Substance Abuse Case Study
The client in case study #1 is no doubt experiencing problems as a result of his alcohol use. The client’s alcohol use has put him at risk of losing his job, which would also put his family’s well-being in jeopardy (he is married with two young children). In addition, the client has some health issues that are likely exacerbated by his alcohol use.
Upon the client’s first visit to my office, I would administer the TWEAK to him in order to get a quick “snapshot” of his drinking habit (Hester & Miller, 2003). Though the client is likely physiologically dependent upon alcohol, I would initially give the diagnosis of Alcohol Dependence Without Physiological Dependence (303.90) until I could gather more substantial information to confirm this suspicion. The evident criteria that he meets, indicating Alcohol Dependence are as follows: tolerance (he has started drinking hard liquor more often), a desire to reduce his alcohol use, occupational impairment as a result of alcohol use, and he continues to use alcohol despite having some health concerns (American Psychiatric Association, 2000). Furthermore, he reports experiencing “blackouts,” a common feature of alcoholism (Maxmen & Ward, 1995). If I were to find out later that the client experienced withdrawal after reducing the amount of alcohol he consumed, I would give the diagnosis of Alcohol Dependence With Physiological Dependence (American Psychiatric Association, 2000).
Another issue that I would later address would be the client’s smoking habit. I would, therefore, also give a diagnosis Nicotine Dependence (305.1) (deferred). I would defer the diagnosis until I could establish if he was, in fact, addicted to nicotine. The client is a very light smoker, smoking only two packs per week. However, given his health concerns, the client may also be interested in getting help to quit smoking. Because the client is in imminent danger of losing his job as a result of his alcohol use, I feel this should be dealt with first and foremost (American Psychiatric Association, 2000).
Treatment Issues and Counseling/Rehabilitation Plan
If the client was not comfortable with using English (since English is his second language) as the dominant language during our sessions, I would refer him to a Spanish-speaking therapist. If the client was comfortable continuing in English (perhaps with is wife translating), my treatment would be as follows.
The client appears to be in the contemplation stage. People in the contemplation stage are beginning to consider quitting drinking or using, but they have not yet acted upon it. They recognize that they have a problem and are trying to make sense of it. I think it is important not to push this particular client too hard in order to ensure that he does not revert back to the precontemplation stage (Connors, Donovan, & DiClemente, 2001). Although he is in the contemplation, he remains ambivalent about his drinking and feels that he really does not have a problem (e.g., as he stated, he is just being “singled out” about his drinking by his boss). Therefore, I would begin with a behavioral self-control training approach (BSCT), as I do not believe he would consider abstinence without at trying to first reduce or control his drinking.
Before beginning BSCT, I feel that the quantity and frequency of the client’s alcohol use should be established. I would conduct an interview to establish how much and how often the client drank. I would also conduct a collateral interview with the client’s wife, since alcohol abusers often underestimate the amount of alcohol that they consume (Hester & Miller, 2003).
The goal of BSCT would be to have the client cut down on his alcohol use. In other words, instead of aiming for complete abstinence from alcohol, BSCT would allow the client to drink in moderation, and in a responsible manner. Of course, if the client’s stated goal at the beginning of treatment was to achieve abstinence, BSCT would not be used. In using BSCT with this particular client, I would have the client sign a two-week contract, in which he agreed not to have more than two drinks on days before he had to be at work, and not to exceed more than a total of 16 drinks per week (Hester & Miller, 2003).
During the two-week period, in which the client attempts to drink in moderation, I would have him keep a journal regarding his alcohol use (e.g. On what occasions does he overdrink? When does he have hard time turning down drinks? What happens in his life that makes him want to drink?) The information gleaned from this journal may help the client understand why he drinks, as well as help the counselor with developing future treatment plans and goals.
In order to initiate BSCT as early as possible, before the client left my office on his first appointment, I would encourage him to set limits and to self-monitor his drinking. Furthermore, I would role play refusal skills with him (i.e., how to turn down drinks). I would have the client come back in a week to monitor his progress (Hester & Miller, 2003).
This client seems to enjoy the social aspects of drinking. He commented on how all the men from his family drank back in Mexico. I, therefore, think he would benefit from attending AA. I would encourage him to attend at least one AA meeting during the two-week trial period (preferably, a Spanish speaking meeting). AA meeting-attendees form their own community and pride themselves on their camaraderie. This sense of community may help to fulfill the social aspects of drinking that he seems to enjoy (Maxmen & Ward, 1995).
At the end of the two-week trial period, I would have the client come in for an interview. I would also conduct a collateral interview with the client’s wife at this time. If the client was successful in adhering to the contract (per the interview with the client and his wife), I would encourage the client to continue with BSCT (Hester & Miller, 2003). If, however, he could not fulfill the contract, I would change methods. Below I described my plan B.
Since the client is concerned about his health, I would have lab tests done on the client to measure the potential damage that his alcohol use may be having on his health. For example, lab tests like the CDT could identify hypertension and other alcohol-related health problems, while the GGT and the MCV could detect the possibility of liver damage. After receiving the results of the lab tests, I would provide the client with a “drinker’s check-up.” That is, I would explain the results of the lab tests to him in an objective manner. I suspect this feedback would show that his drinking has done damage to his health, which would likely serve to enhance his motivation to change (Hester & Miller, 2003).
I would then begin therapy using motivational interviewing (MI). I feel that MI is very useful for people in the contemplation stage (as is the case with this client). Contemplators are often experiencing a great deal of ambivalence about their drinking/drug use (Connors, Donovan, & DiClemente, 2001). One of the hallmarks of MI is to help people resolve ambivalence (Miller & Rollnick, 2002).
Furthermore, the client is entering into therapy apparently for the first time. Because other tenants of MI include expressing empathy and unconditional positive regard, MI seems to make people, especially those who have never been in therapy, very comfortable. This ensures that they will continue to come in for treatment. Based on the information provided about this client, he may be somewhat resistant to therapy. If this is in fact the case, MI would work well, as another feature of it is to role with resistance (Miller & Rollnick, 2002).
Lastly, it is my personal belief that one must choose for him- or herself to become clean and sober. MI emphasizes freedom and personal choice. Perhaps it is paradoxical, but I feel that when one is given the choice, rather than told to become sober, then he or she is more likely to choose sobriety (Miller & Rollnick, 2002).
In closing, the short-term goal for this client is to reduce his drinking enough, so that he could keep his job (the most pressing concern, in my opinion). If he could maintain an ability to drink in moderation, then the long-term goal would be to enhance this ability through continued BSCT. If, however, he could not drink in moderation, the long-term goal would be to reduce his drinking until he was able to become abstinent, thus ensuring his livelihood and his family’s well-being, as well as improving his overall health. I would seek to accomplish this through feedback (the drinker’s check-up) and motivational interviewing.
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR (4th ed. tr.). Arlington: Amer. Psychiatric Assn.
Connors, G.J., Donovan, D.M., & DiClemente, C.C. (2001). Substance Abuse Treatment and the Stages of Change. New York: The Guilford Press.
Hester, R.K., & Miller, W.R. (2003). Handbook of Alcoholism Treatment Approaches: Effective Alternatives. (3rd.). Needham Heights: Simon and Schuster Co.
Maxem, J. S., & Ward, N. G. (1995). Essential Psychopathology and Its Treatment. (2nd.). New York: W.W. Norton and Company.
Miller, W.R., & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change. (2nd.). New York: Guildford Press.