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Case Study – Ms. Nicole W. Sarah Daniel East Carolina University Integrative Seminar SOCW 6550 Tracy Carpenter-Aeby, MSW, PhD, LCSW January 30, 2011
Sarah Daniel 6550 Integrative Seminar Case Study 2 Sarah Daniel-6550-Case Study I chose for my assessment tool the Biopsychosocial perspective because it embodies the whole person concept as it includes all of the areas of mental health that the individual may present with. The perspective focuses on genetic inheritance, temperament, physiological differences, social factors and individual needs. I feel that in conducting this type of an assessment a well informed and effective plan can be developed that will meet all of the treatment services the individual will need for success. As with all perspectives there may be flaws but for me this perspective by far is the most effective in my practice delivery.
I. II. A.
Case History - Ms. Nicole W. Description Client Identification
Date/Time of Interview: January 28, 2011/3:00-4:30 P.M. Interviewed by Sarah Daniel, BS Person Interviewed: Ms. Nicole W., Date of Birth: May 20, 1970 Residence: 800 West Mount Road, Rocky Mount Home Phone: (252) 443-3111 Employment: ABC Marketing Inc. Business Phone: (252) 937-5000 Household Composition: Ms. Nicole W is divorced with no children Referral Source: Ms. Nicole W (client)
Sarah Daniel 6550 Integrative Seminar Case Study 3 B. Presenting Problem
Nicole is a 40 year old sales executive for a marketing firm seeking treatment for cocaine use. She reports that she is seeking treatment because of her increasingly severe and debilitating depression and her fear of the powerful drug addiction that has taken control of her life. Nicole complains of feeling extremely fatigued and frightened today. She does not make note of having any problems with her appetite but admits to taking Valium for insomnia after her use. Nicole states that her constant exposure to the drug by her live-in boyfriend who sells drugs makes it impossible for her to stay away from cocaine for no more than 5-6 days. When asked about previous history of hr presenting problem Nicole hesitated and stated that during her younger years when she was in college she used marijuana and uppers and on occasion would drink but not often. She stated that she started snorting powder cocaine after a rough patch with her husband to relieve the stress and after the divorce she began to use more frequently. Nicole stated she believes that if it had not been for the influence of her father’s alcohol and drug problem where she was around all of the time she may not have started drinking and using. Nicole denied problems with marijuana and alcohol. Nicole stated that she occasionally used cocaine during the week to function at work and would either drink or take a pill if she felt jittery afterwards. She reported trying to quit several times on her own, but, would wind up using more afterwards. She also described symptoms of withdrawal. Nicole also related doing inappropriate things while using, like having sex with the dealer. Nicole stated that her last use was a couple days earlier and that it had been with some acquaintances. She expressed a preference for outpatient treatment as she did not want the stigmatization of being an addict and wants to quit the use of the cocaine but states she does not want to give up the alcohol.
Sarah Daniel 6550 Integrative Seminar Case Study 4 C. Social History Nicole does not go into detail about her education but it appears that she has been to college since she referenced college in her drug use. Regarding work history Nicole reports that she is an executive for a marketing company with a high level position. Stated because of her position she is given some flexibility but that it is an unwritten policy to exercise judgment. She reports that she has missed days at work being hung over from her cocaine binges and has made vague excuses for her lateness. Nicole also stated that she has missed several business dates out of town or has to reschedule due to her drug use and that it has created a huge amount of stress as she is not keeping the numbers up in her contract deals as her counterparts. Nicole does not report any social isolation since she does not socialize with her co-workers and does not report any financial difficulty or relationship problems. D. Family History Nicole reported that both her parents are living but that she is estranged from them. She also stated that she has two sisters who are both married and reside out of state. Nicole stated that her father is an alcoholic and that she grew up around alcohol and drug use within her biological family. E. Medical History Nicole reported she takes Valium to help relieve the insomnia brought on by her cocaine use and states that it is provided to her by her boyfriend. F. Substance Abuse History Cocaine: Nicole states that she snorts at least $200-$300 a week and that the longest period of abstinence was a 5-6 days. Her symptoms as reported are jitters, insomnia and fatigues. She stated that she has had some drug dreams during the period of her abstinence.
