Mr. James Work
Programs records (see copies of Work Program records attached)
reveal dates when he did not attend, arrived tardy, or arrived
drunk to his appointed job site. In addition, the records
reflect that in one instance, he had a clash with a supervisor
while at a job site, which resulted in her requesting that he not
be not be sent back to that particular job site because of a "Bad
attitude". .
In her 2-10-94 evaluation of Mr. James, Beverly Ballard,
Ph.D, conducted formal tests. In her report, Dr. Ballard states
that although Mr. James falls in the high end of the borderline
intellectual range in verbal and full scale IQ testing, . . . .
"It is likely that he functions in the low average range and
these scales reflect poor aquisitation of verbal skills,
particularly, since he started drinking at age 8. " She further
states that he "exhibits memory problems often associated with
chronic alcohol abuse". She adds that "he falls in the 10th age
percentile on these scores reflecting that 90% of individuals in
his age range do better than he". Upon administration of the
MMPI, a test to determine the existence of a personality
disorder, Dr. Ballard states that the evaluation presented a "cry
for help profile". She further stated that "the profile
evaluations reveal a chronic tendency toward schizoidal
withdrawal, social seclusion, and depression. " She added that
"individuals with this profile have poor adaptive skills for
their lack of confidence, insecurity and feelings of social
inadequacy", and she also states that "he managed to work
steadily until age 22 despite his alcohol reliance, but his work
history has been intermittent since that time. " Dr. Ballard
concludes that Mr. James "has a substance abuse disorder,
characterized by regular use of alcohol" Additionally, she
states that "He shows some mild signs of congnitive impairment
based on alcohol use. This is manifested by slow motor
performance, and motor learning tasks, ability to sustain
attention to tasks (distractibility) , decreased ability to learn
complex verbal tasks, and impaired ability to maintain new
information into intermediate memory. She further states that
"he is depressed in mood, has marked restriction of daily
activities of daily living and difficulty maintaining social
functioning", and that Mr. James cognitive deficit along with an
attention deficit disorder and early use of alcohol "are going to
affect his reliability, dependability and performance". With
regard to risk of injury, Dr. Ballard states that "He fell off a
roof in the past, while under the influence of substances, and he
readily admits "being stoned" on all his jobs" .
An individual assessment based on reasonable judgment,
relying on current medical knowledge or the best available
objective must be made to ascertain:
a. The nature, duration, and severity of impairment(s) ,
b. the probability of risk or of injury if Jess James is
required to participate in GA-employable activities, (unlike
GAADS meetings which are unrelated in this case and appeal) , and
5.
c. whether his medical and/or mental impairments by
reasonable modification of CCC/DSS GA Workfare policies,
practices or procedures can be provided by auxilliary aides or
services. By this appeal, we formally request that the county
review his records of disabilities for a determination that he is
GA-U.
By conducting an individual assessment as outlined
above, it must be found that Jess James is an unemployable man
due to alcoholism. Mr. James began drinking at age eight. He
admits to drinking "anything" including anywhere from a "six pack
of beer to a pint of hard liquor a day" . Medical records from
the Pittsburg Health Clinic and recent mental evaluations support
the a finding of a disabling impairment due to alcoholism.
claimant's impairment of apparent that Mr. James continued use
of alcohol has affected his ability to maintain steady
employment, and to comply with GA Work Program requirements.
Because of his substance abuse, he is an active participant in
the General Assistance GAADS Program (verified in GAADS records)
However, his participation in the GAADS program in no way implies
that he has the capacity to participate in Work Programs. GAADS
meetings are not comparable to working an eight hour day.
It is apparent that the county cannot accomodate an
"employable" alcoholic such as Mr. James. He is so disabled by
alcoholism that it limits his ability to perform in a work
setting. In addition, Mr. James has a personality disorder,
attention deficit disorder, impaired social functioning,
depression, and memory problems, all compounded by his
alcoholism. Mr. James has applied for Supplemental Security
Income Benefits (SSI) due to his disabling impairment. (For
further reference to vocational implications of alcoholism, see
attached Section on alcoholism from the U.S. Department of
Rehabilitation Services Administration's Handbook of Severe
Disability - 1981 edition - current) .
The risk of injury to Mr. James is serious enough when one
considers the fact that on the days when he does attend Work
Programs appointments, he has already consumed alcohol. He
testified that he drinks every morning. This in itself puts him
at serious risk of injury in his daily performance of work
related activities. His judgment, concentration, and insight are
already impaired upon his arrival to a job site.
It is reasonble to conclude, on the basis of Dr. Ballard's
report, that if Mr. James were to continue in Work Programs, he
is at risk for injury to himself, and possibly those around him.
The evidence supports the claimant's position that he lacks the
capacity to participate in Work Programs due to a disabling
impairment.
6.
IV. CONCLUSION
CCLSF requests that the Board of Supervisors comply with
their own Board Order, #92/857, and with county and Federal Law.
RESPECTFULLY SUBMITTED,
CONTRA CO LEGAL SZRVICES FO DATION
%
JAW
E e'anor Mad i al,
Paralegal
7.
BEV RL Y ALLARD P14. D
C3 sn3ca Psyc1zo3CDP CT1t:
P.O. BOX 245 PTE. RICHMOND, CA 94807 510-232-7732
February 10, 1994
Contra Costa Legal Services Foundation
1017 Macdonald Avenue
P .O. Box 2289
Richmond, Ca 94802
Attention: Eleanor Madrigal, Paralegal
Re: Jess James
Psychological Evaluation
REASON FOR REFERRAL: Jess James was referred by Eleanor Madrigal who
is processing Mr . James ' appeal for resumption of General Assistance
(GA) . She requested a psychological evaluation with psychological
testing to ascertain the extent, effects, consequences, and prognosis
of his substance use, outlining 10 specific questions which will be
addressed in the body of the report .
PERTINENT DATA: Jess James is a 35 year old male who was terminated
from GA benefits of $300 per month after allegedly failing to attend
two work. fare appointments, 9/23 & 9/30/93 . Mr . James did not attend
those two sessions because he had reportedly received a termination
notice for a previous alleged noncompliance and because he was
appealing that termination, he thought he was exempt from work fare.
That decision is being appealed on this basis, but in addition, •there
is a question about the relationship between his regular alcohol use
and his behavior and how that might affect his participation in GA
work programs . Jess James appeared on time on 2/03/94 and completed a
clinical interview with personal history and six -test instruments .
TESTS ADMINISTERED: Trails A & B, from Halstead Neuropsych Battery e
Wechsler Adult Intelligence Scale-Revised (WAIS-R)
Wechsler Memory Scale-Revised (WMS-R)
Controlled Oral Word Association Test (COWAT)
Bender-Gestalt (BG)
Minnesota Multiphasic Personality Inventory, Revised (MMPI-II )
OBSERVATIONS AND TEST BEHAVIOR AND MENTAL STATUS EXAMINATION: Jess
James is a medium-built, 35 year old, caucasian male who dressed in a
flannel shirt, jeans and wore a cap on his head . He was adequately
groomed with a beard, mustache and nape-length curly hair . His
affect was pleasant and honest, and his mood was anxious . His speech
was coherent and there was no evidence of hallucinations, delusions
or a thought disorder . He did not appear under the influence of
intoxicants, although he did report that he had had a "bourbon and
coke and a beer" that morning. There was no evidence of malingering
and he appeared to do his best on the test protocols . He had some
difficulty remembering ' .details of his history, and noted that his
"short-term memory is shot" .
PSYCHOLOGICAL EVALUATION OF JESS JAMES CONTINUED: 2
His alcohol history includes beginning to drink at age 8, "with my
brother" . He has used most drugs in the distant past, but only
occasionally smokes marijuana now. He has never been in voluntary
treatment, has no known medical problems, and admits that alcohol
"interferes with my daily life" . His longest sobriety was 45 days,
during an incarceration two years ago for trespassing while
intoxicated . He has never had alcohol-related seizures, but he does
have blackouts and shakes . His fine motor hand coordination was
visibly shaking during pen and pencil tests and reflects the usual
problem of chronic alcohol users in fine motor control .
He was very anxious about performing the tests, often wanted to know
if he got the correct answer, and actually enjoyed some of the test
tasks, especially those that demonstrate his skill areas . He was
self-denigrating when having difficulty with responses . When given
the 350 question MMPI, where he had to mark true or false, he asked
if he could randomly mark it, "like I did in school", but was asked
to honestly read and answer the questions . The results of this
interview and the test data appear to reflect his current
psychological and cognitive functioning.
INTERVIEW: Jess James reported, unsuredly, that he had not received
General Assistance for December, January or February, although he
does get food stamps . He lives "homeless", sleeping in his non-
operative car and showers at friends ' houses . He repeated that he
had been on appeal for a missed work-fare discontinuance and did not
think he was obligated to attend work-fare while on appeal . Thus his
contact - with legal-aid paralegal Ms . Madrigal . He has been on
General Assistance since 1991, after losing his last job as a
maintenance worker for an apartment complex in 1990 . He attends the
GRADS program for substance abusers, but says it is "generally a
hassle", although "there are some good conversations . He would not
attend the once a week, 1 1/2 hour group if not mandatory.
His alcohol use began at age 8, "drinking beer with my brother" . He
prefers 100 . proof schnapps, but drinks "anything. He has early
morning shakes, and begins using first thing in the morning to
eliminate the ahakes . He was vague about how much he drinks, saying
he drinks til he "passes out" . He has had numerous blackouts, but no
seizures, and went through a week of sickness,. without
hospitalization, when he was incarcerated two years ago. His drug
use . includes "everything", and he once was dependent on speed, while
being a dealer . He has been incarcerated once for dealing
methamphetamine, three times for driving under the influence and
again for driving with a suspended license and no insurance. He
shoplifted a candy bar once as a child, and burglared one residence
in his teens, "an event I 'm not proud of" . Criminal activity has not
been a modus operandi for him.
