A Case Formulation Example

The Dual Disorder CBT Treatment of a Childhood Trauma Survivor
I. Introduction to the Theoretical Model The approach to this client’s evaluation and therapy is within the Behavioral Therapy domain of counseling theory. Within the behaviorist strand of counseling theory, Cognitive Behavior Therapy (CBT)1 has been successfully used to treat Anxiety Disorders.2 In this case study, the client has Post Traumatic Stress Disorder [PTSD]; which is one of the most multi-problem mental health categories in the Anxiety Disorder cluster. The clinician uses CBT methodology. A leading CBT Theorist, Albert Ellis, has developed an enriched CBT model called Rational Emotional Behavioral Therapy (REBT)3 that fit this client’s treatment needs. The client’s substance use disorder, separate but entwined with her PTSD, is the second component of her “dual disorder”. REBT is an effective behavioral therapy model for addressing the developmental history model of addictions treatment; which is more commonly treated from a Psychodynamic Therapy domain of counseling theory. In REBT, like a Psychodynamic [sometimes called Psychoanalytic] method, the client’s historical awareness of her progressive disease and its distortions in thinking [i.e. “problem denial”] is addressed through what Ellis calls the ABC’s of irrational thinking.4 The therapist assists the client with an REBT problem selfassessment; which is called a “First Step” in Minnesota Model chemical dependency treatment.5 In the example transcript of the third session, used for explanatory purpose, the client brings her daughter to the therapist’s office which creates an enactment of mother—daughter dynamics. The therapist allows the family dyad to derail naturally between the multiple subjects of dysfunction that have existed within the family addiction and multi-generational trauma. In the session, the therapist uses the framing model of REBT to exhibit the inability of the dyad to resolve here-and-now decisions due to long-standing irrational beliefs about their relationship. II. Basic Demographic Client Information Name: Age: Race: Sex: Laura Client 42 Bi-racial1 Female

Marital Status: Single, Divorced Employment: Pedicure, Cosmetology without formal education Referral: Treatment:
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Tacoma Indian Center Outpatient Clinic, Individual counseling

Native American and European American

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The key presenting issues are Ms. Client’s efforts to develop a sustained addiction recovery that includes the level of behavioral health necessary to parent a 14 year old daughter who is on the Washington State early intervention program for truancy and delinquency [i.e. the BECCA law]. III. Client Background Summary 3.A. Substance Use History Laura Client was introduced to alcohol use by her family when she was in her pre-school years. An anecdotal description told in her family is a joke about when the client was a baby and could “suck down her bottle of beer”—but had a hard time drinking her bottle of milk. She remembers the ongoing consumption of alcohol from age five when she would drink with her grandmother. Her substance abuse was established in her elementary years and, by the beginning of junior high years, she was consuming marijuana, alcohol and hallucinogens [“LSD”]. Prior to reaching adulthood, dropping out of high school in her senior year, her poly-drug abuse escalated to adding cocaine [including the highly addictive smoked version called “crack”] and methamphetamine. As she entered early adulthood years, her memory is clouded by the polydrug nature of her drug abuse, but she had further added the highly toxic combined use of heroin and methamphetamine to her addictive behavior. 3.B. Psychological Functioning and History Along with childhood neglect through the use of alcohol provided by her family, she was verbally and physically abused by her parents and grandparents. The middle of three children, she was the only adopted child. She perceives this difference resulted in her parents treating her more poorly than her siblings, not feeling accepted by her parents, and even questioning whether her parents wanted her as a child. Her mother is an alcoholic. Aside from her very early exposure to alcohol, her mother’s alcoholic behavior created an environment that she describes as being a “self-medication” reason for her own teenage and adult alcohol use. At this level, she is able to connect the genetic and environmental influences on her dependence. She has an inaccurate perception that, outside of the substance use, she didn’t really have any behavioral health problems. She also fails to connect her own mother—daughter narrative to her current situation with her daughter. Once her addictions began to include more expensive and neurochemically addictive drugs [methamphetamine, heroin and cocaine] she began to engage in prostitution and theft to finance her lifestyle. She has also experienced psychotic symptoms in her adult life. She does not hear command voices, but she does hear and see negative auditory and visual hallucinations. An explanatory anecdote provided by Ms. Client was an incident about 3 years ago when she believed Satan was talking to her through her cheek. As a result of this psychotic delusion, she took a scissors and cut out a substantial chunk of her cheek to “remove Satan’s influence.” Currently, she presents with very low self-esteem, high levels of anxiety, and mood swings which have been diagnosed as a Bipolar disorder. She is now abstinent from substance use with

