Case Study
Patient Demographic: Name: Robin Clinical Issues: Substance use/addiction issues Diagnostic Category: Substance Use Disorders Provisional Diagnosis: F10.20 Alcohol Use Disorder, Moderate Age: 28 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Not Married Modality: Individual Therapy Location of Therapy : Private Practice  
Mental Status Exam: The client is well-groomed. She reports her mood as depressed due to her relationship breakup and feeling that she is unable to talk to family members about her life. Her affect is characterized by anxiousness and difficulties in answering questions. Her overall speech is slow and soft, with little eye contact as she speaks. The client's insight is fair. She recognizes that alcohol has been a major factor in her life, and she is aware of the negative effects it has had on her relationships and work performance. She states that she is at a point where she feels like she needs help to make changes in her life. Though she presents as sober at the time of the interview, her judgment appears impaired due to her continued heavy drinking despite the negative consequences.
Presenting Problem: First session You are a clinical mental health counselor at a community mental health center. You see many clients who struggle with substance use issues. A 28-year-old female presents for outpatient services today. She is an attorney who works long hours, specializing in family law. She and her boyfriend of ten years recently ended their relationship due to the client's excessive drinking. She says, "I can't live with the pain of our separation much longer, and I don't know how to cope with it." She tells you she is devastated and does not know what to do next. The breakup has triggered her to drink even more lately, and she is currently facing a DUI charge. Her attorney recommended that she seek an assessment for substance use disorder treatment in an effort to avoid a criminal conviction.    You administer an assessment to determine the severity of the client's alcohol use and further evaluate her statement about being unable to live with the pain of her breakup. She reports an urge to drink daily, and acknowledges she has lost control of her drinking on many occasions. She also states that she has increased her alcohol intake because "it helps numb the pain and I can forget about everything for a little while." The client discusses her father's death when she was 17 and how this affected her life. She states that his death hit her hard, and only made matters worse because of her family's lack of emotional support in the wake of his passing. Even though she was still in High School, she began drinking heavily to cope with the grief, a pattern which has been present ever since. She drinks alone, typically at home or in bars after work. When asked about the effects of alcohol on other areas of her life like her finances, she says, "One of the perks of my job is that I get paid pretty well, so at least I'm not in debt like my brother." She pauses for a moment, then says, "Well, not yet anyway. I've got some court costs coming up."    You explain to the client that substance use disorder is treatable and that it is important to take an honest look at her relationship with alcohol, in order to make positive changes to her lifestyle. You discuss the effects of excessive drinking on physical health, mental health, and personal relationships. You review the various options for treatment available and encourage her to be proactive in seeking help. The client acknowledges your advice but expresses hesitancy about beginning treatment due to fear of the stigma associated with addiction. You empathize with her feelings while emphasizing the importance of taking action now rather than waiting until her issues become worse. You present evidence-based treatment modalities that have been shown effective in managing substance use disorders. You let the client know you are here for her to help develop healthy coping skills, explore the underlying causes of her drinking, and create a plan to avoid future drinking and driving offenses. Then, you both discuss a treatment plan with the goal of helping the client resolve her current crisis and developing a strategy to maintain sobriety and avoid future legal issues. She provides you with releases to speak with her mother and her attorney. You set up a follow-up appointment one week from now.  Second session The client had an appointment to meet with you two weeks ago, but she called to reschedule twice, citing a busy work schedule. The client shows up 10 minutes late for her second counseling session today, looking slightly disheveled. She starts off by telling you that "this morning has been a mess." She overslept and missed two appointments with clients. She contacted her secretary to reschedule the appointments, but she is still feeling stressed and overwhelmed. She tells you she was up late last night talking to her ex-boyfriend. You ask what motivated her to talk with her ex-boyfriend and she tells you, "It felt like the only way I could make sense of what had happened between us." She is not forthcoming with any additional details about their conversation. You then ask if anything else has been on her mind lately. She reports that her mother told her that she should be focusing more on finding someone new to date instead of worrying about getting back together with her ex.    