Work History: Jess 's steadiest job was from age 17-22 when he worked
in. a warehouse. He acknowledges being a "very good worker", though
he was often loaded. He usually was laid-off from jobs which were
short-term manual labor and he says his bosses always knew he was
loaded, so he is uncertain what role that played in his lay-offs. He
has subsequently worked for oil-refinerys, was a basket tree-trimmer,
shipping and receiving clerk, truck and forklift driver, and
carpentry; he has his own tools . His oldest brother is a carpenter .
PSYCHOLOGICAL EVALUATION OF JESS JAMES CONTINUED: 3
Past History: Jess was born, the youngest son of three boys, to his
father and mother who are still married. His father retired from
civil service for the Air Force because of two heart attacks and lung
problems . His mother 's health is good. Alcohol was "always around"
but he was not aware of either parent being alcoholic . He was
hyperactive as a child and prescribed Ritalin, which he refused .
When Jess was 18, the family moved to California, while he remained
in Texas and Oklahoma, where he had a girlfriend and did carpentry.
He moved here in 1984 and ' shortly thereafter he fell off a roof,
crushing his heel, and keeping him from employment for about a year .
He' said "it has been downhill ever since" .
He has had a few girlfriends, but he has never married and has no
children. He has contact with one brother who has a family in
Oklahoma and is on physical disability for injuries> He has no
contact with his . California brother, "whose wife controls him" and
wants nothing to do with Jess . . He occasionally visits his parents,
who always ask about his alcohol use. Both brothers were alcoholics
and his "role models" .
His daily activities include "hanging-out" and fishing with friends .
He lives on Bethel Island around other alcoholics and has to hitchike
10 miles to the nearest bus stop. He once had a driver 's license,
but it was long ago suspended; he has never had a California
license. He has driven without a license, but his car is currently
broken-down. and he sleeps in it or at friends ' houses . He eats "once
a day. . .out of a can", or "with friends", not using ahy food
programs .
He sees his life as a "vicious circle" . He is out of money within 10
days, then borrows and pays back . He does not receive medical care.
He said he was able to get to GAADS and work-fare until about
October . If he missed because he was "too drunk", he usually was
able to get to the Brentwood Clinic to get a medical excuse.
Occasionally, he has gone off General Assistance when he would get
temporary carpentry jobs, so his use has been somewhat sporadic. He
says he is unable to promise that he will keep an appointment because
it is entirely dependent on the effects of his alcohol use.
His . sleep is fair, his mood "easy-going", but generally describes
himself in a happy mood, "going with the flow" because there's no
point in worrying. He occasionally gets depressed and "has an
attitude. "
TEST RESULTS : Intellectually, Jess falls in the high end of the
borderline intellectual range in verbal and full scale, and in the
low end of the low average range on visual-motor tasks (VIQ=79;
PIQ=81: FIQ=79 ) . There was no indication - of diffuse organic or
localized ' organicity. It is likely that he functions in the low
average range and these scales reflect poor acquisition of verbal
skills particularly, . since he started drinking at age 8 .
PSYCHOLOGICAL EVALUATION OF JESS JAMES CONTINUED: 4
The memory indexes reveal. comparable scores in the high borderline
range for attention/concentration and visual memory (79 .. and 78,
respectively) with low borderline ranges in verbal memory, general
memory and delayed memory ( 70, 70 & 73, respectively) . These latter
scores reflect the memory problems often associated with chronic
alcohol abuse. He falls in the -10th age percentile on these scores,
reflecting that 90% of individuals in his age range do better than
he. He does show ability to learn through visual association tasks,
with a slowed encoding process that does consolidate into long term
storage. Verbal learning tasks are limited to simpler, rather than
complex tasks .
Other tests revealed no frontal lobe impairment (COWAT, Clock Times )
and - sequencing tasks revealed mild impairment in motor speed .
Tremulous lines and careless mistakes occured on the BG, which is a
motor copy task, and reflects very soft signs associated with chronic
alcohol use, as does the slowed motor speed .
PERSONALITY: The MMPI is a forced-choice, self-endorsed personality
inventory and this evaluation is based on this instrument solely. He
responded in a valid, typical test-taking manner, indicating balance
between disclosure and openness, and presenting a cry-for-help
profile. The profile elevations reveal a chronic tendency toward
schizoidal withdrawal, social seclusion and depression. Individuals
with this profile have poor adaptive skills for their lack of
confidence, insecurity and feelings of social inadequacy. Although
likely to be. a conscientious, hard-worker, such individuals often
have difficulty handling authority issues which affects their job
stability. Angry feelings are not easily expressed and somatic
symptoms and withdrawal may replace them. There appears to be an
underlying ocnflict over dependency needs which is handled by keeping
emotional distance, especially from the opposite sex. Jess does not
have the profile typical of alcoholics, therefore his use may reflect
an early learned and reinforced behavior pattern which interfered
with healthy and normal adolescent development and mastery over the
vissitudes of daily life. He managed to work steadily until aged 22,
despite his alcohol reliance, but his work history has been
intermittent since that time.
RESPONSE TO QUESTIONS AND CONCLUSIONS : 1. Yes, Mr . James has a
substance abuse disorder, characterized by regular use of alcohol .
2 . He shows some mild signs of cognitive impairment based on his
alcohol use. This is manifested by slowed motor performance and
motor learning tasks, ability to sustain attention to tasks
(distractability) , . decreased ability to learn complex verbal tasks,
and impaired ability to maintain new information into intermediate
memory. He is not disoriented nor does he have hallucinations or a
delusional disorder . He is depressed in mood, has marked restriction
of activities of daily living and difficulty maintaining social
functioning. His attention deficit and distractability is likely to
eventually affect his work performance and reliability.
PSYCHOLOGICAL EVALUATION OF JESS JAMES CONTINUED: 5
3 . Clinically, Mr . James shows a lot of motor tension and
performance anxiety; he was diagnosed with attention deficit disorder
as a child and prescribed Ritalin, which he declined to take. His
personality test . (MMPI ) revealed depression and schizoid -personality
features, which are withdrawal tendencies into fantasy and avoidance
of social interactions . The early use of alcohol appeared to affect
his developmental maturation, and shaped his personality.
Paradoxically,. the inadequacies that he experiences may be self-
medicated through the use of alcohol, and the vicious cycle
continues .
4 . Mr . James reports a crisis in living in the fall of 1993, wherein
he lost his usual housing and was forced to retreat to his car and
with friends .
5. He reports ever-increasing interference in his activities of
daily living by his continued use of alcohol . He has not been
motivated to seek treatment or rehabilitation for this problem.
6 . The impairments described in #2 and #3 are going to affect Mr .
James ' reliability, dependability and performance. It appears that
he was able to get medical excuses or make contact until he lost his
abode in the fall of 1993 .
7 . On quick perusal of Mr . James ' GAADS records, it appears that he
was valued early on as a hard-worker, but his reliability
deteriorated overtime. This would seem typical behavior of a chronic
alcohol abuser .
8 . I am not certain of the risk of injury for Mr . James if he
participates in work programs . He fell off a roof in the past, while
under the influence of substances, and he readily admits "being
stoned" on all his jobs . It appears that the laws of probability are
likely to catch up with him with time and aging, just as his
incarcerations were related to driving under the influence and with
suspended license. Alcohol suspends concern about the consequences
of one's behavior .
9 . Whether risk of injury can be mitigated by provision of
auxilliary aides or services I cannot determine. The use of such
services would seem to depend on some alcohol-related screen related
to the level of intoxication. Mr . James is capable of being
reasonable, . but alcohol is a disinhibiting contributor to behavior
and judgment .
10 . Mr . James is -young enough that if he were motivated to engage in
sobriety, the symptoms he exhibits are mild enough to possibly be
reversed. This can take up to a year of sobriety.
If you have any further questions, please feel free to call 232-7732 .
Respec lly submit ,
Beverly Balla , Ph.D.
Clinical Psychologist
4 .
Z ixx .i �.
• P� HOL245 PTS. RICHMOND,�CA 94847� _ _ (415) 232-7732
ERUCATION .ANQ,"HQ.NO�.i__
1980: PH.D. - CALIFORNIA SCHOOL OF PROFESSIONAL PSYCHOLOGY - BERKELEY
California State Fellow, Clinical Psychology, 1975-1980
1975., B.A. - SAN FRANCISCO STATE UNIVERSITY - Summa cum laude
Psychology Major - San Francisco, California
CURRENT PROFES§IDN L .XPERIENCEe
SINCEt
1983— CONSULTING CLINICAL PSYCHOLOGIST AND MEDICAL STAFF MEMBER
Merrithew Memorial Hospital, Martinez, Ca
-DIAGNOSTIC EVALUATIONS and psychological treatment of
medical patients.
"CONSULTATION AND LIAISON to physicians and inter-
disciplinary staff regarding behavioral management
and therapeutic interventions of medical patients.
-BRIEF PSYCHOTHERAPY with patients and their families with
anxious or depressive adjustments to health disorders,
life-threatening or disabling diagnoses .
'"NEUROPSYCHOLOGICAL ASSESSMENTS of brain-inJury with
cognitive rehabilitation treatment recommendations;
family and patient interventions and follow--up.
"CHRONIC PAIN CLINIC COORDINATOR providing assessment, multi-
disciplinary group treatment and consultation to primary
physicians .
"GROUP FACILITATOR FOR CHRONIC PAIN, wellness, cancer and
disability and cardiac rehabilitation.
"'PSYCHIATRIC EMERGENCY as9eSSments, crisis intervention,
admissions, involuntary holds, family interventions,
alcohol and drug treatment, community liaison .
"'FACULTY MEMBER of Family Practice Medical Residency program.
"SUPERVISION of doctoral Interns . -
"
1979- PRIVATE PRACTICE 2340 Vard St. , 9105, Berkeley, Ca.
3249 Mt.Diablo Blvd, 210, Lafayette, Ca .
""BRIEF THERAPY with individuals, couples, and families .
"NEUROPSYCHOLOGICAL and psychological assessments .