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continuing care in support groups; but has a very hard time dealing with anger and frustration that she would historically sedate with one or more drugs. In developing services for Laura, social and health agencies are assisting her develop life skills when she has little or no prior learning. These deficits are further aggravated by sleeplessness created by dreams similar to the hallucinations noted above. While abstinent from addictive use of drugs at this time, she reports the beginning of compulsive overeating late at night [“binge eating”]. 3.C. Education Ms. Client reports to having good grades prior to dropping out in 12th Grade. She reports no history of Special Education needs. She plans on further education to complete her GED and is considering post-GED business studies. She reports vocational interests in cosmetology and pedicure services [“applying make-up and being a nail artist]. She has had no formal education in either activity. 3.D. Legal History Ms. Client has been arrested in the past for prostitution and possession of narcotics. In light of her extensive adult lifestyle of admitted criminal behavior, her time of incarceration appears less than might be expected. She was a crime victim with two extensive situations of rape. During the second rape, at age 19, she was held captive for three days by a man who raped her repeatedly while he put a gun to her head. In other areas of contacts with law enforcement, either as a violator or victim, she cannot remember a lot of her past. She knows that she has had numerous legal interactions, but cannot recall specifics. She identifies her drug of choice for the last 30 years as being Methamphetamine, which has extensive connections to the illegal community of drug manufacture and distribution. It also left her, as she notes, in an ongoing “fog.” Currently, her major legal issues are in the role of a parent. Her 14 year-old daughter, Jericah, is involved with the state truancy system [BECCA Bill]. Jericah has stopped attending school and Laura can’t figure out how to intervene successfully on this behavior. Jericah has a history of suffering from depression and self-injury [cutting] behavior. Client does believe that a substantial amount of Jericah’s emotional pain and behavioral health problems are the result of Laura’s drug abuse and her parallel parental absence during Jericah’s childhood years. 3.E. Social History In addition to her drug addiction, she also reports her overall lifestyle has been influenced by problem gambling during periods of active substance use. She reports the assumption that if she gambled she could get more money for drugs. During the past one year period abstinence from alcohol and drugs, she has not engaged in gambling behavior.

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She reports an “on again—off again” boyfriend that goes by the nickname “Yogi.” Yogi is currently serving a prison sentence. He has a history of being physically and verbally abusive towards Laura. However, she justifies his behavior by saying that he was only abusive when he was under the influence of substances. It should be noted that she reports he was “high most of the time.” He also influences her ability to recover from addiction; reporting that the only times she has been able to stay clean is when he’s locked up. When he is released from prison, they usually get back together and then she resumes active substance use. She reports a new awareness of this dynamic, saying that this time will be different because she “now knows that, although she may still care about him, they are toxic together.” She is unclear about what this revelation means in terms of behavior change. She still visits him in jail and reports that he is sometimes verbally abusive towards her during these visits. She reports few friends in her social environment; but has a very strong Christian faith that has provided her access to church-related relationships. She talks about a conversion experience where “God saved her after he appeared in her dream after a drug possession arrest.” She was attending bible study which provided her with a sense of relaxation. After that activity ended, her anxiety increased dramatically. She partakes in activities at the Tahoma Indian Center [Tacoma WA], which gives her a sense of pride in her heritage and community connection. She appears to have time management problems with difficulties emerging when she doesn’t have a structured schedule. For instance, her schedule changed when bible study ended—with resulting anxiety increasing as her time structure decreased. She reports being employed as a manicurist. However, the business has been very slow. She is involved in an unrelated business venture, which she believes will “make her rich”. Basically, this venture is a spa treatment that she sells during “spa parties.” The process is similar to Tupperware parties. This business plan hasn’t been working out for her yet; but she is very hopeful that business will improve. Ms. Client’s daughter and her religion appear to represent her primary support system. Unfortunately, her daughter is currently suffering depression of her own. She also has a 21 yearold son who is in prison. She reports visiting him on a regular basis. She feels most of her family has “given up on her” or would not be positive influences in her life. Despite this awareness, she lives with her parents and reports her mother is verbally abusive towards both her and her daughter. She sleeps on the couch and her daughter Jericah has a small bed in the “storage room”. This is the same house that she grew up in and she believes it is evil. She uses a dream she had as a child to describe her feelings where “she was trying to leave the house but the devil stood at the end of the driveway and wouldn’t let her go.” She believes that the devil is still there trapping her in that negative environment because “he doesn’t want her to succeed.” She goes on to portray the house as “full of clutter and negativity”.

