Substance Abuse Case Studies

Daniel

Clinical Issues

Daniel presents with comorbid conditions of Alcohol Use Disorder, Severe and Stimulant Use Disorder, Cocaine, Severe (American Psychiatric Association [APA], 2013).  He meets most of the DSM-5 criteria despite the negative familial, interpersonal, medical, and social consequences.  According to the case study, he is regularly consuming both alcohol and cocaine at weekend parties, which is leading to him sometimes having unprotected sex.  While his work as an attorney is still ok, he is starting to experience diminished effectiveness at work which could put his practice in jeopardy, is sleeping around which could cause the end of his relationship with his partner and is starting to isolate himself and have suicidal ideations.  Despite all of these problems, he is still using.  It is likely that he is experiencing both Alcohol Use Disorder and Substance Use Disorder, Cocaine, however, it is likely there are also negative self-images that the client may have that are driving both of these addictions (Singh & Lassiter, 2016).

The initial concerns for Daniel center around his health and well-being.  As a gay male, the use of cocaine is lowering his inhibitions, causing him to expose himself (and his partner) to various diseases including HIV (Card et al., 2018).  As Singh and Lassiter (2016) note, because homosexual sexual activity is not accepted in mainstream society, many of the social events that Daniel attends would be in private locations where AODs are present.  It is estimated that 28-35% of gay men have some sort of substance addiction problem.  Given that Daniel is a gay man and is likely already suffering from depression and is having suicidal ideations, this should raise grave concerns that Daniel needs immediate help.

Legal and Ethical Issues

The major legal and ethical issue that arises here is how Daniel is getting home from these parties.  The therapist will need to tactfully determine if Daniel is driving home from these parties (risking DUI) or is using some other means after building a trusting relationship with Daniel.  Because Daniel may not be “out” with his family, the therapist will need to inquire about this so that they do not err in exposing information that Daniel does not want to be exposed.

Cultural Issues

Culturally, Daniel is of Irish Catholic background, but his gay identity is the strongest component of his cultural background.  The case study does not reveal if Daniel is “out” with his family about his sexual orientation.  Gay men who are not yet “out” tend to have higher levels of depression, and Daniel may be using the alcohol to self-medicate his depressive states (Levine, 2017).  While going to parties and drinking loosens him up, and if cocaine is present, he uses, followed by unsafe, unprotected sex, this may jeopardize not only his health but his relationship with his partner.

Diagnosis and Treatment Plan

Because of the extent of his alcohol and cocaine use, Daniel may need to access a medical detoxification program.  As Singh and Lassiter (2016) outline, developing a trusting relationship with Daniel will be crucial before any treatment can be addressed.  If a strong therapeutic alliance is not built with Daniel, he will not be motivated to start the recovery journey and be able to sustain it during difficult times.  It will also be critical to involve Daniel’s partner in the recovery journey, as well as members of his family or support group that he prefers to have involved in his recovery process.  It will be important to get a complete psychosocial background in Daniel to determine where he uses, patterns of Alcohol and Other Drugs (AOD), doses, frequency, and signs of tolerance. 

Group counseling may be of benefit to Daniel, but it will need to be done in a special way in order to make certain that Daniel does not experience homo-prejudice in that setting as well.  As Singh and Lassiter (2016) detail, the counselor may need to educate the non-LGBTQ clients in the treatment group about treating all members of the group with respect, along with ground rules that prohibit disrespect or discrimination against any group member.  This may actually benefit Daniel because it may be one of the only times that Daniel may have shared his identity with heterosexual individuals in an accepting setting.  Because AOD is often at the parties that Daniel goes to, he will need strategies and skills to empower him to be successful in recovery.

Referrals and Community Resources

The therapist will need to research the local community to find out if there are AA or Alanon support groups with an LGBTQ orientation.  Membership in one of these groups could be a powerful support in Daniel’s recovery.  The therapist may need to reach out to the Pride Institute to see if they could provide local resources (Singh & Lassiter, 2016).

Rochelle

Clinical Issues

Rochelle is presenting with Alcohol Use Disorder, Moderate (APA, 2013).  Based on the information collected in the initial session, Rochelle appears to meet the DSM-5 criteria for recurrent alcohol use despite the negative family, social, and interpersonal consequences.  According to her husband, she has been misusing alcohol for three years, and during the past two and one-half years, their physical and emotional intimacy has almost completely ceased.  The finding of alcoholism is not unusual, as Native Americans have the highest rates of death due to alcohol abuse of any ethnic group in the United States (Rheineck & Lugo, 2016).

The initial major concern for Rochelle is her health and well-being.  As Veach, Moro, Rogers, and Jessic (2016) outline, because the liver must metabolize the ethanol contained in alcohol, continued heavy drinking could put Rochelle at risk of liver damage.  Numerous other physical ailments could result from this as well.  It is likely that Rochelle is using alcohol to self-medicate, so the depression she is experiencing must be considered a co-morbid disorder and should be treated as well.