1980- ADJUNCTIVE FACULTY-CALIFORNIA SCHOOL OF PROFESSIONAL PSYCHOLOGY
"CLINICAL SUPERVISOR of doctoral interns, of first year
Interviewing Techniques students, and team member of
Clinical Proficiency Performance Review evaluators .
1983- CONSULTING EXAMINER- SOCIAL SERVICE ADMINISTRATION
"DISABILITY EVALUATIONS for Federal social service disability
19$5- COMMISSIONER - PSYCHOLOGICAL EXAMINING COMMITTEE, SACRAMENTO
"ORAL EXAMINER for California State psychology Licensure
1987- NEUROPSYCHOLOGIST - CONTRA COSTA HEALTH PLAN
BEVERLY BALLARD, PH.D. PAGE 2
P EVIOUS PROFESSIONS EX EP RTEN
1979-83: CLINICAL PSYCHOLOGIST - ACUTE PSYCHIATRIC SERVICES
"TEAM LEADER with direct clinical caseload and clinical
and administrative supervision of case assignment/
management/ disposition by teai members .
"DIAGNOSTICS/TREATMENTPLANS on dmission . and discharge.
"BRIEF PSYCHOTHERAPY with individuals/couples/families .
with a wide-range of psychiatric diagnoses .
-CONSULTATION for psychopharmacology,. -and with community
resources for discharge continuity of care.
"GROUP PSYCHOTHERAPY three tines weekly.
"PSYCHOLOGICAL ASSESSMENTS and reports .
"ADMINISTRATIVE reports/program planning/staff development
"SUPERVISION of pre-doctoral interns .
FORENSICS for conservatorships, patients' rights,
legalities of involuntary W & I/jail holds & Medi-Cal..
1978-79t PSYCHOLOGY INTERN - COMMUNITY MENTAL HEALTH, MARTINEZ, CA.
"BRIEF AND LONG-TERM THERAPY-individuals/couples/families .
GROUP TREATMENT for weekly women's depression group.
-FAMILY THERAPY of identified high=risk pediatric cases .
"SUPERVISION of medical resident in family cc-therapy.
1977-78: PSYCHOLOGY INTERN - PSYCHIATRIC EMERGENCY & ' CRISIS SERVICES
`COMPREHENSIVE ASSESSMENTS . of crisis clients, involuntary
and voluntary, drug/alcohol brain syndromes, organic
and personality disorders, suicidal/homicidal behavior
children through geriatrics in life crises .
"CRISIS INTERVENTIONS in brief model, and inpatient admits
"PSYCHOLOGICAL TESTING and reports.
1976-77 : PSYCHOLOGY MASTERS TRAINEE - Alameda Mental Health Clinic
"INTAKE ASSESSMENTS, drop-in evaluations/telephone intakes
"BRIEF PSYCHOTHERAPY with individuals/co.uples/families .
"PSYCHOLOGICAL TESTING and reports .
1974-761 AREA COORDINATOR - PARENTAL STRESS SERVICES - OAKLAND
"CHILD ABUSE PREVENTION 24 HOUR CRISIS HOTLINE
"CASEWORK MANAGEMENT of 300 monthly telephone crisis calls
ADMINISTRATIVE scheduling and case assignment to 40 para-
professionals, with follow-up consultation, training,
and case conferences .
-CRISIS INTERVENTION/BRIEF THERAPY, in-home assessments and
intervention with high-risk families of violence.
"GROUP THERAPY weekly for high-risk parents.
1975-79 : GROUP FACILITATOR/INSTRUCTOR - Parenting Class for high-risk
parents funded by Adult School Education and liaisoned
with Alameda Mental Health .
"GROUP FACILITATOR - 4 year weekly group focused on commun-
ication skills, role expectations, value systems,
parent-child conflicts, single-parenting, interpersonal
problem-solving, military role and community resources .
. :. BEVERLY BALLARD, PH.D. PAGE 3
PROFSAOION -REFLATE! WO2K EXP RIN .
'
i975-76t ADULT SCHOOL INSTRUCTOR - ,Xssuaq Fagir13 Wo
1974-75: COLLEGE OF ALAMEDA CO-INSTRUCTOR - ov �c Marriage_
1973-•74 : WOMEN'S HISTORY RESEARCH CENTER - Berkeley, Ca.
"Compilation/Microfilming of Women's Movement/Bookkeeper
1955-73: FULL-TIME PARENT/PART-TIME SECRETARY
RESIDENTIAL EXPERIENCE IN JAPAN/MIDWEST/SOUTH-URBAN AND RURAL
O MUMIT'-RELATAD EXP_EI2 E Ci•;
1975 "THE BATTERED WIFE" PANEL MEMBER - College of Alameda
"Collaboration/development of legal diversionary program.
1475 "NON-ADVERSARY DIVORCE PANEL MEMBER - Berkeley Counseling
Center with Judge Avakian/Dr. Gerry Smith/Atty Evlyn Rice
1976-77 : ALAMEDA SOCIAL SERVICE BOARD MEMBER
1975-76: ALAMEDA EARLY CHILDHOOD EDUCATION ADVISORY BOARD MEMBER
1975-76: ALAMEDA ADVISORY COMMITTEE-High School Community job--training
1973-84 : K.O.P.S. MEMBER - Housing discrimination advocacy/testcases .
29701 ALAMEDA MASTER PLAN FOR EDUCATION MEMBER
Pre1970: DIRECTOR AND COUNSELOR OF VARIOUS YOUTH CAMPS - Michigan
BASEARN F F,ER I F
19801 DISSERTATION sa:� ionin Roje Adju$t=nt_of Single
Parent Mojheraas A Function of Sex-Rol-e- Orientat on and
3Qgial_Networks
1977: MASTER THESIS -- &;Iya„DtacLe,� ang Dia, da vanka_cses of $ren ina
19751 APA PRESENTATION - Ajgobgj hbuse = Woom,� .
1976-771 "Piaget Conceptual and Conservation Tasks of 5/6 Year Olds"
"Piaget Interview on Magical Thoughts and Dreams of Children"
"Learning Disabilities of a Six Year old"
"Dream Analysis of a Five Year Old Child"
B HOLARSHIP ANDAWAR S s
1975-801 CALIFORNIA STATE GRADUATE FELLOWSHIP
19741 BUSINESS AND PROFESSIONAL WOMEN'S SCHOLARSHIP
1970: HONORS SCHOLARSHIP - Grand Valley state College, Michigan
VALEDICTORIAN - Wayne Memorial High School, Michigan -
PROFESSIQUA_L AFFILIATION "
American/California/Contra Costa/Alameda County Psychological
Association Memberships
American Academy of Pain Management
Department of psychiatry and Psychology - Merrithew Hospital
Medical Staff Member -- Herrithew Hospital, others pending
CRSDRNTIALS,
19821 CALIFORNIA PSYCHOLOGY LICENSE PSY 7935
1979: CALIFORNIA MARRIAGR, FAMILY, CHILD COUNSELING LICENSE M-13712
1977: CALIFORNIA LIFE CREDENTIAL-COMMUNITY COLLEGE COUNSELOR AND
INSTRUCTOR IN PSYCHOLOGY
19751 CALIFORNIA LIFE CREDENTIAL - ADULT SCHOOL INSTRUCTOR of
English, Psychology, Humanities.
DECLARATION OF CUSTODIAN
,I�� j� 11r10r1� -OF MEDICAL RECORDS
AND CLINICS
K. Clevenger, MRT
(CUSTODIIW OF MEDICAL RECORDS)
REPLY TO: RE: James, Jess
MEDICAL RECORD#: 57-00-55-4
❑ MERRITHEW MEMORIAL
HOSPITAL AND
HEALTH CENTER: says as follows:
Medical Records
2500 Alhambra Avenue That the declarant is the duly authorized Custodian of Medical Records of Contra Costa
Martinez,CA 94553 County Health Services and has authority to certify said records and,
(510)370-5220 ❑ That the Medical Records are all the records described in the subpoena duces
tecum as indicated below and have been released for documentation on microfilm
❑ BRENTWOOD to the deposition notary .
HEALTH CENTER:
Medical Records ❑ That the ❑ original ❑ copy of the Medical Records attached to this Declaration
118 Oak Street are all the records described in the subpoena duces tecum as indicated below:
Brentwood,CA 94513
(510)634-1102 ❑ That the Medical Records are all the records described in the request as indicated
below and have been released for documentation on microfilm to the deposition
•
® PITTSBURG nary
HEALTH CENTER: ® That the copies of the original Medical Records attached to this declaration are all
Medical Records the records described in the request as indicated below:
550 School Street
Pittsburg,CA 94565 ® no exceptions.
(510)427-8077 ❑ except those portions of the record which come under the provisions of Section
5328 of the Welfare and Institutions Code.
❑ RICHMOND
HEALTH CENTER: ❑ which by law are permitted to be disclosed.
Medical Records
38th&Bissell ❑ other exceptions.
Richmond,CA%W5 ❑ Billing information will follow under separate cover.
(510).374-3M
❑ X-Rays will follow under separate cover.
❑ CONCORD That the records were completed by the personnel of the Health Services, staff
HEALTH CENTER: physicians, or persons acting under the control of either, in the ordinary course of
Medical Records hospital business at or near the time of the act,condition or event.
3052 Willow Pass Road
Concord,CA 94519 1 declare under penalty of perjury that the foregoing is true and correct
(510)646-5506
❑ OTHER: (SIGNA E of CLARANT)
Date: 1128/94 at Pittsburg ,California.
NOTE:This report is strictly Confidential and
Is for the Information only on the person to
whom it is addressed.No responsibility can be .
accepted If it Is made available to any other
Person,INCLUDING THE PATIENT.
MR 161-6(4/92) , Contra Costa County
CONTRA COSTA COUNTYAEALTN SERVICES._.,..• :.,.
MERR7,TNEW MEMORIAL HOSPITAL AND .CLINICS
- 03 or 93
PITTSBURG HEALTH'CENTER
pUTpATIENT"N07ES' , ID Page �,
,Patient
Date JAMES JESS
{ GNT DARE,
MAR 4 1993
cl 10/17/.19 58
V
t�R-1 pxc (11-sj (side' 1)_ : '
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LL.Q. � 6388c 0
'a'ri'a•;y c •
CONTRA COSTA COUNTY HEALTH SE.
r', } : �•= �
}.. .