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3.F. Physical History As reported, Laura Client has been physically abused and assaulted on a repeated basis, has been raped, has been involved in numerous car accidents (most of which she doesn’t remember) and has had numerous sexually transmitted diseases [STDs]. As a result of these multiple traumas and acute health problems, she reports chronic back, hip, and rib pains. She was recently diagnosed with Hepatitis C. Current test results for other STDs are negative. Her historical reporting of physical and other health problems is unreliable because her long-term memory has appears insufficient. She notes memory gaps in much of the last 30 years. This memory deficit could, hypothetically, be from resistance to talk about known experiences, actual gaps in memory, or a combination of both. When she was actively using substances, she was substantially under weight. Although she realizes this type of actual physical condition, she experiences a body image distortion that she is “fat and disgusting” because she has gained weight towards a normal level. She has experienced antibiotic-resistant infections [often called “MRSA”], which caused a pusslike infection on different parts of her body, including areas on her face. 3.G. Treatment History Laura Client has been through three different cycles of inpatient—outpatient chemical dependency treatment. Prior to the current episode of recovery, the longest she was able to stay clean was for 2 years. When Yogi was released from prison, she relapsed into active substance use. She has currently been clean for a little over a year. She attends clean and sober support meetings that are held within her church and at The Tahoma Indian Center. IV. Multi-Axial Diagnosis Axis I 298.9 309.81 304.83 296.33 799.9 Psychotic Disorder, NOS Post Traumatic Stress Disorder Polydrug Dependence, in sustained remission Depression Diagnosis Deferred

Axis II Axis III

Hepatitis C Sleep Disorder Minor Body Aches and Pains Temporary Vocational Disability Lack of Primary Support Involvement with Legal System through Daughter Global Assessment of Functioning=40

Axis IV

Axis V

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Laura Client has been diagnosed as Bipolar in other settings due to her obvious Depression and mood swings. In her current clinical setting, she exhibits Depression with a mood that swings into the agitation state in a way more consistent with Post Traumatic Stress Disorder than a manic phase. She reports the following three criterion areas for diagnosing PTSD 1. Historical numbing through substance use and faulty memory mechanisms. 2. Hypervigalence and Central Nervous System arousal with fear of control loss, prolonged agitation and nightmare sleep interruption. 3. Re-experiencing trauma response with anger, paranoia, problems with intimate relationships and social connections and thoughts of suicidality. Laura Client has been the victim of assault and sexual violence from childhood forward; along with life-threatening automobile accidents. All of these traumas, separately, are consistent with generating Acute Stress Disorders. She does not acknowledge any social or health interventions to address those behavioral health crises; confirming a basis to associate the above-noted PTSD criterion to the multiple traumas. The major treatment response differences between Bipolar and PTSD diagnoses would be medication and cognitive attribution. The major difference in psychiatric medication management between PTSD—Depression and Bipolar would typically be strength of prescriptive emotional regulation [e.g. Depakote addition to an SSRI mood medication]. It is important that the primary care provider or Psychiatrist monitor medication response to further refine diagnosis between Bipolar and PTSD disorders. The major difference in cognitive attribution between the two disorders would be: 1. Bipolar. Biological cause of mood swings; with a minor focus on changing interpersonal stressors to support a primary medication management strategy. 2. PTSD. Interpersonal trauma cause of mood swings; with a minor focus on changing medication to support a strategy of primary resolution of interpersonal stressors. The current client treatment plan developed for dual disorder services begins with the second paradigm; with parallel medication monitoring to identify Manic or Hypomanic episodes that might indicate the presence of Bipolar Disorder instead of, or concurrent to, PTSD. Ms. Client has extensive vegetative symptoms of Depression: scattered concentration, eating pattern changes, sleep disruption and lack of mental energy. She has substantial behavioral problem patterns of serious depressed mood; including: suicidality, hopelessness and lowered self esteem. The etiology of Laura’s Psychotic episodes is not clearly defined; though the law of parsimony would suggest they are connected as symptoms of the Depression or PTSD. Medication management and treatment that reduces Axis IV stressors should reduce, and ultimately eliminate, the non-command hallucinosis.