Sarah Daniel 6550 Integrative Seminar Case Study 5 Alcohol: Nicole stated that alcohol was not a problem with her and that she sometimes drinks to relax or when she snorts too much and has the jitters. Marijuana: Nicole reports that she used marijuana more during her younger years and that she rarely smokes these days. Hallucinogens: None Reported Prescription Drugs: Nicole reports taking Valium to alleviate her jitters/insomnia after her binges so that she can function at work. She does not state her first use and the most she has ever used. She does not report any abstinence from the use of the prescription drug or complication from her use. Mental Status: Nicole is a 40 year old divorced female. On rough estimation, Nicole’s level of intellectual functioning appears to be high. Nicole’s orientation is normal but reports being extremely fatigued. Her affect is mood congruent and reports being severely depressed. No reports of suicidal or homicidal risk. Her judgment and insight are limited. Diagnosis: Axis I: Cocaine Dependence; Depression, Moderate; Alcohol Abuse; Hallucinogen abuse by history; Marijuana abuse by history Axis II: None Reported Axis III: None Reported Axis IV: Problems with job, family/social support; relationship problem; problems related to social environment Axis V: GAF 48
Sarah Daniel 6550 Integrative Seminar Case Study 6 Interventions Teach Nicole how to identify dysfunctional thoughts and behavior and explore evidence that supports or contradicts her view and hypotheses. Assign Nicole homework of keeping a daily journal of negative thoughts and feelings she has then substituting them with positive thoughts and feelings. Outcome can be determined by Nicole be able to verbalize a decrease in her dysfunctional thoughts by flipping them with positive thoughts and through the use of feedback. Engage Nicole in setting up a daily log to monitor her moods which trigger her behavior. Teach her a range of specific coping skills to deal with her current problems and possible future problems and encourage her to build positive social interactions and relationships. Discuss with Nicole the negative consequences of alcohol/drug use and promiscuous behavior, the effect drugs have on the body/brain and the risk taking. Outcome can be determined by Nicole verbalizing her understanding of the negative consequences of her behavior, self reporting her attempts at abstaining from the use of drugs/alcohol and a decrease in inappropriate behavior and her social interaction by participating in community activities. Interventions Its’ effectiveness can be obtained through the use of active listening skills including good eye contact and body language during our sessions. This also involves reflecting content, feelings, perceptions and asking questions to ensure an understanding of what she is experiencing. Sustained empathic inquiry by asking questions that brings forth a true understanding of what is going on which helps her to develop a subjective sense of self. Interpreting what Nicole shares to promote insight and awareness and remembering that these interpretations are my perceptions and should only be presented to her to draw out her thoughts. Developing a relationship with Nicole is critical in determining her responses to as her therapist. Outcome can be determined as
Sarah Daniel 6550 Integrative Seminar Case Study 7 Nicole begins to gain insight into her own patterns, desires and motivations, she will begin to use it to make the necessary changes to deal with life’s stressors. Clinical Impression: Nicole’s Strengths and needs: Nicole is educated, employed, with financial stability, and has adequate housing. Nicole is in need of developing a positive relationship or encouraging her partner to participate in treatment, substance abuse services for her abuse of alcohol/drugs, counseling for her depressed moods, participation in a 12 Step Program for alcohol/drugs. In addition Nicole needs to recognize lifelong patterns that might be interfering with her current thinking, organization skills and family. The goal would include Nicole gaining insight into these lifelong patterns and motivations so change can be made possible now and in the future if these patterns would resurface. Nicole also needs to develop a means to function flexibly to internal and external stress and developing mutually satisfying relationships with her family. Diagnostically speaking Nicole has a Cocaine Dependence and Depression, Moderate as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) (American Psychiatric Association, 1994). It is clear based on the assessment and the interview conducted that Nicole is suffering from cognitive distortions and irrational thinking and as a result of unhealthy relationships and a troubled relationship at home with family the drugs became a part of her personal therapy.
There are a couple of therapeutic approaches I plan to use in working with Nicole in treatment, the integration of Psychodynamic Theory and Cognitive Behavioral Theory. Cognitive Behavioral Therapy is a branch of psychotherapy as stated by (David, D., 207, 172), lends on attitudes, theories standards and findings of intellectual psychology. CBT as it is typically called
Sarah Daniel 6550 Integrative Seminar Case Study 8 is a combination of behavior therapy and cognitive therapy. According to (Albano & Kearney, 2000), an important aspect of cognitive behavioral therapy is to solve problems that occur within a client’s life as a result of the existence of faulty behaviors and cognitions coupled with emotions that are irrational. These are the case of Nicole as she clearly demonstrates this with her narrative of her problems. In determining what makes people act the way they do CBT helps people to modify their negative thoughts thus improving their emotional state and since a belief is a thought it plays an important part in behavioral responses. Beck’s original CBT model of therapy (Beck et al. 1979) suggests that client’s early experiences may lead to particular maladaptive schema or beliefs about the world and that such schema can be dormant until activated by events that are consistent with their early experience. As in the case of Nicole her early exposure to drugs and alcohol by her family gave approval to her use of drugs. Through treatment I plan to help Nicole in changing such schema for change occurs in CBT when a modification of negative thoughts enables clients’ to improve their emotional state. According to (Corey, 6th ed) when a client commits consistent practice of new behaviors that replaces the negative ones. Cognitive barriers inhibit behavioral change as does according to (Beck, 1995) client’s deep rooted feelings of hopelessness which is an emotion as stated by (Corey, 6th ed), one of the criticisms of CBT as it downplays emotions as being necessary in the approach of cognitive and behavioral therapy to bring about change which is the reason for my use of psychodynamic therapy in conjunction with CBT which will be discussed later. What makes CBT promising as treatment for cocaine addiction is that it is short termed, has gone through many clinical trials it is evidenced based, it is structured and goal oriented, It has flexibility in that it can be used in any setting, it’s compatibility with other treatments and its’ success rate.