MEMORIAL HOSPITAL 'AND .CLINICS t .: q,E 5 J E S S
11 10/17/1958 510 684-9572
:�r .•
PITTSBURG ...HEALTH CENTER :
"•
OUTPATIENT NOTES OGS 1 O S S-4 AO
Patient ID PI�eT ,'.` •CE
Y;
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rac ace tiA.
24 1%4
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�
_ `ti rC�- fiP a
mil-l-Pl'1C (11-86) (Side- 1)
CONTRA COSTA OOUNT HEALTHi'SN CMS.- 012494 P TTS . tp
Alr;tRT'rlll,w MUtORIAL HOSPITAL AND CLINICS
.
' PITTSBURG HEALTH CENTER �� JAMESJESS:
H-110/17/1958 510 684-9572
cllTPATIENT N s 005_100SS-4 AO Pie #
Patient ID
nate .
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(Side 2} (11-86)
t:. .; +s•.a.s!=>-S�ti�_, w'j>'•'}�, fir::.... .
' .. ...�". n :•SS,11ryM1..plttl';i�:.4J .'::::•a��N'�.':i'=-i'.•tw•:.
CONTRA COSTA COUNTY HEALTH SERVICES','..::.'
e' MTa.1%TTREW.MEMORIAL HOSPITAL AND CLINICS''
PITTSBURG HEALTH CENTER
OUTPATIENT NOTES
Patient ID Page
U a t e
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17,
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(Side 1)
.*1R-1-PHC
RUN DATE: 01/25/94 CONTRA COSTA COUNTY HEALTH SERVICES PAGE 1
RUN TIME: 0740 Summary OUT PATIENT Discharge Report
LOCATION
PATIENT:: :'.;'ACCT .; M02567-3153 :.,I;oC:..:>;<:PHC' .:.,,:.;:';:' :':"'.V'':#.;.;:966576055
::...
::.:.:....:::::.. :::.:'€A(3E/SB:=€:€s1:3:5/M,...... :::::::>:`'':: 01/24/94
:...:. . ......:... . ...;:...;..
REG DR: :.":.UNKNOWN:.:
:�:.'.: . .. ;COMPLETE::.BLOOD COUNT;:- .:'...:..::::� :. . . .... ..::...
Day 1
Date JAN 24
Time 1349 Reference Units
�--
->WBC.. �.. .. ��.:::.;�. •�; . . ::.:s>•:..>:• ..� �:....::: 4`"�8 �10�:°8 �•:TH CMM.
->RBC 4.74 (4.7-6.1) MIL/CMM
_>HGB .: : ::.:.,.;.; :...:::: 15'.2 ::.>°::::':.;.:. ;: ..:.. °:"..:: .::.:: .: : ° ' (14-18)
->HCT 44.9 (42-52) %
:... . ...... -,,-- ...
&HCH(C
MCH :2z `:: (27-31) PG
: '. . :.: 34: :0 ". :...;.;.: : . :::';:.:::::.:.: : .;:(33::37:); G/DL :.
->RDW 12.6 (11.5-14.5) %
>PLT . 42 <% '^'<''::y::: 130=400 TH CMM..
->MPV 8.8 (7.2-11.1) FL
#+##;www.www:*wwww.v.www.v►,�www*+rrr.ww:wwwwwwww**CHEMISTRY***************w�r,►+*w**+.w*r�►*+�**,r*,r.r++*�* r
CHEM.::-13:�:'PROF I LE.•:':
Day 1
Date JAN 24
Time 1349 Reference Units
->GLUCOSE,.. j3:: t';':�>` ..... . (70-108) MG/DL
->BUN 10 (7.0-22.0) MG/DL
>CREAT (0.5 ). MG/DL
->CALCIUM 9.9 (8.7-10.7) MG/DL
->PHOSPHOROUS..:... ::<: 4:cc:7 .;.„::: :'':::::. :::.':'.: : (2'.6-4':"9) ' : :::: MG/DL
>T.PROTEIN 7.9 (6.1-8.0 G DL
>ALBUMIN• k :•. .. . (3.5-4.8
�� G DL
->BILI,TOTAL 0.7 (0.3-1.2) MG/DL
->ALK PHOS...:;.'::::.::::' °.;::'6'3 :.:.,:::::::°. .:.'°>'.:': :..: ..:..;:,: (30-107) U/I;
->AST 37 (8-42) U/L.
->URIC ACID >::.>'? 1 %: (3.9=7.8) MG/DL
i I-Al
i
;.:...
:. ..:: .. . . . .. .
:
?Patient: JAMES;JES$'.-:.- ::.:'::.: ::: .:.;.;.::.•: °:::::Age/Sex:e..35/M::::: "...-Acct#M025673153 :.;..:Unit M005700554
.W. . RUN DATE: 01/25/94 CONTRA COSTA COUNTY HEALTH SERVICES PAGE 2
RUN TIME: 0740 Summary OUT PATIENT Discharge Report
LOCATION
........ .:.
Patient: JAMES' :7ESS: :.`;::>:.;. :,. :::': '.'°::'.:>< <':'....'<:>°#M0256Z3153 (Continued)': . . :
***.**.**.*CHEMISTRY::;:..(Corit:
.LIVER:€::'PROFILE:�.
Day 1
Date JAN 24
Time 1349 Reference Units
ALBUMIN: ..:�.:.: .. . ::�.,:: �...#):x,,..:..:;;•....�]>;..: ...:'.:;:�:'..'`� :�..':.: :......
....
�:.��.�. . .>.(•3 5 �4.:8.)���� �>.�::.::. . ::::... G/DL. .....
->LD ]$2r' :;4##>kEIz•.`•'`s (94-172) U/L
>ALT :: :";:'.::::':. 47:.':: :.>:>::: '.:: .. :' .:::. °:: : :€ ::.(0-55) U/L
:LIPID PROFILE:>.
Day 1 E
Date JAN 24
Time 1349 Reference Units
>CHOLESTEROL-'':..r:'::r .�. 191���.:�:;:�:�����:.� :.'�:.:�����: ,. �. .�:. . .� ���. (120-200) . ...� MG/DL
Patient: JAMESJE$S :; Age%Sexe `35/M Acct#M025673153 .Unit#M005700554
Skti
� I
17 ALCOHOLISM
Vernelle Fox, M.D. -
James P. Conway, M.S.
Jeri Schweigler, M.S.
i
.i -
I -
DISEASE DESCRIPTION disabilities and does not always refer to the disease
Alcoholism, with or without a simultaneous drug "alcohol addiction." Much of the confusion and -
abuse problem, is one of the most prevalent disabilities pessimism surrounding this illness is due to the fact
in the United States. More often than not, the that we label abusive drinking as alcoholism without
alcoholic client's stated reason for seeking vocational trying to differentially diagnose the mechanism by
rehabilitation services will not be a candid declaration which the individual developed the alcohol addiction or
of alcoholism, but this disease will be the major the specific manifestations and prognosis for that
disability after the client has been adequately individual. Prior to the mid-1950's, alcoholism was
evaluated. If the alcoholism is not diagnosed and only regarded as willful misconduct rather than as a
realistically dealt with, as opposed to simply treating disease, and alcoholics were handled punitively by the
the complications or presenting symptoms, there is legal system. The individual was blamed for his lack of
virtually no chance of the individual being will power, and medical treatment was only available
rehabilitated. for the advanced complications of alcoholism.
Alcoholism occurs in all ethnic, socioeconomic, and In this chapter, the terms "alcoholism," "alcohol
age groups. However, the incidence of the disease is abuse" and "alcohol addiction," and the terms i
higher in some groups (for example, Irish and native "alcoholic" and "alcohol addict" are synonymous. i=
Americans)and lower in others(for example,Jews and The National Council on Alcoholism (NCA) and the
Chinese), and is reported three times more often in American Medical Society on Alcoholism (AMSA) I _
men than in women. It has been estimated that one- have defined alcoholism as "a chronic, progressive
quarter to one-third of the persons who have and potentially fatal disease . . . characterized by: _L
alcoholism also abuse other drugs, usually sedatives or tolerance, physical dependency and/or pathological
tranquilizers prescribed for them in an attempt to organ changes, all of which are the direct or indirect =
control their alcoholism.The disease is seen in persons consequences of the alcohol ingested."of all occupations, but tends to be higher in some Tolerance is that phenomenon whereby a much it
occupational groups, such as physicians, career and greater and more toxic amount of alcohol(or any drug) i E
service personnel, painters, and short-order cooks. is required.to produce the same subjective effects that a i
Although speculations have been made, the reason for smaller amount originally produced. The exact
higher incidence in persons in these vocational areas is mechanism for tolerance is not proven, but it is known
not known. that certain changes occur in the liver and that persons
The total number of alcoholics in the United States develop central nervous system adaptation to the '
is estimated to be nine million. About 5 percent of all sedative effects of alcohol. How much tolerance is due
employed persons are thought to have the disease, to altered liver metabolism and how much to central a=
while the "skid row" or homeless male with frequent nervous system adaptation is not yet known.
arrests,often thought of as"the alcoholic,"constitutes Alcohol addicts usually develop cross tolerance to other _
only 3-5 percent of the alcoholic population. During sedative drugs and sometimes to narcotics. The
recent years, there has been an increased prevalence of individual who develops a high tolerance for one j
alcoholism among women and youth. sedative drug will subsequently nearly always have a ! -
higher tolerance,from the beginning, for related drugs.