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V. Treatment Planning 5.A. Summary of Clinical Presentation Laura Client presented to Catholic Community Services [CCS] for therapy in May of 2007. She entered the CCS five-session community pro bono service program. First Session. Her overall mood at our initial session was overly optimistic and forgiving of the contribution of others to her difficulties [e.g. abuse perpetrators]. She credits this attitude as coming from the principles of her Christian faith, saying she has “forgiven all the people that hurt her because God taught her the importance of forgiveness. She openly talked about her extensive history of traumatic experiences. Her descriptions were devoid of significant negative emotion, consistent with PTSD numbing, and delivered in a nonchalant and “matter of fact” manner. Second Session. During her second session we discussed her own expectations and goals for therapy. Talking about her concerns led to a realization of her very low self-esteem. An agreedto framing of her needs led to the goal of improving her current functioning and increasing her positive self-evaluation. This should result in her self-esteem experiencing an associated increase. In selecting therapy strategies to meet that goal, we agreed that, although her historical addictions and relapse prevention will be important in the treatment plan, we would focus more on her interpersonal difficulties with historical assessment more focused on the cognitive— affective distortions from the PTSD. The short-term objectives, as a group, are to increase her self-esteem, deal with anxiety more effectively, and improve her relationship with her daughter Jericah. Third Session. We had planned on finalizing a treatment plan during our third session, which could be the blueprint for additional sessions at CCS and/or social service support at the Tahoma Indian Center. However, at that session, her daughter came in with her in an unannounced manner which, as noted in the introduction, resulted in a session of facilitated mirroring and framing their interpersonal expectations for the client to see that, if her daughter simply “forgave” her; this would not lead to a gain in self-esteem, reduction in anxiety or initiate a satisfying mother-daughter relationship. During the session, the clinician framed parent-child boundaries according to the mother’s perceptions of the ideal interpersonal communication style. The therapist attempted to support this dynamic by framing the mother’s verbal requests for forgiveness and follow-up “parental” guidance on how Jericah “should” view the world. In addition, the therapist facilitated the mother’s active discussion of her vocational role in her spa sales business so the daughter would “understand” her status as the future family breadwinner. Even with therapist framing and advocacy for Laura’s Parent-Child2 dialogue, the interpersonal
Eric Berne, in Transactional Analysis Theory, describes this as an adult authority figure using nurturing and/or critical guidance to another person in a manner to evoke subservient [“childlike”] responses.
2

