Case Study
Patient Demographic: Initial Intake: Age: 35 Sex: Male Gender: Male Sexuality: Gay Ethnicity: African American Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual
Mental Status Exam: The client presents appropriately dressed and is well-groomed. His stated mood is congruent with stated affect but you note a limited range of emotions. He appears to be cooperative and forthcoming. He endorses no use of illegal or inappropriately prescribed drugs and a 20-year history of alcohol abuse, with one driving citation at age 21. He currently drinks 3 to 4 beers per day and 16 or more on the weekend. He acknowledges using alcohol to relieve emotional discomfort and feels the need to cut down. He is able to offer insight into his thoughts and behaviors, and demonstrates appropriate memory and judgement.
Presenting Problem: You are a counselor in a private practice setting.  During the intake session, you learn that your client and his spouse have been married for 7 years and together for 10 years. He states they have 2 children and he is their primary caregiver from early afternoon until evenings; this includes transportation, preparing dinner and homework. He states his spouse and he moved their family here earlier this year to be closer to his husband’s family. He works as a high school teacher. He presents relationship issues as his main concern and rates these as “very difficult,” and has been told that he and his husband “may be heading for divorce.” He states he often feels “suspicious” because his husband has multiple friendships with other males, online and face-to-face, including old boyfriends. The client tells you he feels this is inappropriate but that his husband disagrees and will not end these friendships.  He admits being stressed, overwhelmed, sad, having little energy, and experiencing crying spells, irritability, and angry outbursts. He says he feels like a failure. He says his husband said he has not been “emotionally available” since their marriage. The client notes that during the year they married, he finished his teaching credentials, the couple adopted their first child, and he began working as a first year teacher in a high school with tenure requirements.
Other Contexts: Family History:
The client states he has three siblings. He relates he has a “pretty good” relationship to his brother, a moderate connection to his younger sister, and a tenuous connection to his older sister. He says he has cut himself off “emotionally and physically” from his own parents and his husband’s family due to “conflicts.” He describes his mother as manipulative and attributes the lack of many extended family relationships to her. He describes the relationship between his parents as conflictual but that his father “goes along with her” and has cut off relationship with the client’s older sister, his father’s twin sister and her spouse. The client says his mother has never liked the client’s spouse. He said she was not happy he married a man, but was even more upset that his husband is White. During one family visit, his mother left a derogatory email about his husband in a visible place so he would find it.

Question: When considering the client's desire to address his alcohol use in counseling, which of the following interventions would be used first?
(A): Identify irrational core beliefs
(B): Implement an abstinence contract
(C): Implement motivational interviewing
(D): Use the Prochaska-DiClemente's Stages of Change assessment

Correct Answer: Identify irrational core beliefs
Explanation: Identifying irrational or negative core beliefs is a proven CBT intervention that is part of the process when addressing substance abuse issues. Clinicians use different methods to identify these, however, identifying and modifying unhelpful core beliefs is the most important part of the process. Both the Stages of Change model and motivational interviewing are used when a client is resistant to making changes or when the counselor is unsure whether the client is interested in making changes. As the client has presented with a stated desire to address his alcohol use, the counselor can move directly into helping him work in this area. Abstinence contracts have shown positive and negative outcomes depending on the client and their values and willingness to embrace abstinence. Substance abuse treatment counselors vary in supporting an abstinence model or a harmful reduction model of treatment. Implementing an abstinence contract may not coincide with the client's values and desires. Therefore, the correct answer is (C)
Competency: counseling skills and interventions