For example, an individual whose metabolism is so :� z
Definition changed that it takes a fifth of whiskey to make him .i r
Alcoholism can be the person's only disability, or it drunk will also probably require two or three sleeping
can occur with one or more other physical or pills to put him to sleep, more morphine to kill pain, i T
psychiatric disabilities. The label "alcoholism" is and more anesthetic to induce unconsciousness than a
frequently loosely applied to several groups of person with normal metabolism. Also, a person
231
: 232 Fox, Conway, and Schweigler
AM
addicted to one drug obviously has a much higher risk A great deal of sociological research has been done JIM
of becoming addicted to other drugs. regarding drinking habits and other behavioral
Withdrawal symptoms begin to occur 6 to 12 hours patterns of subcultures. Drinking patterns are so
after the long-term heavy intake of alcohol has ceased. influenced by peer pressure and cultural value systems
The symptoms reach their peak in 1 to 2 days and that it is impossible to answer such pertinent questions =
gradually subside after 3 to 6 days. The symptoms of as whether children who are taught responsible
withdrawal can be quite mild, such as lack of appetite, drinking, such as wine with meals or an occasional
�- �_
sweating, and nervousness, or they can be very severe cocktail,are less likely to develop alcoholism than those
and potentially fatal, such as severe tremors, who are taught total abstinence. Although it is known '-
hallucinations, convulsions, cardiac irregularity, and that the incidence of alcoholism is very high in -y
shock. environments where drunkenness is "normal" and
Physical dependency on alcohol is defined by the sobriety "abnormal," not all individuals who live in
appearance of some withdrawal symptoms when the these environments become alcoholics. There is ;
individual decreases or ceases alcohol consumption. In obviously a great deal yet to be learned about the
addition, an alcoholic is generally a person whose influence of the environment in the development of
drinking repeatedly and seriously interferes with one alcoholism. Ma
or more major spheres of his life, such as work,health, Reality avoidance. Some persons develop their high
or interpersonal relationships. exposure to alcohol by learning to use the drug as a -
The NCA has developed groupings of signs, tranquilizer, a means to avoid reality. They control ;
- symptoms,and criteria for the diagnosis of this disease. their anxiety or depression by drinking, and alcohol �}
During the early stages of the disease, the individual increasingly becomes their most effective coping skill.
often drinks increasing amounts to feel a "glow," Gradually, as their tolerance develops, they stay in a
gulps and sneaks drinks, looks for more occasions to state of low-grade chronic withdrawal,with a resultant
drink, lies about the amount consumed, misses more craving for the drug. They drink in order to avoid
work and shows decreased performance when at work, withdrawal symptoms and to be able to maintain :y
has morning shakes, and shows a loss of appetite. In routine functions. Eventually, alcohol may become the
the later stages, the alcoholic typically stays drunk for most important thing in their lives and they frequently r :x.
weeks at a time,is unable to go a day without drinking, become preoccupied with getting a drink, stopping
.n.
displays severe withdrawal symptoms lasting for days drinking, or staying sober.
sometimes including convulsions and hallucinations), ws
and showsh sical damage to the liver, nerves, heart, 4t
P Y g
gastrointestinal tract, and other major organs. Complications °mow
Alcohol is a relatively short-acting drug that is
rapidly absorbed and circulates unchanged in the
Etiology1cm
blood stream and cerebrospinal fluid. The most
There are three distinct ways a person can develop common acute complications of alcoholism are falling ''
alcoholism. Most commonly, however, a combination and driving accidents causing bruises, broken bones,
of these mechanisms is present. and other injuries. ,• :
Physiological susceptibility. A certain portion of the Every organ system in the body is affected to some
alcoholic population appears to be biologically degree by alcohol, and prolonged heavy usage often
abnormal in their physiologic response to alcohol. causes pathological changes in the brain, liver,
They appear to have a potential at birth for developing stomach, pancreas, peripheral nerves, and heart.
y antritis, pancreatitis, neuritis, and fatty
abnormal metabolism and tolerance to alcohol if the Anemia, g
are exposed to it. Persons with high susceptibility may changes of the liver can occur. There can also be
develop gross tolerance and withdrawal symptoms impaired brain function, resulting in confusion and
after only brief exposure, while those with only slight memory loss. Cirrhosis of the liver, a devastating, . Y`
'.�S•::
susceptibility would take longer exposure to develop destructive disease, is not as common as it was once '`�
the same set of clinical symptoms that we call thought to be.
alcoholism. There is substantial evidence that this Individuals have great variance in their organ •
physiological susceptibility to alcoholism is familial. susceptibility to alcohol damage. It is not known why
Peer group pressure. The drinking culture in which two alcoholics drinking approximately the sarr.
the individual lives has a substantial influence on the amount over the same number of years will develop ;:
development of and recovery from alcoholism. In some different complications. For example, one individual '
subcultures in the United States,drinking is so much a may have severe gastritis or ulcers, while another
way of life that the abstinent individual is viewed as a develops some level of brain damage and associated
social deviant and regarded with suspicion by his symptoms, such as impaired judgment, loss of recent
peers. memory, irritability, or emotional instability. Organs
: 4
,•t:u
i
Alcoholism 233
• are not affected in any specific pattern, nor is there a Some persons "mature out" and virtually stop
'I
� I
specific relationship between the amount or duration of drinking unassisted,while others have variable periods i
drinking and the development of organ damage. of spontaneous remissions. Since there are no reliable I
I �!
Undoubtedly, the degree of malnutrition and vitamin indicators or characteristics to predict the natural I ;!
deficiency that the person suffers to some extent course of the disease, remission should never be relied
governs the severity of organic pathology that will upon for the individual's recovery. However, the
!.I
develop. majority of alcoholics can show improvement or
Since the complications of alcoholism can mimic completely recover with abstinence and appropriate ; ;I
almost any disease, it would require several textbooks treatment over a sufficient period of time.
of medicine to completely describe all the organ
damage that can be caused. If a client reports high
!
levels of alcohol ingestion and has multiple other FUNCTIONAL DISABILITIES
j I!I
diagnoses,the counselor should suspect alcoholism and physical Disabilities !i
request a thorough medical evaluation. ;R
Although major complications and organ changes The degree of physical disability may be severe for ;'
usually develop in the later stages of alcohol addiction, • the alcoholic even in the early stages of the disease. !�
work problems can be diagnosed much earlier. With During drinking episodes, motor functions, such as
earlier recognition and appropriate treatment leading memory and judgment, will obviously be affected. As
to abstinence, these complications are usually organ involvement becomes more pronounced, the
preventable or easily reversible. The majority of magnitude of symptoms and resultant impairment of ' l�
physical complications are reversible with long functional abilities increases.
abstinence and .good nutrition, even in the more Impairment of fine or even gross forms of motor i
advanced stages. coordination generally do not interfere with activities
In addition to these medical complications,the social of daily living. In the first 6 to 12 months of recovery,
and economic costs of alcoholism are awesome. The clients may have tremors which interfere with their
NCA estimates that 50 percent of all fatal accidents ability to write, or they may experience lapses in short- '!
A
involve the use of alcohol, with two-thirds related term memory and the ability to concentrate. ;
directly to .the actions of alcoholics. In addition, a Physical restoration will be gradual and is predicated
conservative estimate of the cost of alcoholism to on the client's ability to remain abstinent. Milder
industry is 25 percent of each employed alcoholic's forms of dysfunction will reverse within a few months
salary when such factors as absenteeism, tardiness, after abstinence, while more pronounced dysfunction i
spoiled materials, decreased efficiency, on-the-job may require 6 to 12 months. Although uninterrupted ! i.
accidents, and medical benefits are taken into account. alcoholism over a long,period of time can result in
irreversible organ damage and physical disability, in j
Prognosismost cases these are fairly temporary in nature if the
individual can achieve and maintain abstinence. If the
Alcoholism is a slowly progressive disease. The client has impairment in self-care, ambulation, and
typical male alcoholic has been drinking abusively for 8 gross motor performance after several weeks of proven
to 12 years before he develops complications or abstinence, advanced complications or another ° W:
otherwise deteriorates sufficiently to seek help. For disability must be suspected. In these cases, the
women, the time period is usually somewhat shorter. counselor should refer the client for complete medical
Individuals with serious psychiatric disorders who evaluation.
i i•.
become more disturbed when they drink and
individuals who have previously been, or currently psychosocial Disabilities
are, addicted to other sedative or narcotic drugs also
require a shorter exposure time to develop alcoholism. Long-term combined alcohol/sedative addiction can
For example, the former heroin abuser or the produce manifestations of severe psychopathology
methadone maintenance patient is virtually an instant during the addiction and for as much as 6 months
alcoholic if he begins to drink any appreciable amount. afterwards. When these manifestations occur, they
This is due, at least in part, to cross tolerance, but may be suggestive of severe debilitating mental illness
there may also be specific biochemical alterations that and may possibly even require acute temporary
result in this difference. intervention.The severity of the symptoms,sometimes
The natural course of addiction is quite variable accompanied by a self-destructive component, may
across individuals. Although it is commonly believed lead the counselor to assume that an underlying
that, once developed, addiction is steadily progressive chronic psychiatric disability is surfacing. This
;y':
and the individual's condition worsens in an determination cannot accurately be made until all the ��A
uninterrupted fashion, this is not necessarily true. organic brain syndrome secondary to alcohol and drug
I'M234 'Fox, Conway, and Schweigler
abuse has reversed. The vast majority of alcoholics around him and of relieving.the pain caused, in part, '.
who come for services have the potential for becoming by lack of meaningful communication. He may have
emotionally adjusted and functioning adequately in established his entire social life around alcohol v :'
i 3
.. their environments. consumption and find that, in recovery, his ability to _ !
