Using the biopsychosocial approach, complete a mini assessment of Maria Santiago (Vignette below). List all of the biological, psychological, and social factors one should consider when for an assessment for this client. How would you use this information, from your assessment, to intervene with Maria?

Maria Santiago Vignette for Week 2 Discussion

Maria Santiago is a 63-year-old woman of Hispanic descent, who has been in recovery from alcohol abuse for 20 years. She works as a discharge planning assistant at a large urban hospital. Many of the patients she sees are her age or older and some suffer from alcohol dependence. Two social work students interviewed her in a private office at the hospital and found her to be friendly and forthright in discussing her experience with substance abuse. She "made steady eye contact with the interviewers and seemed pleased to share her history. Her tone of voice was calm and pleasant, and at times she made jokes, it seemed, as a way to divert from the sadness of her history." She is currently attending college and will receive her undergraduate degree in May and hopes to become a full-time counselor in substance abuse following her graduation.

Ms. Santiago never knew her biological father. When she was four years old her mother, "not a drinker," married a man whom she called "Daddy," an alcoholic whom she thought for several years was her father. He was affectionate to her while her mother was cold and critical; however, this affection soon took the form of sexual molestation. By the age of nine, she realized "something was wrong here," and she started trying to escape from him. For the next six years he was "always trying to rape me." When he was drunk and she resisted, he would physically abuse her as well, but not her stepsister who was five years older and his biological daughter. Finally, when she was 15, his alcoholism became "so bad that he became abusive to my mother," and her mother left him. Throughout this period some extended family members were aware of the sexual abuse of Ms. Santiago but were afraid to bring it to her mother who was in denial about it. Ms. Santiago, who also felt it was useless to tell her mother, was left feeling unprotected, depressed, and with "low self-esteem."

During her adolescent years, her mother was very strict, but some drinking was allowed. "I couldn't wear lipstick, or certain clothing. I couldn't go out with friends, but I could have a drink in the house." She attributes this seeming paradox to what she believes is a cultural acceptance of drinking among Hispanic people---especially for men, but for everyone "drinking is like a national pastime." When people do drink to excess, it's not talked about, nor is depression or other mental illness. In retrospect, she realizes that several male cousins were alcoholics, and some died because of alcohol related illness or accident. But "no one talked about it and nobody ever went into treatment or detox that I know of."

She began drinking seriously in her twenties, because "I was very shy and I found that alcohol let me be sociable, to talk with people...to go out, and to dance," which she loved. "Without it I couldn't because I was always afraid of people." However, drinking also led to some "bad relationships." At first, she drank only on weekends, but gradually increased to daily drinking and by the time she was 29 she realized she "had a problem." She drank mostly rum but sometimes used diet pills or even cocaine because they "enabled me to drink longer." She soon stopped the pills and cocaine, thinking those were the problem. "There was more shame to admitting that I had a problem with alcohol, than a problem with pills."

During her twenties, Ms. Santiago had three sons and says that despite her drinking, she "managed not to lose my children or my job." Still there were problems, especially as her drinking "took off" during her thirties. She called in sick more frequently, using up her sick days and vacation days. She fell behind in her bills. As her children grew, she felt she was losing control over them. She also was aware that she had lost control of her drinking. "To cope with anything that was going on... I had to have it bad."

Finally, as she approached 40, after 10 years of very heavy drinking, she became a "blackout drinker," sometimes getting hurt and waking up in strange places with no memory of how she got there. This frightened her. Her boyfriend at the time, also a drinker, threatened to leave her because "I drank too much and couldn't keep my word." The Road to Sobriety

At the age of 40 she attended her first AA meeting to appease her boyfriend, with no real intention of stopping her drinking. She persuaded her boyfriend to accompany her hoping that "if he went to the meeting with me, he'd stay with me." She felt shame entering the church basement where the meeting was held, "thinking someone from the neighborhood would see me.

Never mind how many times people probably saw me coming home drunk. I didn't think about that." The boyfriend never went back after the first meeting and soon thereafter they broke up, but Ms. Santiago kept going to AA despite her embarrassment, because she "knew I couldn't drink anymore. I was getting scared; I was getting hurt; I was afraid something would happen to my kids one day when I was drunk."