Sarah Daniel 6550 Integrative Seminar Case Study 9 Psychodynamic Theory focuses on the unconscious processes as they are manifested in the client’s present behavior. The goals of psychodynamic therapy as cited in (SAMHSA/CSAT Treatment Improvement Protocols Center for Substance Abuse Treatment, 1993) are client selfawareness and understanding of the influence of the past on present behavior. Its’ approach enables the client to examine unresolved conflicts and symptoms that arise from past dysfunctional relationships and manifest themselves in the need and desire to abuse substances. As in the case of Nicole her earlier experiences with her family and their use of substances played a huge role in her present perceptions, thoughts and behavior.
The theory supporting psychodynamic therapy was developed by four major schools of psychoanalytic theory as cited in (SAMHSA/CSAT Treatment Improvement Protocols Center for Substance Abuse Treatment, 1993), those being Freudian, Ego Psychology, Object Relations, and Self Psychology. Freudian psychology derives from the theory formulated by Sigmund Freud and sometimes referred to as the structural model. In essence Freud’s theory is that sexual and aggressive energies originate in the id or the unconscious and modulated by the ego and defense mechanisms are constructions of the ego that operates to minimize pain and to maintain psychic equilibrium (Messer and Warren, 1995). Nicole’s behavior is a true indication that her past has a bearing on her present and the defensive mechanisms that she portrays. Ego Psychology which is a derivative of Freudian psychology according to (Pine, 1990) focuses on the enhancement and maintaining ego functions with the demands of reality. It stresses the individual’s capacity for defense, adaptation and reality testing. Object Relations as indicated by (Messer and Warren, 1995) reflects that we as humans are always shaped in relation to the significant others surrounding them. That our struggles and goals in life focus on maintaining relations with others while at the same time differentiating ourselves from others. The internal
Sarah Daniel 6550 Integrative Seminar Case Study 10 representations of self and others acquired in childhood are later played out in adult relations. This seems to attribute to the unhealthy relationship that Nicole has with her boyfriend, the drug dealer. Self Psychology according to Blaine and Julius, 1977, p vii) refers to the person’s perception of the experience of self to include the presence or lack of sense of self-esteem. The self is perceived in relation to the establishment of boundaries and the differentiations of self from others (or the lack of boundaries and differentiations). That persons suffering from substance disorders also suffer from a weakness in the core of their personalities which is a defect in the formation of the “self”. Substances appear to the user to be capable of curing the central defect in the self. To uncover Nicole’s past experiences as they relate to the present a therapeutic alliance has to be developed between Nicole and myself to success and this can be accomplished. Psychodynamic therapy sets the tone for the establishment of this relationship and is the vehicle through which change occurs. I strongly believe that individuals must gain insight and awareness into their thoughts and actions before they can make changes or move forward with their lives.
To be effective in my approach in treatment with Nicole my own values and beliefs have to be reexamined. Coming from a grassroots history of recovering from the impact of a significant other’s addiction (my brother) I have to be cognizant of the influence the perspective of the application of theories to counseling as I can become wedded in my own view of recovery. I have to be mindful that this frame of reference can limit my theoretical perspective and defeat the process.
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Albano, M., & Kearney C. (2000). When children refuse school: a cognitive behavioral therapy approach: Therapist guide. New York: Psychological Corporation Beck A.T.., Rush A.J., Shaw B.F. & Emery G., (1979) Cognitive Therapy of Depression. John Wiley & Sons, Inc., New York Beck, J.S. Cognitive Therapy: Basics and Beyond. New York: Guilford, 1995 Blaine J.D., Julius D.A., (1979) Psychodynamics of drug dependence. J. Aronson., New Jersey Corey, G., (2001): Theory and Practice of Counseling and Psychotherapy 6th ed David, D., Journal of Cognitive and Behavioral Psychotherapies Vol 7, No 2 pg 172 Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) (American Psychiatric Association, 1994). Messer, S.B., & Warren, C.S. Models of Brief Psychodynamic Therapy; A Comparative Approach. New York: Guilford, 1995 Pine, F., (1990) Drive, Ego, Object & Self: A Synthesis for Clinical Work. Basic Books (SAMHSA/CSAT Treatment Improvement Protocols Center for Substance Abuse Treatment, 1993). Brief Psychodynamic Therapy
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