A combination of Cognitive-Behavioral Therapy (CBT) and motivational interviewing (MI) is the recommended treatment.
Summary
Frank, a 33-year-old African-American man, came to the caseworker of record after relating negatively to an initial caseworker. His came for treatment because he and his attorney hoped it would favorably influence the judge who would consider the case stemming from Frank's shooting his wife, who had startled him out of a restless sleep. Frank claimed that his alcohol use was not relevant. The first caseworker's probing about alcohol use prompted Frank's referral to the caseworker of record.
The caseworker established rapport early in the first session by remarking on Frank's cowboy boots -- which were distinctive in contrast to his plain clothing. When asked about any problems, Frank referred to his almost constant "traveling partners," fear and worry. He also reported restless nights and bad dreams, which dated from his military service in Vietnam.
Frank's history of behavioral problems included several drunken driving arrests, and although not acknowledged as such they suggest alcohol abuse and/or dependence. The shooting of his wife was the presenting problem.
Frank's family history included a sister with emotional problems, a troubled marital history and heavy drinking and drug use and a heavy-drinking father, who could "handle his liquor."
Frank himself had a long drinking history, from social drinking in high school to heavy drinking -- twelve bottles of beer a day along with a pint of hard liquor -- after release from military service. He admitted to regular blackouts, fear of withdrawal symptoms if he did not drink each day, and morning shakiness, which he combated by adding alcohol to his coffee. He also admitted to an increase in alcohol consumption after the shooting. At the time of the shooting, he was on probation for his third drunken driving arrest. He had avoided jail or loss of driver's license because his lawyer, a specialist in drunken driving offenses, argued that Frank was a truck driver by occupation.
Frank's current environment is bleak, living alone in a hotel, drinking, and watching television. Before the shooting, he lived at home with his wife and 2-year-old twin daughters.
He left home because he feared further injury to his wife, who "he loved to look at because she was so beautiful." Frank did, however, seemed detached from his daughters and reported that he was more comfortable on the road, where there was less noise and chaos.
Frank did not mention any recreational activities aside from drinking, which he did alone himself. He had no close friends, other than with Fiona, and he claimed that his wife and family were enough
Frank met the criteria required for a diagnosis of alcohol dependence on Axis I: needing to take alcohol with his morning coffee to avoid withdrawal symptoms, trying unsuccessfully to cut down on his consumption, and increasing his consumption "quite a bit" after moving out of the house after the shooting. He also met the criteria for a diagnosis of PTSD: an initial trauma;re-experiencing the original trauma(s) through flashbacks or nightmares; avoidance of stimuli associated with the trauma and numbing of general responsiveness; increased arousal, as indicated by difficulty falling or staying asleep and exaggerated startle response; duration of symptoms more than one month; and significant impairment in social and other important areas of functioning caused by the disorder.
Frank also had problems relevant to Axis IV: anguish over shooting his wife, irritation with messy, noisy 2-year-old twin daughters, disapproval by wife's parents, and discord with older sister. He had, at the time of coming to treatment, little if any social support as well as the possibility of job loss and incarceration.
When he appeared for treatment, Frank was clearly in the precontemplation stage of change with regard to his drinking. He saw no reason to even discuss it. At the end of the second session, he seemed to have moved to contemplation; i.e., he seemed to consider that there might be a problem and that change might be necessary. Thus, beginning treatment will focus on emphasizing awareness and environmental reevaluation.
A combination of Cognitive-Behavioral Therapy (CBT) and motivational interviewing (MI) is the recommended treatment.
Treatment Plan
The treatment plan must jointly address Frank's diagnoses of PTSD and Alcohol Dependence. Although some practitioners might argue that the client should be abstinent from alcohol before dealing with another psychiatric problem, it seems in Frank's case too risky an approach. We can't be sure that alcohol misuse was a (partial) cause of the PTSD or a way of coping with PTSD, so that removal of the alcohol might not address all the problems. It could in fact make things worse; Frank seems to have little in the way of other coping mechanisms and support.
For the Alcohol Dependence aspect of the treatment, the writer will incorporate some of the goals, objectives and interventions suggested by Wenglinsky and Dziegielewski (2002) and Hanson and El-Bassel (2004). For the PTSD and dual diagnosis aspects, the writer will...
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