She detoxed on her own, not knowing that there were facilities to help her with detox or rehab. The following year she did enter psychotherapy at a community mental health clinic, and found it helped her to recognize her depression and to understand the causes and triggers of her drinking. She has continued to go back to therapy in times of stress and has attended AA meetings weekly for the last 20 years.

Recovery remains difficult, so she structures her life carefully to avoid relapsing. Initially, she had to stay away from friends who drank and to stop attending their parties. "It was like going through the stages of grief." She suffered months of loneliness before making new friends through AA, with whom she could go to dinner and sober dances. Temptation to drink is always present, so she tries to avoid triggers, such as those signified by the acronym H.A.L.T., which stands for being Hungry, Angry, Lonely, or Tired. Above all, she continues to "work on 'the Steps'...to go on retreats, including religious retreats...and to surround myself with people who don't drink." In addition, she advises, "Don't go to places where there's drinking...if you find yourself in a place with drinking and you feel uncomfortable, leave... and if temptation is too great, call your sponsor."

Her children and grandchildren have been supportive of her recovery and this has helped her maintain it. Her oldest son, who grew up during Ms. Santiago's heaviest drinking years, drank too much for a while, but "he admitted he had a problem," and she helped him get help. He died a few years later of cancer, but Ms. Santiago takes comfort in the fact that before he became ill he was alcohol free and "doing real good." Also, she was then strong and able to care for him in his final illness. Her youngest son, 10 years younger than the oldest, is a policeman and stays on "the straight and narrow." Recognizing her part in her sons' attitudes toward liquor, Ms. Santiago adds, "[Fortunately] I went into recovery when my youngest was 10 years old." This son and a 21-year-old grandson have accompanied her to meetings and especially to her anniversary events.

She never told her mother about how far her drinking had gone or about her entering recovery. "She didn't want to hear about things like that. She always said I wasn't going to amount to anything... so I would never tell her that." Ms. Santiago told only a few of her cousins because most of them "would see it as a failure. They don't understand the concept of recovery." The

Five years into her recovery after a series of gynecological infections, a hysterectomy and severe weight loss, Ms. Santiago was diagnosed with HIV, which she realized in retrospect she contracted years earlier from a man she "met drinking." She blames her alcohol-impaired judgment, "plus no one ever taught me how to protect myself. That's cultural, too."

She initially found the medical bureaucracy unresponsive and unsympathetic. While her T cells dropped and she felt sicker, it took her a month to get an appointment for treatment. Then she had to fight to be included in a study for a new medication which helped "turn me around." Later she had to push for changes in her drug regimen because of severe side effectsincluding three years of bad nightmares with one drug. Currently she has gained back her weight and her T cells and is taking just one drug for her HIV. In the meantime, she has developed congestive heart failure, for which she also takes medicine, and is aware that either of these illnesses may well shorten her life. On the positive side, she has learned to be proactive in getting help from doctors and hospitals and has become active with an AIDS advocacy organization to help others get needed help. Her boss is aware of her health problems; others at her job are not.

She feels grateful that she never developed cirrhosis of the liver and was never drawn into any illegal activity, so she was never arrested. She also thanks God that "I haven't had a relapse, because the minute I pick up that drink, the school goes, the job goes and forget about my health."

Now she is enjoying life and catching up on all the things she didn't do or couldn't afford in her drinking yearsgoing to college, taking vacations, buying clothes, fixing up her apartment. Alcohol abuse and aging

When Ms. Santiago first went into recovery, she thought she would only have to go to meetings "for a while... that by the time I was 60 or 65, no one would care if I did drink. Now I realize that I care. I don't want my sons to be picking me up off the street somewhere. Also, I already have congestive heart failure. If I pick up a drink, I'm going to have a heart attack, or a seizure or a stroke, who knows?" She knows now that she will be going to AA meetings for the rest of her life.

In her job as a discharge planning assistant, she has seen homeless alcoholics who have convulsions, with no one to take care of them. "It's frightening."

She is more confident of her ability to resist drinking now. "I used to worry about what people would think of me if I refused a drink or had to explain myself. Now I don't care so much what people think of me... I have to take care of myself...

It's never too late to stop. Some people don't try because they think about all those years they lost. But you've got to think about the years that you have left, how you can live them productively. You know, I'm doing a lot of things that I didn't do before. Getting old is hard enough. I want to live as much as I can!"

(Teaching Workbook forPractice in the Workplace,Maria Santiago's Story. CSWE, Gero-Ed Center, n.d.)