Other psychosocial disabilities are often observed in maintain old contacts or develop new relationships and 'T.I
the untreated alcoholic and often also extend into the communicate meaningfully with others is impaired or
early stages of recovery(0-12 months). These include lost. , =
pathological • dependency, marked anxiety, The recovering alcoholic has often been given
pathological isolation, denial, and decreased ability to ponderous amounts of unsolicited critical advice which s
establish long-term goals, proceed in a step-wise he has generally learned to ignore effectively. '
manner, and handle responsibility. Typically, he doesn't trust people and seemingly is
Dependency. Alcoholism reduces the person's ability more concerned with getting something from them "=
to act effectively in his own behalf. As a result, than in genuinely relating to them. This is often
alcoholics become increasingly dependent on others for misinterpreted by the counselor or consultants to be
both economic and physical support. They may expect indicative of surfacing psychopathology. Both the =<<
to have their dependency needs met in all their client and the counselor should recognize'that it takes '
relationships 'and may attempt to develop new time to develop new avenues for social contact and f=.
relationships 'for this purpose. Accompanying the meaningful interpersonal relationships.
dependency is often a feeling of resentment toward Denial. The alcoholic can be particularly adept at
those who are viewed as having power or authority denying reality. Misperceptions of reality can be an
over them. Even after abstinence begins, many effective tool in defending himself against pain and
alcoholics will continue to seek the same sort of avoiding some of the unpleasant aspects of the
dependent relationships with'people or institutions, alcoholic life style. For example, he may have "
often including the counselor and rehabilitation convinced himself that if he stops drinking, everything7.
agency.The client may want the counselor to do things will be rectified, the pain he has inflicted and suffered
that he could do for himself, such as make contacts will be healed,-and his life will automatically readjust
with agencies and communicate with family members. to normal. This type of oversimplification can often = ;:
Since .reduction of dependency is nearly: always hamper his commitment to a total treatment plan. '�
desirable, the counselor should avoid doing things for Inaccurate self-appraisal. The alcoholic is often ?�-.
the client that he honestly believes the client could do unrealistic in assessing his own aptitudes and skills and
himself in setting suitable goals for himself. He may •�.��
In many instances, the client's family may overestimate his abilities and have unrealistically high
contribute to his alcoholism. Often in their effort to achievement expectations. Further, his level of =`
help, 4amily members perpetuate the alcoholic's functioning is often not congruent with his potential as ;5=
dependency and lack of responsibility by rescuing him measured by psychometric instruments. It is not
from the consequences of his drinking behavior. uncommon for trained and experienced professionals
g
Examples of rescuing behavior include making excuses to be misled by the apparent abilities of an alcoholic. It
?.;
to employers, bailing the. alcoholic out of jail, is important for the professionals evaluating the client
providing money, and covering bad checks. to guard against overestimating the. alcoholic's
Anxiety. The tension-reducing properties of alcohol functional abilities. ;
also deplete the alcoholic's natural coping abilities and impatience. In addition to his unrealistic expectations, '.
leave the recovering person vulnerable and prone to the alcoholic is impatient and seeks immediate rewards
crisis. Anxiety - states may render the person for his efforts. He is not only likely to have a firm :=,
1 temporarily dysfunctional and interrupt his ability to concept of what he wants but also•will demand ;
perform in a job or training setting. Often the anxiety immediate action. Although the recovering alcoholic
=r
will be cyclic and related to trying to remain sober. At has begun to live without alcohol, he usually does not 7r
other times the anxiety will be related to new situations simultaneously give up his need for quick solutions. In
and responsibilities resulting from sobriety. Whenever fact, in giving up alcohol, his attention may be drawn "=
the client is undergoing some type of change, stress even more acutely to other needs which he may
and anxiety are likely to increase. honestly feel must be satisfied without delay if he is to -
Isolation. Alcohol is widely regarded as a social remain sober. He may have great difficulty =N
"lubricant" that .facilitates communication and understanding why others do not respond immediately ,S
personal contact. Often the alcoholic has learned to to his needs.The amount of pressure that such a client
depend on alcohol as an aid either in making social can exert on the counselor can be appreciated only by
contacts or tolerating a dearth of social contacts. ' those who have encountered this force. All too often,
Alcohol consumption is frequently the alcoholic's' these pressures can result in the counselor either giving
most effective' way of communicating with persons what is being requested without proper evaluation or
:.r
IN �1
I
Alcoholism 235
rejecting the request, and possibly the client, entirely. meaningful evaluation and planning. No one has yet
Both these extremes should obviously be avoided. learned how to make an alcoholic stay sober. In fact,'it j
To complicate matters, drinking is not always the seems that the harder people try to keep him away li
worst possible course of action for the alcoholic to from alcohol, the more intent he becomes on asserting I
follow. He may have reached a point of crisis in his life his independence by drinking. lI
when his alternatives are reduced to three perceived Drinking can occasionally serve a kind of
courses: (a) become openly psychotic and require therapeutic purpose for the client. An occasional ,I
hospitalization;(b)kill himself and/or someone else;or "slip" can help to convince an addicted person who
(c) drink. In such a context, the client- may view has been sober for a relatively long time that he still has I Ili
drinking as the only choice by which he can retain a problem with alcohol, and that there is no "cure"
some degree of control over himself and his that will allow him to drink with impunity or without
environment. It is easy for the professional to see destructive consequences. The counselor has the task I
treatment as a preferred course and to encourage the of deciphering the reasons for any drinking episode
client to seek help. But while this seems an acceptable and relating the episode to the other observations by
alternative to someone else, it may be completely which he is determining the feasibility or prognosis.
impossible for the client. Many reach a point in their The rehabilitation .potential of an alcoholic is
recovery when their feelings toward the treatment affected more by his psychosocial disabilities than by I j
person or group are so intense that contact with these his physical disabilities. This is particularly true of the f
"helpers" is the least tolerable thing they can imagine. impatience, lack of realistic self-appraisal, and limited
From the alcoholic's perception, then, drinking ability to handle stress so often characteristic of
becomes not just a "good" choice, but the only choice alcoholics. Prior to recovery, the practicing alcoholic
available. lived a life marked by increasing irresponsibility and I
Any of these psychosocial disabilities can contribute impulsive behavior,and a decreased ability to set long- t)
to the occurrence of a relapse in which the recovering term goals.In early sobriety,he may wish to"make up
alcoholic returns to the use of alcohol. As such, they for lost time by resuming a job or career at a
should not be regarded as isolated from the disease previously achieved level. Also, as a rehabilitation
itself.The counselor should anticipate the possibility of client, he may wish to establish vocational goals with •��
their' occurrence, develop the rehabilitation plan quite unrealistic time frames. I'`
accordingly, and integrate his planning with other The counselor should be prepared to deal with such
treatment resources in the community. expectations and to regard them as natural for a
recovering person in the first year. He should guard
Rehabilitation Potential against either (a) considering the client as unfeasible,
or (b) being manipulated into poor planning and
�.�
The stage of the client's alcoholism or treatment potential crises. Agencies with short-term rehabilitation j
must be taken into account to accurately appraise an production goals are especially vulnerable. The
individual's feasibility for rehabilitation services. For alcoholic may be able to exert heroic efforts for short
the vast majority of clients, the ability to achieve and periods of time while pressures are simultaneously I
maintain abstinence is the critical difference between building up toward a relapse. It is'extremely important
success and failure. Major clues in determining the that counselors and agencies not encourage the
probability of success are to be found in the client's recovering alcoholic to achieve too rapid a "success." j
response to general interview questions and specific The recovering alcoholic needs both long-and short- I •'
treatment elements. Among questions the counselor term goals, a sense of the long-range process of his i I
should ask are: rehabilitation, and a continued source of ongoing
I. Does the client accept the fact that he has a reinforcement. The longer the alcoholic continues his
serious drinking problem? involvement in a total treatment process, the more
2. Is the client able to accept the need for a long- stability he gains in all areas of functioning. This I
term recovery plan which includes a new peer stability is accompanied by increasing capacity to make
group identity? long-range plans and to handle emotional stress.
3. Is the client willing to take deterrent medication? During the course of treatment, the counselor should
4. Can significant others be involved in the client's regularly reassess the client's changing ability to
recovery process? assume more responsibility and independence and '
If most of the above are answered positively, the client plan the next phase of vocational rehabilitation
i.!
has a relatively good prognosis for success. However, accordingly.
the counselor should be wary of too rapid acceptance of j
the total treatment plan and anticipate a certain STANDARDS OF EVALUATION j
amount of limit testing and acting out.
The initial struggle for the alcoholic is maintaining Behavioral impairment and the development of
sobriety, which is a prerequisite of any realistic and physical organ damage are usually viewed as the major
. i
W!
236 Fox, Conway, and Schweigler
criteria for diagnosis of alcoholism. Evaluation should through routine interviews is usually sufficiently
consist of a complete general medical examination accurate to serve his practical needs in developing a
including standard blood tests, urinalysis, and liver preliminary rehabilitation plan. In fact, the clierit's
function studies. In addition, an electrocardiogram ability to function in t' ! environment, especially the
should be included if the client is over 40 years of-age. vocational environmen is usually a more significant
Although nearly all physicians can be expected to indicator of impairme! E than either the physical or -i-K
perform an accurate appraisal of physical status, most psychiatric pathologies. Chis environment may be the
will not be equipped to provide long-range treatment client's job, if he has n rained employed, or a variety
for the client with alcoholism. The counselor should of work evaluation/adjustment settings, depending on
identify specifically trained and interested physicians the individual needs of the client and the community
in the community and encourage them to become resources available.
involved in the treatment plan. Unfortunately, there is if an individual is referred for evaluation and
not yet a board or certified specialty in the area of services immediately after entering alcoholism
addictions. Although this may evolve, at present the treatment for the first time, it is virtually impossible to
counselor must personally inquire about the make an accurate evaluation in a brief period. In most
physician's training and interest in this field. Reliable instances, a period of several months to observe the ti
indicators are membership in the American Medical client's response to alcoholism treatment is the preferred .!fnPh-
Society on Alcoholism and recent attendance at any course of action. Data obtained during this period
alcohol and drug abuse conferences.These conferences should include feedback from clinical'staff regarding
Q..
are often sponsored by organizations such as the his attendance and level of active participation in the
Alcohol and Drug Abuse Problems Association, of treatment program. If the client has a sponsor for
North America, the National C,uncil on Alcoholism, Alcoholics Anonymous, or if contact can be made with
and the National Drug Abuse ( onference. close family members, these lines of information
Each state has a special _gency dealing with should also be established. In addition, the counselor
alcoholism information and tre: ment referral. These should make direct observations by attending open
'irough the National Alcoholics Anonymous and treatment staff meetings
agencies are partially funded
Institute for Alcohol Abuse and alcoholism(NIAAA). with the client. Taken together, these behavioral
A,.