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communication remained tangential, largely unproductive and provided a wealth of verbal data to further work with the client’s perceptions using REBT in future sessions. Session Four. The basic tenets of a treatment plan were prepared, with supervisory consultation, and discussion was initiated with Ms. Client in the fourth session. At this session, she no longer exhibited confidence that she had the interpersonal intimacy skills to fully and effectively parent Jericah. There was also an absence of the assertion that forgiveness, by itself, represented a solution for long-term family dysfunction. Session Five. At what would have been the terminal session, Laura Client did not attend her scheduled appointment. Since this behavior has the high probability of representing her trepidation to discontinuing therapy, a treatment plan was developed for CCS to conduct a utilization review in order to authorize additional sessions. After approval of the treatment plan, the therapist and CCS case coordination staff will conduct follow-up contact to re-engage her in the treatment plan. 5.B Treatment Plan The treatment interventions are outlined by priority. The measurement by objectives will be established with the client at her first session. Psychotic Disorder, NOS; 298.9. The first session will begin with coaching in use of the King County WA Crisis Line [211] and local Emergency Rooms with a contract for safety. The client will be referred to the CCS consulting Psychiatrist for a medication evaluation and monitoring plan; which will include intervention on hallucinosis, vegetative symptoms of Depression and ongoing review of Bipolar versus PTSD criteria. Post Traumatic Stress Disorder, 309.81. The client-therapist will use the “Courage to Heal” Workbook to reframe her developmental cognitions, reality-test rational-emotive perspectives and practice resulting behavioral change in real-life social situations. Polydrug Dependence, in sustained remission, 304.83. The client will practice behavioral change in 1-to-1 settings, with mentor [“sponsor”] and peers in the community of recovery; as well as group settings in AA and NA meetings. This will include participating in all-women’s meetings to process her personal discoveries in the PTSD workbook activities. Depression, 296.34. Along with medication management, the therapist will assist the client develop functional boundaries and effective parental relationships with her daughter in conjoint sessions that continue the Structural Family Therapy intervention begun in Session Three. VI. Case Discussion In a client emerging from the distorted perceptions of an addicted lifestyle that is further compromised by PTSD; it is important to reality test their developmental history with particular attention to techniques of Rational Emotive Behavioral Therapy. When REBT is augmented with a workbook like “Courage to Heal”, the client is challenged to move towards a more rational

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interpersonal world view and visualize new behaviors. This reframing and guided visualization represent classic examples of Cognitive Behavioral Therapy using Bandura’s Social Learning Model6 to prepare for transfer of training to real-life environments. CBT homework activities can be naturally designed for the addiction recovery culture of mentors, meetings and social activities. In Session Three, the clinician used Structural Family Therapy7 techniques that fit well in supporting CBT approaches. PTSD and addiction are both disorders that destroy clear interpersonal boundaries and further result in problems with intimate relationships. Structural Family Therapy seeks to create clear boundaries through the therapist joining the family system; which in this case is the mother-daughter subsystem. The therapist entered Laura-Jericah’s subsystem and used REBT reframing statements to support the client’s faulty perceptions of how her relationship with her daughter “should be.” Laura was able to view this enactment as a fantasy model when, even supported by the therapist’s advocacy, the interpersonal communication continuously derailed and was largely ineffective. Structural Family Therapy, sometimes called Structural Strategic Family Therapy, is a CBT model of choice for adolescents experiencing depression in dysfunctional family systems8--which is the current situation for Jericah and her mother Laura. While CBT strategies, such as REBT and Structural Family Therapy, create a strong theoretical and evidence-based rationale for treating the dual disorder client in this case study--it is also taxing to the clinician’s personal resources. This is particularly true in the Structural Family Therapy intervention which came about in an unplanned, but fortuitous, manner. When facilitating a partially delusional mother-daughter interaction, it is almost impossible to avoid the intrusion of a therapist’s own counter-transference issues. By staying on a well-defined CBT approach, instead of a less linear and more symbol-laden psychodynamic approach, the therapist maintains their own best protective shield of rational assessment during the exchange. Nevertheless, the potential to be pulled off course requires use of supervision and, where possible, audiotape transcription to self-assess the interaction at a later emotional distance. Citations
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"A Guide to Understanding Cognitive and Behavioural Psychotherapies" British Association of Behavioral and Cognitive Psychotherapies. Retrieved on 2007-1-1 2 Beck, A., (1993). Cognitive Therapy and the Emotional Disorders, NY: Penguin, 1993. 3 Ellis, Albert (1975). A New Guide to Rational Living. Prentice Hall. 4 Ellis, Albert (2001). Overcoming Destructive Beliefs, Feelings, and Behaviors: New Directions for Rational Emotive Behavior Therapy. Prometheus Books. 5 Spicer, Jerry (1993). The Minnesota Model: The Evolution of the Multidisciplinary Approach to Addiction Recovery. Center City MN: Hazelden. 6 Bandura, A. (1986). Social Foundations of Thought and Action. Englewood Cliffs, NJ: Prentice-Hall. 7 http://www.minuchincenter.org. The Salvadore Minuchin Center for the Family. 8 Journal of Family Therapy. Special Issue—Family and Couple Interventions in Depression. 25(4):406-416, November 2003.

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