The client becomes distant and quiet during the session. She makes minimal eye contact and her responses are brief, often giving a one-word response to your questions. You can tell that something has shifted in her since last week's session as she presented to the intake as more talkative and open. You decide to address her change in behavior directly, saying "I notice that you seem more closed off today compared to the last session we had. Is there something specific that is causing you to feel this way?" The client responds, "I don't know, I'm just so tired of it all." When you ask her to elaborate, she closes her eyes and takes a deep breath before responding. She says that she feels emotionally drained. She is overwhelmed with the weight of all that has been happening and feels like she is a "total failure" for allowing things with her ex-boyfriend to come this far. She describes feelings of guilt for "treating him like dirt" the entire time they were together and sad that "I messed things up so badly." She also shares that she is feeling ashamed about being charged with a DUI. She says, "I'm an attorney, not a criminal. People like me don't get DUIs, yet here I am. What's wrong with me?" The client expresses both a desire and a fear of change. She often talks about wanting to make changes in her life, but is also uncertain about how to go about it, feeling overwhelmed by the idea of taking action. Her tone reveals a sense of hopelessness as she talks about where her life is headed. You empathize with her, acknowledging the difficulty of changing deeply-rooted patterns. You provide her with psychoeducation about the nature of addictions and the biological and environmental factors that can contribute to substance abuse.  Fifth session It has been a month and a half since you first met with the client and she has rescheduled multiple therapy appointments, continually citing a busy work schedule. The last time you met with her, she told you that the judge sentenced her to six months probation, provided that she follow through with Alcoholic Anonymous meetings and counseling sessions. She was also required to do 60 hours of community service. Though she was relieved to have the sentencing behind her, she remarked that she still felt shame and humiliation at having gone down that path. During that counseling session, she communicated to you that she tried to go one day without drinking but couldn't do it. She described the idea of quitting drinking as "impossible" because "I have never been strong enough." You explored the client's motivations and concerns about changing her behavior. You explained to her that while it was normal to feel overwhelmed by the thought of making changes, there were strategies that she could utilize in order to build a support system and make progress towards sobriety.    Based on the client's behavior, you do not believe that outpatient treatment is the best fit for the client at this time, and you plan to discuss alternate options with her today. She is scheduled for an afternoon session but does not show. When you attempt to call her, her phone goes directly to voicemail. You continue to wait in your office even though the client does not respond to your calls or appear for the session. You are concerned about her because although she has rescheduled appointments before, she has always done so in advance and has never been a "no show." You take the appropriate ethical actions to check on her.
Other Contexts: The client has a younger brother. Her father died when she was 17, and her mother never remarried. The client's family has a history of problematic alcohol use, with family members utilizing alcohol to mask underlying emotions and distress. This pattern can be seen in her mother and brother, as well as extended family. Her mother is particularly reliant on alcohol and uses it as a way to cope with negative feelings. This has been an ongoing issue for many years. The client was raised in an environment where emotions were not discussed openly. The client expresses she learned early that it was best not to bring attention to any discomfort or upset she may have felt because it would only be met with more criticism and judgments. She states, "My mother and brother 'don't believe in depression.' When I told my mom that my boyfriend broke up with me and I was feeling depressed, she told me to that I needed to 'get over it and move on.' It's like I'm talking to a wall when I try to tell her anything about how I'm feeling." Although the client does not feel that her family understands her problems, she does communicate with her mother weekly.  The client has been using alcohol as a way to cope with stress for many years. She expresses she has "been through a lot" in her life and that going to bars after work is an escape. Alcohol has maintained a significant presence during various phases of her life.

Question: The client has missed several sessions and has shown a lack of commitment to therapy. What is the best way to introduce alternate options for the client's care?
(A): "Based on your current needs, outpatient treatment may not be the best fit for you at this time, so I'd like to discuss some other options with you that might be more beneficial."
(B): "You seem to have difficulty following through with your appointments, so let's talk about some different treatment options that may be more helpful to you."
(C): "You have obviously been struggling with this, so let's explore some different options to see what could work better for you."
(D): "I need to be honest with you. Your commitment to these sessions has been lukewarm. Individual counseling is not enough for your situation. I'd like to explore more intensive options."

Correct Answer: "Based on your current needs, outpatient treatment may not be the best fit for you at this time, so I'd like to discuss some other options with you that might be more beneficial."
Explanation: This response is sensitive and appropriate because it acknowledges the client's current needs, while still allowing room for discussion of alternative options. It also emphasizes that the client has a choice in her care plan, which can help build trust and mutual respect between the therapist and client. Finally, it avoids any language that could be seen as judgmental or critical of the client. Therefore, the correct answer is (A)
Competency: professional practice and ethics