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...

(Short-term)
Help Frank link up with Veteran's Administration and its services. (Short-term)

Help Frank connect with AA meetings and Dual Disorder meetings. (Short-term)

Help Frank see the discrepancy between his current behavior and his broader goals. (Short-term)

Assist Fiona in dealing with Frank's alcohol dependency and PTSD. (Short-term)

Help Frank continue to attend AA and Dual Disorder meetings. (Long-term)

Assist Frank in developing a post treatment plan; e.g.,What to do it symptoms return? (Long-term)

Objectives and interventions in service of these goals are discussed in the next section.

Intervention Planning and Implementation

As indicated earlier, Motivational Interviewing and CBT will both be utilized with Frank. Motivational Interviewing is particularly useful for those in the contemplation stages of change, where Frank seems to be. The approach helps the client explore and resolve ambivalence as a way of motivating change. The purpose will be to encourage Frank to undertake the cycle of change (Rollnick & Miller, 1995).

CBT seeks to change the patterns of thinking and behavior responsible for a trauma victim's negative emotions and, thus change the way he feels and acts. In CBT, individuals learn to first identify thoughts that make them feel distressed and replace them with less stressful thoughts. (Wenglinsky & Dziegielewski, 2002). Frank seems a good candidate for this approach.

Objectives and interventions in service of the short-term Goals are listed below and will use a combination of the two approaches.

1. Assist Frank in seeing how certain thoughts about his experience in Vietnam cause stress and make symptoms worse.

Objective: Frank will discuss his Vietnam experiences and how he feels about them.

Intervention: The caseworker listens, reminds, recapitulates and gives feedback. The caseworker also educates Frank on techniques for anxiety reduction (e.g., relaxation exercises).

2. Help Frank link up with Veteran's Administration and its services.

Objective: Frank will contact the Addictions and PTSD staff at the nearest VA Center.

Intervention: the caseworker will supply contact information and inquire about outcome.

3. Help Frank connect with AA meetings and Dual Disorder meetings.

Objective: Frank will discuss his experiences at the meeting, and if and how they have helped.

Intervention: Frank will keep a journal of these experiences.

4. Help Frank see the discrepancy between his current behavior and his broader goals.

Objective: Frank will list the good things in his life and his strengths.

Intervention: the caseworker will give reasons why this can help and then prompt and nudge. (It does not seem that Frank has had much practice in seeing good things.)

Objective: Frank will discuss how his current behavior impacts the good things and how he can bring his strengths to bear on any undesirable impacts.

Intervention: The caseworker listens, reminds, recapitulates and gives feedback.

5. Assist Fiona in dealing with Frank's alcohol dependency and PTSD.

Address Fiona's and daughters' needs. Encourage Fiona throughout treatment.

Intervention: The caseworker will help Fiona connect with Alanon and other supports as well as having sessions with Fiona alone and also with Frank.

Termination, After Care and Follow Up

Objectives and interventions in service of the long-term goals are listed below.

1. Help Frank continue to attend AA and Dual Disorder meetings.

Objective: Frank will meet with the caseworker on a less intensive treatment schedule and discuss AA and Dual Disorder meeting.

Intervention: Caseworker will discuss with Frank how the meetings have helped and whether and how he "has carried the message" to others with similar problems.

2. Assist Frank in developing a post treatment plan; e.g., What to do it symptoms return?

Objective: Frank will present a written plan that considers what to do in difficult times, how to prevent relapse, and what to do in the case of relapse.

Intervention: Caseworker will suggest elements of the plan -- only as need or requested.

References

American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders: DSM-IV. Washington, DC: Author.

Banarjee, S., Clancy, C., & Crome, I. (2002) Co-existing Problems of Mental Disorder and Substance Misuse (dual diagnosis). Retrieved from http://www.web.archive.org/web/20040309142330/www.rcpsych/

ac.uk/cru/complete/ddipPracManual.pdf

Hanson, M. & El-Bassel, N. (2004). Motivating substance-abusing clients through the helping process. In S.L.A. Straussner (Ed.), Clinical Work with Substance-Abusing…