The State agencies, in turn, support organized factors can provide meaningful evaluative material for _K
community alcoholism treatment programs, and can timing of rehabilitation efforts and establishment of
iq
-the counselor with a directory of State and vocational goals.
provide
local resources. Research directed toward the
development of improved alcoholism treatment :Li-g
techniques is also supported by NIAAA. The coun-
TOTAL TREATMENT
selor should be aware of all these resources and Alcoholism treatment is an ongoing process rather
establish a working relationship with the staff of these than a single act. The alcoholic has many obstacles to
programs. overcome and a total process is the key to gaining
If gross psychiatric and behavioral symptoms are stability.in all areas of functioning. It is important that
manifested, a psychiatric evaluation, with or without the rehabilitation counselor have a full understanding
psychological testing, can provide valuable treatment of this concept and of his role in the multistaged Al.
and prognostic information. However, it is essential process. Without this base, he is likely to respond to
that the client be recovered from the organic brain the client's instant solutions, fantasies, and
W
syndromessociated with alcohol and drug abuse overinvestments. If this happens, the counselor may
before interpreting tests or psychiatric evaluations. subsequently become disillusioned and reject the client.
Experience has shown that routine or extensive he is trying hardest to help. The counselor can be
psychological testing frequently offers little useful instrumental in the client's rehabilitation by
information. For example, intelligence tests or recognizing the many facets of the problem and being
aptitude batteries can be so responsive to the willing to help the client organize and integrate a
temporary intellectual impairment associated with an recovery process.
-Y
acute or intermediate brain syndrome that they give an A continuum of services is essential, and each client
inaccurate and misleading indication of the real needs a different combination of services at the various
aptitudes of the recovering alcoholic. Similarly, stages of recovery. The rehabilitation counselor can
personality inventories such as the Minnestoa play a critical role in the delivery of services at any W.q
Multiphasic Personality Inventory (MMPI) can often stage by serving as the client's advocate and/or case
give an erroneous prediction of the recovering manager. Almost never is it desirable for the counselor
alcoholic's stability. to assume a solitary or prime therapist relationship with
A trained counselor's clinical evaluation of the the recovering alcoholic client. This may be difficult
client's attitudes and intellectual functioning obtained since it is not uncommon for-the alcoholic to seek out
Alcoholism 237
!I
one thing or one person to solve all his problems.When After detoxification, the client is best served by a Vii!
the counselor avoids solving all the client's problems,it thorough evaluation of his indivic:ual needs and
decreases the client's dependency and supports his selection of the appropriate services to meet those
efforts to solve problems and take responsibility for his needs. There are many approaches to the treatment of
own behavior. alcoholism; for example, medical, psychological, and
The critical first step of treatment is early diagnosis social. Most alcoholics will benefit from a combination
and motivation by the client to seek help to change. of these services, which will be avai!-ible in different
For a great many years, alcoholism was only forms in different communities. In general, the
acknowledged in its terminal stages, as manifested by following are the major components of alcoholism
repeated legal problems or advanced medical treatment which can be combined, as appropriate, for
complications. In the past two decades, however, an individual client.
industrial, drunk driving, and armed services Environmental manipulation in varying degrees may be
alcoholism programs have sprung up across the needed depending upon the individual circumstances
country. These programs have made a great deal of of the client. When the alcoholic comes for !I+
progress in the development of effective techniques of rehabilitation services, he is often immersed in a l:
early diagnosis based on performance factors, such as variety of life crises, such as divorce, dental problems, i '!
tardiness, absenteeism, and decreased productivity on legal actions, overdue bills, and revoked driver's
the job, rather than on complications. In these license. The client can be helped to solve these
programs, emphasis is placed upon identifying the -problems and thereby create an environment more j
troubled employee and providing early intervention conducive to abstinence. { If
and treatment. Internal change therapy may be provided through a {'{
The rehabilitation counselor has a great deal to wide range of psychotherapeutic techniques aimed at !
contribute in this area by helping to establish such the:development of insight and the modification of i
detection programs, by working closely with the behavior. These treatment modalities are not required
industrial counselor, and by being a source of by the majority of clients and are inappropriate for a ; !
counseling for the disabled employee. It is desirable large number at the beginining of recovery. An �
that counselors become familiar with industrial excet;on is those programs designed to prepare the I ;
"troubled employee" programs and the activities and alcoh;..:c to enter a regular treatment program.
materials of local branches of the National Council on Inv, cement in the treatment plan of significant other persons,
Alcoholism and local Alcohol Safety Action Programs. such s spouse, children, probation officer, sexual
When diagnosed early, a great many persons with parm, or anyone else in a position to contribute
uncomplicated alcoholism may recover with the help of positi%ely or negatively to. the client's recovery, is
14
their industrial counselor and a self-help group. essential. Often these persons also need treatment in
For clients who have been drinking recently,the first order to increase the prospects of the client's success.If '
stage of any treatment program is acute detoxif:cation. the client has a family, alcoholism and its treatment is a
This refers to the treatment of the withdrawal family matter. j
syndrome. Mild withdrawal symptoms are sometimes Antabuse(disulfiram)is a drug that interferes with the
treated on an outpatient basis in a medical facility or in normal metabolism of alcohol, thereby causing acute
a nonmedical detoxification facility. More severe gastrointestinal distress. When taken daily, it acts as a ' !
withdrawal symptoms, however, do require medical deterrent to alcoholism because ingestion of alcohol
supervision and usually hospitalization. Tranquilizers will produce the unpleasant reaction. It can be
are commonly administered to reduce the symptoms extremely helpful in support of other program. i
and prevent the development of delirium tremens. elements. The courts may require individuals to take
Medical management usually also includes the Antabuse regularly in order to retain or get back their
administration of fluids, electrolytes, and vitamins. driver's licenses. In some cases, it may be appropriate .,
Individuals with more severe withdrawal symptoms for the counselor to require Antabuse maintenance
and greater organic damage will require chronic to help alcoholic clients keep their jobs, stay in school, .,
ddoxf:cation for 3 to 6 months. Medical monitoring will and the like.
be needed intermittently to counter the adverse effects Modification of peer group identity may be achieved
of alcohol on the digestive, nervous, and endocrine through membership in a self-help group which, for I {
systems. The physician may prescribe vitamins, many alcoholics, will be the mainstay of treatment. In
special diets, and specific drugs., this country, the established, effective, and available '{
In addition,alcoholics may have associated illnesses, self-help group is Alcoholics Anonymous (AA). This j
such as psychiatric disorders or emphysema, which group is based on the philosophy that alcoholics can {
require appropriate treatment. Because the needs of gather together and provide each other with support !
clients will vary so widely, it is important that the for sobriety and recovery. The principles and methods j!
counselor identify at least one physician he can rely for recovery are incorporated in a 12-step.program.
upon for this aspect of the total treatment plan. Alcoholics Anonymous and its companion
10
238 Fox, Conway, and Schweigler
i
organizations, Alanon for adult family members and vocational training. The applicant makes these
Alateen and Alatot for their offspring, are highly requests quite firmly and expects the counselor to make
available, virtually free, and indisputedly effective for a decision immediately. Any attempt on the :fir
a great many alcoholics and their families. Especially counselor's part to evaluate such requests against the
when family members are inadvertently contributing applicant's vocational, social, educational, and
to the client's alcoholism and dependency, they should medical background is apt to be met with bewilderment
be strongly encouraged to become involved in the or anger. _
Alanon and Alateen programs to help them Vocational planning is dependent upon first, a
understand their role in the total treatment program to reasonable amount of sobriety, and second, the
the greatest degree possible. assessment of individual strengths and problem areas.
Any counselor who is going to accept even one client It is essential that the counselor help the client
a year with alcoholism is grossly negligent if he does recognize that entering and maintaining.a program
not develop a working knowledge of, and relationship designed to help him remain abstinent must be
with, Alcoholics Anonymous. This can be simply accomplished before any job seeking or retraining is
and pleasantly accomplished. Local chapters usually undertaken. The counselor must then determine what
have at least one open meeting a week to which the individual client's past job difficulties were.
most members would be delighted to invite a Common problems include inability to tolerate stress,
counselor. AA literature is easily available, lack of job skills, or attempting to achieve beyond _
inexpensive,and quite readable,and every community ability level. With this information, the counselor and
- has many stable members who would be most willing client should develop rehabilitation plans.
to sponsor an appropriate new member. Groups have There is great variance in individual client's responses
their own traditions and procedures which they adhere to different situations. Some are more successful working
to quite rigidly. If the counselor becomes familiar with with people,and others are more successful working with
these traditions and procedures and respects them, the data and things.Careful work history,vocational assess-
AA group will be an excellent ally for his client's ment,and individual evaluation are critical.Consultation -
recovery. with other members of the client's treatment team is
Some clients, for physical, psychological, or other most important in making these determinations.
reasons, are not able to use Alcoholics Anonymous as In general, alcoholics must be helped to avoid three
their recovery mainstay. This is especially likely to be common pitfalls: (a) believing that an appropriate job
true early in the recovery process. These individuals will "cure" their alcoholism; (b) overcommitting _
may need various levels of professional treatment themselves by working too many hours or too many
directed toward preparing them for entry into a regular days; and (c) taking-on more responsibility than they
alcoholism treatment program. This preparation are stable enough to handle. Usually the alcoholic
usually takes 1 to 4 months, and can be provided by should not be encouraged to undertake retraining or a
some combination of medical, psychological, spiritual, new type of job until he has achieved sobriety for 6 to
and social service. Usually a combination of hospital, 12 months. Planning must be directed toward helping
day care, outpatient, and residential settings is needed the individual establish an environment of low
for this type of preparatory treatment. pressure. Continued observation and supervision by
the counselor while the client participates in treatment
VOCATIONAL IMPLICATIONS and retains an easily managed job can be a most _
useful technique.
