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Case Study for Counseling Substance AbuseCase Study

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¶ … Conceptualization

David first tried alcohol when he was seven years old, and started drinking heavily and smoking marijuana when he was in high school. He admits to drinking up to eight beers or a pint of hard spirits each day, and smokes up to four joints per day, too. In addition to his primary substances of preference, David also takes sedative pills (Valium) several times a month. Since his DUI conviction, David has been confined to the house and admits to smoking pot and drinking in his basement room rather than going out with friends. David claims he has "few friends." He does exercise and practice martial arts at home, but has no plans for the future and remains unemployed.

When David was six years old, he was sexually abused by an older boy. This event may have precipitated his turning to alcohol and later, other drugs, as self-medications and coping mechanisms. David has no mental health diagnosis and has never sought counseling, and has never spoken with his parents about the sexual abuse incidence, suggesting that he has systematically suppressed emotions and cognitions regarding his experience. Although David has no history of suicidal ideation, he has a history of violence in that when David was fourteen years of age, he sexually abused an eight-year-old girl and never confessed the crime to anyone. He also reports having had "problems" with his sexual relationships and his relationships with females in general.

David's primary diagnoses include alcohol and cannabis abuse disorders. Further assessment may reveal underlying personality disorders, although David appears to be stable. Given David's lack of interest in improving himself, lack of interest in the future, and lack of passion for any particular vocation or career path, depression should not be ruled out as an assessment. Viewed within a family systems perspective, it is likely that David's parents, both of whom are elderly, have been enabling their son's behavior by allowing him to live at home and perform chores around the house instead of getting a job. His parents give him money for performing some of their household chores, too. Similarly, David's parents have agreed to help him pay off his driver's license fines from the DUI and have never recommended that David seek psychological counseling. They are generally unaware of the extent of David's substance use.

David was referred to counseling services through a criminal justice program, to divert people with their first DUI into treatment. This is David's first legal problem. David is aware that he drinks too much, and that his drinking and drug use have diminished his interest in working and in "life in general," as he puts it. Likewise, David admits that his substance abuse issues have persisted long after his friends stopped using drugs and alcohol for recreational purposes. Whereas many of his former school friends have gone off to college or have full time jobs, David quit high school and has not stopped using drugs and alcohol. David claims to have had a brief period of clarity and lucidity, during which he acquired his GED and enrolled in a local community college. He received thirteen credits but claims that at the time, his mother fell ill and he needed to take care of her more than he needed to go to school. If David can commit to a comprehensive treatment plan that involves counseling, cognitive-behavioral therapy, and life coaching, his prognosis might be good considering the absence of any known mental or physical illnesses that might otherwise complicated treatment.

Treatment Plan

Treatment for David should be as diverse and comprehensive as possible, also lasting as long as possible. Research has shown that the more time spent in treatment, either in-patient or outpatient, the more successful the person will be at remaining clean and sober (Cooper, MacMaster, & Rasch, 2009). Therefore, it is recommended that David complete an initial thirty day residential (in-patient) treatment program followed by one year of combined interventions including counseling, cognitive-behavioral focused therapy, mindfulness therapy, and occupational counseling or life coaching.

Once per month, it is recommended that David and his parents engage in family counseling sessions. David's relationship with his parents has both enabled the development of his substance abuse problem, but also provides one of David's most important protective factors in that social structure and social networks will be necessary for supporting his recovery. It will also help the therapists involved in David's case, and any case managers, to understand his parents' point-of-view regarding David's substance use and their willingness to assist their son in a recovery program.

According to the National Institute on Drug Abuse (2015), cognitive-behavioral therapy can help reduce the maladaptive thought processes that underwrite dysfunctional behaviors like substance abuse. A central element of cognitive-behavioral therapy is "anticipating likely problems and enhancing patients' self-control by helping them develop effective coping strategies," (National Institute on Drug Abuse, 2015). One of the goals of David's treatment program is to enhance David's sense of control over his own life, fostering a greater sense of independence from his parents, and bolstering his self-esteem. Another goal in David's therapy is allowing him to unearth the unpleasant memories of his childhood sexual abuse trauma and his feelings toward his parents in relation to that abuse, given his inability to confide in them during this time. Cognitive-behavioral therapy will help David to recognize the underlying thought and emotional processes that fuel his desire to drink and use drugs, and help him to develop different behavioral patterns and reactions to those thoughts when they arise. Moreover, cognitive-behavioral therapy can be used to help David channel his energy into constructive activities. Family counseling sessions will also help David to confront his parents in a safe environment. Role playing and other specific techniques in family counseling might help David and his parents develop a more mutually supportive relationship rather than one that is co-dependent (Whitfield, 2014). It is expected that David's progress will fluctuate, and any relapse will not be treated as a failure but as a sign that he is becoming more willing to recognize the triggers for his substance abuse. It is also possible that David can learn how to eliminate dependency on alcohol and drugs without demanding the rigors of absolute abstinence.

Countertransference

Research has shown that properly managing or eliminating countertransference can improve treatment outcomes (Hayes, Gelso & Hummel, 2011). Countertransference manifests as a type of empathy for the patient that can blur the duties of professionalism and inhibit the ability of counselors to offer quality care for their clients. Managing countertransference does not necessarily mean refraining from offering assistance, guidance, or empathy. Rather, minimizing and managing countertransference requires shifting focus and transforming the dysfunctional patterns of countertransference into genuine empathy (Tansey & Burke, 1989).

Countertransference can also manifest as bias. In my case, I do not believe in the medical model of substance abuse or in the efficacy of the Twelve Step program model. If the Twelve Step model proves to be something that David is interested in, then I will of course set aside my biases and beliefs because the core goals include improving behavioral outcomes. I would also like to address David's disturbing past, particularly his having abused a young girl when he was only fourteen years of age. If I am too emotionally invested in this problem and little progress is made in therapy, then I would recommend David see a different therapist.

Neuroscience of Alcohol and Drugs

Both drug and alcohol dependence reveal clear neurobiological markers, and research continues to evolve showing the etiology or genesis of alcohol or drug dependency, the specific mechanisms whereby dependency is created in the brain, and the potential for intercessory interventions that can either reverse the changes that addiction has already created or provide a protective effect in persons for whom dependence has yet to become a late-stage addiction. Research has revealed that the brain changes with repeated intake of alcohol and drugs, creating the reinforcement for continued use. For example, "chronic exposure to alcohol induces changes in neural circuits that control motivational processes, including arousal, reward, and stress," (Gilpin & Koob, 2008, p. 185). Specific signaling molecules and brain chemicals involved include, but are not limited to, serotonin, dopamine, opioid peptides, and glutamates (Gilpin & Koob, 2008). If David were to agree to neurobiological assessments, it might be possible for therapists to recommend pharmaceutical interventions designed to reduce or eliminate the dependence on potentially dangerous forms of self-medication such as alcohol and drug abuse. Brain structures are also affected by addiction; it is possible too that congenital or environmentally-caused structural abnormalities in the brain precipitate addiction (Walker, 2008). Therefore, it is recommended that David receive MRI and other imaging tests to determine whether he exhibits any structural abnormalities that might be indicative of more global health problems.

As Walker (2008) points out, behavior affects the brain and vice-versa. This means that the more David engages in the risky behaviors of self-medication with drugs and alcohol, the more… [END OF PREVIEW]

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