Case Study
Patient Demographic: Client Age: 48 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Separated Counseling Setting: Private practice Type of Counseling: Individual Presenting Problem: Alcohol use Diagnosis: Alcohol Use Disorder, Moderate, Provisional (F10.20)
Mental Status Exam: Mental Status Exam: The client’s hands tremble, and she becomes tearful on several occasions. There is mild perspiration on her forehead. She endorses feeling hopeless about the future but denies suicidal ideation. The client shows no signs of intoxication or impairment. She presents as well-dressed with good hygiene. Both affect and mood are dysphoric. She apologizes several times for crying and states she has been “a mess” lately due to not sleeping for the last several days. Her demeanor becomes somewhat defensive when asked about her drinking, and she appears to minimize the impact this has had on her life. Fam
Presenting Problem: You are a counselor working in private practice evaluating a 48-year-old female with a history of alcohol misuse. Three weeks ago, the client was hospitalized due to alcohol poisoning. She explains that she was in a blackout before waking up in the hospital and was told her BAC was 0.26, just over three times the legal limit. This occurred on the evening she discovered that her husband was having an affair. The client briefly attended a drug and alcohol intensive outpatient program (IOP) but felt she was not improving with group therapy and would like to try individual therapy instead. She admits that there are times in her life when she has abused alcohol but does not believe she is an alcoholic. The client experiences frequent anxiety and admits to using alcohol “just to take the edge off” and to help her fall asleep. Her alcohol intake increased nearly six months ago when her youngest child left for college. During this time, her husband of 25 years announced he was leaving and filing for divorce. She struggles with being an “empty nester” and is mourning the loss of the life she and her husband built together.
Other Contexts:    ily and Work History: The client worked briefly as an office manager but became a stay-at-home mom once she had kids. As a devout Catholic, she reports feeling heartbroken and ashamed that her husband is filing for divorce. The couple frequently entertained guests at their home, which abruptly stopped after their separation. Her oldest daughter is not speaking to her and is “taking her father’s side,” which has caused her great sadness and resentment. Her middle child, who lives locally, is married with children but does not allow the client to visit her grandchildren unsupervised. She believes her children’s father has spread lies about her alcohol use and feels he “drinks just as much” but appears to do so with impunity. The client’s mother was addicted to pain pills, and her father was diagnosed with bipolar disorder. The client witnessed interpersonal violence between her parents as a child and often felt unsafe growing up. History of Substance Use and Addictive Behavior: The client first started drinking at the age of 14. Her drinking increased significantly while in college and in her early 20’s. The client was able to stop drinking through her three pregnancies but began to drink daily when her children became school-aged. She acknowledges that drinking during the day first started while waiting in the school’s carpool line and increased when her husband returned home from work. She has received three DUIs and had the third offense expunged. After the third DUI, she was court-ordered to attend Alcoholics Anonymous. She stated she resented having to “get a piece of paper signed” and being asked to attend 90 meetings in 90 days. The client denies substance use beyond experimenting with marijuana in college. She concedes that alcohol has been problematic in the past but feels she can successfully control her intake.  You ask your client the following: “On a 1-10 scale, with 10 being the highest, How confident are you that you can stop drinking altogether?” The client states, “I would say a 6

Question: You ask your client the following: “On a 1-10 scale, with 10 being the highest, How confident are you that you can stop drinking altogether?” The client states, “I would say a 6.” Using motivational Interviewing, which response would best elicit change talk?
(A): “Tell me more about how you decided you are a 6.”
(B): “Why are you not a 10?”
(C): “What would your life look like if you were at a 7?”
(D): “Why are you a 6 and not a 0?”

Correct Answer: “Why are you a 6 and not a 0?”
Explanation: Motivational Interviewing (MI) and Motivational Enhancement Therapy (MET) are evidence-based treatment practices that employ a person-centered, strengths-based approach to reduce ambivalence and evoke lasting behavioral change. The confidence ruler is an MI strategy that uses scaling questions to determine the client’s desire to change. By asking, “Why are you a 6 and not a 0?” the client may then respond by providing reasons why she feels confident in her ability to stop drinking, such as abstinence attained during her three pregnancies. This technique helps initiate a conversation about the client’s perceived ability to change. Asking, “Why are you not a 10?” shifts the conversation to one that is problem-based rather than strengths-based. “Tell me more about how you decided to be a 6” may elicit some degree of change talk, but it is not as precise as the response produced when using the MI confidence ruler technique. Lastly, asking the client what her life would look like if she had greater confidence in her ability to stop drinking does not help reduce ambivalence in the same way answer B does. Therefore, the correct answer is (B)
Competency: counseling skills and interventions