Progressive loss of work skills or inability to develop The client's potential skills frequently exceed his
new skills is often the best early indication of alcohol ability to tolerate stress. It is important to remember _.
addiction. Industry leaders have estimated that 60-80 that stress tolerance is usually lowest early in treatment
percent of persistent job performance problems ai�c a but can be expected to improve slowly over the next 3
direct result of alcoholism. Although the disease is years.Often the client does not adequately perceive his
more prevalent in certain occupations, virtually no low stress tolerance and the counselor must
group is immune.Actual or impending job loss is quite continuously monitor the client's tendency to
frequently the reason individuals seek treatment for overextend. The stressfulness of the client's
their alcoholism. The counselor can often intervene at environment can be increased gradually as his
this point to help the client retain his job while he tolerance increases. A series of short-term, easily
participates in a treatment program. @Lttainable goals is the best way to achieve this.
During the early phases of recovery, the alcoholic is The counselor should be aware that stress and
unrealistic in assessing his readiness and capability to anxiety are likely to increase whenever the client is
re-establish ocational, social, and emotional undergoing some type of change and he should be
involvement. A great many alcoholics bring only one prepared to offer greater structure and support during
or two commonly heard requests to a rehabilitation these periods. Repeated crisis counseling regarding
counselor: (a) help me get a job, or (b) help me get work relationships and job stresses can be a mainstay
-:=
Alcoholism 239
it
of the client's recovery. Practicing and recovering The clearinghouse is a major source of current information
alcoholics are excellent in short-term employment or in all areas of alcoholism. The annotated bibliographies
training situations. Many have excellent job-finding (Grouped Interest Guides) are periodically updated, and
skills, and it is not atypical to encounter an alcoholic the one entitled Rehabilitation Strategies for Alcohol
who is able to get one or more jobs per month. Abusers is particularly valuable. In addition, the i
clearinghouse provides an ongoing awareness service to its
However, poor long-term job performance patterns it
subscribers. This resource is free.
can be expected. i
National Council on Alcoholism Criteria Committee:
The vocational counselor is an essential component
Criteria for the diagnosing of alcoholism. AM J Psychiatry
of the comprehensive alcoholic treatment team. In the
P 192:127-155, 1972. •!+
preventive maintenance period of recovery, the This effort by the council expands the basis for the
counselor-client relationship will be most critical. The diagnosis of alcoholism,which commonly has been delayed
vocational counselor is most able to relate to the until the late stages when body organs are damaged. The
recovering person during the early period of re- criteria include behavioral, social, and physical trends-in
employment and is therefore in a key position to the patient which can aid in the early recognition of the
positively influence the final rehabilitation outcome. illness.
Rowntree GR, Brand J: The employee with alcohol, drug,
and emotional problems. A Kentucky occupational
BIBLIOGRAPHY program.J Occup Med 17:829-832, 1975.
This article describes a program designed to identify
Alcoholics Anonymous World Services, Inc. Alcoholics
Anonymous,Box 459,Grand Central Station, New York, troubled employees," 50 percent of whom will have
NY 10017 alcoholism, on the basis of deteriorating job performance.
Commonly referred to as "The Big Book," this is the Early intervention and referral are discussed.
basic text and description of the AA program. As AA is Seixas FA Cadoret R, Eggleston S (eds): The Person with
Alcoholism. Ann NY Acad°Sci 233, 15 Apr. 1974.
the most widely available and inexpensive resource for
the recovering person, it is incumbent upon the counselor The issue is devoted to the psychiatric aspects of j
to be familiar with it. alcoholism. There are articles on various psychological
Catanzaro RJ: General aspects of treatment. In characteristics and problems of alcoholics and on various
Cantanzaro RJ (ed): Alcoholism: The Total Treatment Wiseman
approaches to alcoholism treatment.
Approach, Thomas, Springfield, IL,: 1968. Wiseman JP: Stations of the Lost: The Treatment of Skid
An overview of the multidisciplinary, multiphased
Row Alcoholics. Prentice-Hall,Englewood Cliffs,NJ, 1970.
approach to alcoholism treatment. The counselor can Dr. Wiseman offers two views, often contradictory, of
rehabilitation; namely, the view of.the providers and the
find important information on the acute phase, family
involvement, and AA in the total treatment approach. view of the consumers of services in the Skid Row
Estes NJ, Hanson KJ: Sobriety: Problems, challenges and subpopulation. Chapters 1 and 9 provide descriptions of
solutions. 'Am J Psychother 30(2):256-66, 1976. these separate perspectives, which can be generalized to
Ten wives of alcoholics participated in group therapy for 2 other alcoholic populations seeking services.
years. The new problems they encountered as a result of
their husbands' sobriety are described in this article.
Hough GS:A behavioral approach to alcoholism. Nurs Clin
North Am 11: 507-516, 1976.
This article describes a behavioral approach used in the
treatment of alcoholism.The goals of the program include
either abstinence or controlled drinking for problem
drinkers who do not have any medical reason for
abstinence.
Lowe WC, Thomas SD:Assessing alcoholism treatment effec-
tiveness. A comparison of three evaluative measures.J Stud
Alcohol 87:883-889, 1976.
This article describes three criteria which were used to
evaluate the success rate of an alcoholism treatment
program: vocational rehabilitation, abstinence, and
behavior(such as number of drinking episodes,family and
marital adjustment, 'and participation in outpatient
program).
Mullan H: Vocational counseling with the alcoholic. In
Mullan H, Sanguiliano I: Akoholism: Group Psychotherapy.
and Rehabilitation, Springfield, IL, 175-204. Thomas, 1966.
This chapter offers a comparative analysis of the vocational
counselor's role and approach and that of the psycho-
therapist.
National Clearinghouse for Alcohol Information (NCALI),
PO Box 2345 Rockville, MD 20850.
� z z z � �Ceu- ��, ' K��.
Centra -County—� Social Service Department
: WOR 'ROGRAMS PLACEMENTJATTENDANCE'R.', )RD
1 'MONTH ❑ 1 '❑ 2 ❑8 PR ECT* SLOT*
PARTICIPANT .„ CASE NUMBER i . W PCN
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ASSIGNMEN77: Show this form to the Wbrk Site Supervisor when you report at the time and place listed below: A:
aft d'm brk'S'te rvisorif u haveanyprob/ems. WORK.SCHEDULE
a'. G�NLAL .SR.YICES''. :.DATE' :TIME
WORK SITt - �•
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OUTDOOR MAINTENANCE YORKER .
Tuesday
POSITION
TITLE C 'vTHES Wednesday f i
SPECIAL TOED SHOESARING YOUR UNCI !
REOUIREMEPq Thursday (�
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REPORT TO
4 5 4 5 0 MrKe 'I�T'I�°'B L Y 0 e ANT 1 D CT®lephone Monday -y/. ,r.� r% —__�•/� j
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LOCATION •y��';:�,•''
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Richmond 374.3791 - "Martiner 439.2029 � Antioch 4fV4WW' _
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. . 1 acknowledge receipt of my assignment / !�• 1 �� �/ sl OUIERE UD tR1A TRADUCCIQREN ESPANOL 8E r \ ,
7 ESTE PAPEL LLAME A SU.TRAfiA* R JAI DE- ..C. 3A:I
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help with your transportation expenses,contact your Work Programs Representative a
.,.,week before your work schedule begins. - :Pel:ao�m�11•
ATTENDANCE RECORD 1:
Completion Instructions On Reverse.
TIME IN TIME OUT Tot.Hrs• PARTICIPANT'S SIGNATURE WORKSITE COMMENTS
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A CIPAN NUMBER
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APPOINTMENT _ Day. Date-. Time Thursday '
13130S Macdonal Ave. 'E3 30 Muir Road 4545 tMlfa fait Blvd. i Friday
f4dunond374-3791 Marone=439.2029 Antioch 427-653S,
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ATTENDANCE RECORD
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TIME IN TIME OUT Tot.Hns PARTICIPANT'S SIGNATURE WORKSITE COMMENTS
DAY 1
DAY Z "
DAY 3
;..f DAY 4 .. -
DAY 7
DAY S
DAY 9
PAY 10
ADDITIONAL COMMENTS TOTAL HOURS WORKED FOR THE MONTH OF
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REPORTT '
Worksite SupervisorTekiphCNN Monday .
4545 DELTA FAIR BL 9 ANTIOCH \14 ' � `[
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NEXT WORK PROGRAMS p !wsaneteaY.
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Conus Costs Cow..y.., 0 _ +iotisl Service Department
RECORD OF CONTACTS
CAS NAME CASE NUMBER WORKER NAME
f CONTACT
Comments t Explanation of Contact,plus initials.PUN and Date You Entered Documentation
DATE TYPE*
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`: r= 4545 Delta Fair Blvd. `❑ 1305 Macdonald Ave. eq
Antioch,CA 94509 Richmond,CA 94805 / .0
427-8535 374-3791
.� {• .mem
YOUR NEXT EMPLOYMENT SERVICES APPOINTMENT WILL16Ey f -3�Q at �. m
AT THE OFFICE CHECKED ABOVE. day/date time
Failure to appear for this appointment may result in your aid being discontinued and a period of ineligibility. Your must call
in advance if you are unable to keep this appointment. Lack of transportation and being out of town are NOT valid excuses.
Please arrive at least 10 minutes before your scheduled appointment.
Your appointment is for a: 4EI-6ROUP MEETING ❑ INDIVIDUAL MEETING
SPECIAL ASSIGNMENT/COMMENTS:
❑ 1 ack►�owledge receipt pf t'his apps rriirtit at/assig'nr4*/ft. l undersI' d that failure to appear without good cause may
4dul;j my aid beinq.stgpeed.
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NAME/(Print) ; SIGN RE ' DATE
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`ASS/GNMENT: ow this.form to the.Nbik Site upervkor when you report at the dins,and p/aoe/fisted be%w:.::
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POSITION
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I ' -REQUIREMENTS Thursday .:AW
634-0473 ('
Friday
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::.LOCATION..: .. -
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TIME'.IN... :...;TIME OUT::.: Tot.Hra.,'PARTICIPANT'S SIGNATURE :: KS •COMMENTS
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