Case Study
Patient Demographic: Client Age: 45 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced, single Counseling Setting: Private practice Type of Counseling: Individual counseling Presenting Problem: The client is experiencing difficulty in functioning in all areas of his life due to inhalant use. Diagnosis: Inhalant use disorder, severe (F18.20)
Mental Status Exam: Mental Status Exam: The client is oriented to person, place, time, and situation. The client does not appear to be under the influence of inhalants because he does not display any symptoms of use. The client is friendly and engaged in the ses
Presenting Problem: You are a licensed counselor working in a private practice. You specialize in substance use disorders. The client comes into the session, is very friendly, and states that although his sessions are court ordered, he wants to get help with his inhalant use. The client spent the first half of the session explaining what happened to lead to him getting his third charge of driving under the influence of inhalants. The client says that he had twin sons 13 years ago and they both were in the ICU; one of his sons died after about a month. The client began drinking alcohol to excess daily for about 6 months, which then transitioned to inhalant use. The client says that he uses contact cement, model glue, paint, and permanent markers to become intoxicated. The client identified the following symptoms of inhalant use disorder: increase in frequency and amount of use over the past 5 years, several failed attempts at cessation of inhalant use, craving inhalants throughout every day, losing several jobs because of his inability to get to work on time due to inhalant use, use that has affected his ability to have visits with his children and maintain employment, use that increases the risk of harm to himself and others such as driving under the influence, increased tolerance, and continued use even when he knows it is negatively affecting his life. The client wants to become sober, improve his relationship with his children, and maintain employment.
Other Contexts: The client comes into the session and looks tired, as evidenced by the darkness under his eyes and he is walking slowly. The client starts talking immediately about 2 days prior when he went to his ex-wife’s house to pick up his kids for a visit and she told him that although she cannot stop this visit, due to recent inhalant use a few weeks ago, she talked with her lawyer about changing the status of his future visits to supervised visits, and she will be returning to court to do so. The client says that he spent time with his kids and that when he left, he stopped by a store to get acetone and that he used this substance that night. The client expresses guilt and shame surrounding using, which led to him using the acetone the next day. The day after he used inhalants, the client stated that he was thinking, “I already broke my sobriety; I may as well huff so that I can feel better.” You empathize with the client regarding the situation because you can see how this would be distressing for him. The client says that his children seem bored when they are with him, as if they want to go home, which induces feelings of shame and sadness

Question: Regarding the client’s thoughts after the second day of using inhalants in a row, which of the following would be the most appropriate cognitive reframe of this thought?
(A): “I may not be able to improve my relationship with my ex-wife or have the visitation agreement that I want. I just need to keep moving forward.”
(B): “I got off track, but I can make better choices in order to improve my situation by contacting my sponsor and counselor.”
(C): “I broke my sobriety and need to focus now on how to get back on track.”
(D): “I can contact my lawyer and begin working on the visitation agreement so that I can manage future stress and will be less likely to feel that I need to use inhalants.”

Correct Answer: “I got off track, but I can make better choices in order to improve my situation by contacting my sponsor and counselor.”
Explanation: Helping the client identify that he is not where he wants to be (in terms of breaking his sobriety) and then identifying that he can start working with his counselor and sponsor to improve his situation is the most helpful reframe to his cognitive distortion. It is most helpful to be realistic with the presenting problem and to choose a path forward. Although the reframe that he may not be able to improve the relationship or visitation agreement might have some truth to it, improving these situations is important for his relationship with his children and for his own mental health; therefore, these are important to continue to focus improvement efforts on. Contacting the lawyer may be helpful for the visitation agreement, but this will not guarantee that the client is going to be okay moving forward. The client needs to improve his behavior and thought processes to maintain sobriety and therefore improve visitations for the long term. Identifying that the client broke sobriety and needs to get back on track is true, but it does not provide the next steps for improving his situation. Therefore, the correct answer is (B)
Competency: core counseling attributes