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: The client has arrived 15 minutes late for your scheduled session. When you approach the waiting room, you find her loudly talking on her cell phone. She abruptly ends the call and follows you back to your office. She is visibly shaken and angry. She explains that her soon-to-be ex-husband is a “master manipulator” and is “ruining my life.” She remains confident that she can stop drinking but states she can only do so once her family situation is under control. After all, she states, “You would drink too if you had my problems.” She begins to de-escalate as the session progresses, and she is able to identify and prioritize treatment issues. Her sleep continues to be a concern. Upon further exploration, she indicates she is having nightmares and has been for quite some time. The two of you work together to prioritize treatment plan goals. Her mood and demeanor brighten as the session concludes

Question: When discussing treatment issues, you ask, “How does drinking align or not align with your goal of improving relationships with your family?” What is the value of posing this question?
(A): It allows for the focus to be kept on the client’s alcohol misuse.
(B): It helps create incentive-based interventions used in contingency management.
(C): It helps create a discrepancy between the client’s actions and personal values.
(D): It assists with providing baseline measures for treatment plan goals.

Correct Answer: It helps create a discrepancy between the client’s actions and personal values.
Explanation: According to Miller & Rollnick (2013), developing discrepancy between the client’s values and behaviors helps increase the client’s motivation to change. The onus is on the client, rather than the counselor, to argue for change. In doing so, you help elicit intrinsic motivation by emphasizing the conflict between the client’s drinking and the value she places on familial relationships. This question goes beyond simply focusing on the client’s alcohol use, making answer A incorrect. Developing discrepancy helps the client narrow down treatment plan goals, but it does not provide baseline measures for the treatment plan. Contingency management is a treatment approach that involves presenting clients with tangible rewards for attaining and maintaining abstinence. Therefore, the correct answer is (B)
Competency: treatment planning