Legal and Ethical Issues

The legal and ethical issues here are whether or not Rochelle is using alcohol and driving.  The therapist needs to build a trusting relationship with Rochelle in order to make that determination.  If it is found out that she does, counseling regarding the dangers of doing so should be given, with careful records being maintained by the therapist of that discussion.

Cultural Issues

Misuse of alcohol is rampant in the Native American community.  According to Rheineck and Lugo (2016), Native Americans have the highest risk for substance abuse among all of the minority groups.  Rochelle’s feelings of being culturally isolated may be coming from the fact that she is not living in her traditional native community.  The chronic, historical trauma (mostly at the instigation of Whites) will make developing a trusting therapeutic alliance challenging, as there are major trust issues of those from the dominant culture.

Diagnosis and Treatment Plan

Gaining an accurate knowledge of the extent of Rochelle’s drinking may require laboratory testing.  The DSM-5 suggests that blood tests to determine the level of gamma-glutamyltransferase (GGT) may be useful in this regard.  A modest elevation or high normal (>35 units) may indicate that she is a heavy drinker.  The Alcohol Use Inventory (AUI) may also provide answers as to her views towards alcohol as well as her current level of receptivity towards getting treatment to recover (Laux, Perera-Diltz, Calmes, Behl, & Vasquez, 2016).  If this is the case, she most certainly would need to be medically detoxed for her own safety (Stauffer, Aissen, & Caprizzi, 2016).  This would likely be in an inpatient treatment facility. 

Regarding treating the alcoholism, according to Rheineck and Lugo (2016), Rochelle would likely respond better to an intervention that is more in line with her Native American background.  This could include the use of traditional ceremonial and healing customs and integration of spirituality.  Including her extended kin could also be beneficial, as this has been shown to increase a sense of belonging as well as a shared sense of survival of the group.  Involving her husband in this process would also likely bring the couple closer together as he learns more about her culture and spiritual background. 

As Garrett, Baldridge, Benson, Crowder, and Aldrich (2015) outline, mental health disorders like depression are extremely high in the Native American community.  Depression should be considered to be a co-occurring disorder and should be treated as well.  In order to facilitate preventing relapses, Rochelle will need training in coping strategies as well as relapse prevention techniques (Moss & Cook, 2016).     

Referrals and Community Resources

Because substance abuse is so high in the Native American community, it is likely that there are Native American-specific resources, like AA or similar long-term maintenance programs.  Rochelle should be referred to as one in order to facilitate her long-term recovery.  The therapist should consult with an addiction counselor with Native Americans regarding what other referrals or culturally-appropriate resources might facilitate her recovery and long-term sobriety.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, D.C.: American Psychiatric Association.

Card, K. G., Lachowsky, N. J., Armstrong, H. L., Cui, Z., Wanga, L., Sereda, P., … Moore, D. M. (2018). The additive effects of depressive symptoms and polysubstance use on HIV risk among gay, bisexual, and other men who have sex with men. Addictive Behaviors, 82, 158–165. https://doi.org/10.1016/j.addbeh.2018.03.005

Garrett, M. D., Baldridge, D., Benson, W., Crowder, J., & Aldrich, N. (2015). Mental health disorders among an invisible minority: Depression and dementia among American Indian and Alaska Native elders. Gerontologist, 55(2), 227–236. https://doi.org/10.1093/geront/gnu181

Laux, J. M., Perera-Diltz, D. M., Calmes, S. A., Behl, M., & Vasquez, J. (2016). Assessment and diagnosis of addictions. In D. Capuzzi & M. D. Stauffer (Eds.), Foundations of addiction counseling (3d edition, pp. 119–146). Boston: Pearson.

Levine, C. A. (2017). Health issues. In C. B. Roland & L. D. Burlew (Eds.), Counseling LGBTQ adults. Throughout the life span. Alexandria: American Counseling Association.

Moss, R., & Cook, C. C. H. (2016). Maintenance and relapse prevention. In D. Capuzzi & M. D. Stauffer (Eds.), Foundations of addiction counseling. Boston: Pearson.

Rheineck, J. E., & Lugo, M. M. (2016). Cross-cultural counseling: Engaging ethnic diversity. In Foundations of Addiction Counseling (3d edition, pp. 383–405). Boston: Pearson.

Singh, A. A., & Lassiter, P. S. (2016). Lesbian, gay, bisexual, transgender, and queer-affirmative addictions treatment. In D. Capuzzi & M. D. Stauffer (Eds.), Foundations of Addiction Counseling (3d edition). Boston: Pearson.

Stauffer, M. D., Aissen, K., & Caprizzi, D. (2016). Introduction to assessment. In D. Capuzzi & M. D. Stauffer (Eds.), Foundations of Addictions Counseling (3d edition, pp. 89–118). Boston: Pearson.

Veach, L. J., Moro, R. R., Rogers, J. L., & Jessic, E. J. (2016). Substance addictions. In D. Capuzzi & M. D. Stauffer (Eds.), Foundations of Addiction Counseling (3d edition, pp. 18–47). Boston: Pearson.