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 are nearing the end of your initial intake session

Question: You are nearing the end of your initial intake session. Which of the following actions would best help improve treatment compliance for this client?
(A): Summarize the client’s presenting problem, barriers to treatment, and associated risks of prolonged alcohol use.
(B): Facilitate the negotiation of agreed-upon treatment goals.
(C): Teach basic relaxation and mindfulness techniques to help improve insomnia.
(D): Provide the client with information for online and in-person 12-step recovery meetings.

Correct Answer: Facilitate the negotiation of agreed-upon treatment goals.
Explanation: The therapeutic alliance is associated with instilling hope, optimism, and motivation—all of which are related to improved treatment compliance. One way to establish a therapeutic alliance is to negotiate agreed-upon treatment goals for therapy. This client-counselor collaborative relationship is also strengthened by having confidence in the methods used to attain these identified goals. Due to the client’s previous dissatisfaction with Alcoholics Anonymous, providing the client with 12-step recovery information would not be beneficial at this time. The therapist’s communication skills, including summarization, can positively affect the therapeutic alliance; however, summarizing the client’s problems, barriers, and risks is problem-oriented rather than solution-oriented. Providing problem-focused feedback can prevent the client from joining with the therapist. Relaxation and mindfulness are evidence-based approaches for improving insomnia. Teaching these skills does not ensure successful mastery of the client’s alcohol use, and the client may want to prioritize other issues. Therefore, the correct answer is (D)
Competency: treatment planning