Practitioner Case Study: Establishing Rapport

Practitioner Case Study: Establishing Rapport and Engagement

The Presenting Problem

Frank was a 33-year-old African-American man who had two consecutive referrals. The caseworker to whom he was first referred claimed a poor fit, so he passed Frank on to a second caseworker at the same agency. According to the first caseworker and later reiterated by Frank, he came for treatment because his attorney suggested it. They hoped it would favorably influence the judge when it came time to sentence Frank for shooting his wife. (According to Frank, she startled him out of sleep and he reacted as to a threat.) Frank did not see alcohol use as relevant to his current situation. In fact, it was the first caseworker's early inquiries about alcohol use that alienated Frank.

Emotional, Behavioral and Mental Status

When the eventual caseworker first met Frank, he saw a tall, thin man who seemed worn, tired and older than his 33 years. In his conversation, Frank was reserved and polite but came out of his shell when complimented on his cowboy boots. The boots were noticeably elegant in comparison with his plain and neat clothing.

When asked about any problems, Frank reported frequent fear and worry -- which he called his "traveling partners." He also noted that his nights were often restless and he had nightmares, which dated from his military service in Vietnam.

Frank put himself and others at risk by driving while intoxicated. That he was a risk to others was further indicated by having shot his wife when she startled him out of an uneasy sleep. The several drunken driving arrests are part of Frank's history of behavioral problems, and although not acknowledged as such they suggest alcohol abuse and/or dependence. The shooting of his wife is the current and acknowledged behavioral problem.

Substance Use and History of Behavioral Health Services

The family history, as told by Frank, included a sister who had emotional problems, a troubled marital history and heavy drinking and drug use. Although Frank reported that his father drank every day, and increased the amount after retirement, he claimed that his father had earned the privilege and was strong enough to "handle his liquor."(See genogram in Figure 1.)

Frank himself had a long drinking history, graduating from social drinking in high school to heavy drinking while serving in Vietnam. He reported daily drinking of about twelve bottles of beer a day along with a pint of hard liquor beginning with his release from military service. He admitted to regular blackouts, a fear of withdrawal symptoms if he did not drink each day, and shakiness in the morning until he spiked his coffee with alcohol. He had three arrests for drunken driving within the past ten years and was on probation for the most recent arrest when the shooting occurred. He also reported past marijuana use -- especially in Vietnam -- but quit because of his wife's objection. He had not previously been to treatment, put in jail, or had his driving license revoked -- receiving only probation and required to attend drunken driving school -- because his lawyer, who specialized in drunken driving offenses, argued that Frank earned his living as a truck driver.

Social Screening

Frank lived with his wife and 2-year-old twin daughters, but after the shooting he moved to a hotel -- in spite of his wife's desire that he stay in their home. Frank seemed detached from his daughters and reported that he was more comfortable on the road, where there was less noise and chaos. About his wife Fiona, he stated that he loved her and loved to look at her because she was so beautiful. It seems possible that he felt undeserving of her loyalty not just because of the shooting but also because her Korean parents disapproved of their marriage and would probably disapprove even more after the shooting.

Another schism in the family is that between Frank and his older sister. Frank stated that he was too angry to speak to her because of her drinking and drugging and neglect of her child -- Frank's nephew -- who "mostly" lived with Frank's parents, along with Frank's younger brother. Frank said he got along with his two younger siblings.

Frank's father and mother, Fred and Betty, had been married 37 years. Frank described his father as hard-working, strict and insistent on obedience to the law, so as to "…never give the White man any reason to notice them." Betty was a school teacher -- a source of pride to Fred -- and religious. According to Frank, she insisted that all of her children attend church and graduate from college -- so as to "keep out from under the White man." (I found no mention of whether church held any importance for Frank and his siblings or whether any of them graduated from college.)

Frank's current environment is bleak, away from home, alone, drinking, and watching television. There was no mention of recreational activities aside from drinking, which he did alone. Frank admitted to having no close friendships, other than with Fiona. He claimed that his wife and family were enough. (See eco-map of Figure 2.)

Finances could be a problem. Frank is paying a lawyer, not working and is paying to stay in a hotel. There must still be rent or house payments as well. He risks losing his job if he goes to jail.

Developmental, Medical and Health Screening

No information was available regarding birth or developmental milestones. Because of the heavy drinking history and possible health effects, the caseworker recommended and Frank agreed to a health examination. Of special concern was the possibility of liver or kidney damage.

Frank's experiences in combat while in Vietnam and their psychic effects are of pressing concern above and beyond a concern over alcohol dependence. The possibility that Frank has a posttraumatic stress disorder will be discussed in the diagnosis section of this paper.

DSM-IV TR Diagnosis

Axis I: 303.90 Alcohol dependence

309.81 Posttraumatic stress disorder, chronic

Axis II: None

Axis III: To be determined from results of health examination.

Axis IV: Family problems, little or no social support, potential economic problems and current problems with the legal system.

Axis V: 40 (current)

By his own admission, Frank meets the criteria required for a diagnosis of alcohol dependence on Axis I. He mentioned needing to take alcohol with his morning coffee to avoid withdrawal symptoms (Criterion 2); he tried but was unable to cut down on his consumption (Criterion 4); and claimed that he had drunk the same amount since Vietnam but has increased his consumption "quite a bit" after moving out of the house after the shooting. This increase sounds like a manifestation of tolerance (Criterion 1: a need for markedly increased amounts ... To achieve intoxication or desired effect). More problematic is Criterion 6: important social, occupational, or recreational activities are given up or reduced because of substance use. The problematic part is "because of substance use." Frank's limited participation in social and recreational activities could be as much or more due to posttraumatic stress disorder. The writer considered that Alcohol Induced Mood Disorder (293.83) might be another possible diagnosis on Axis I, but posttraumatic stress disorder (PTSD) seemed a better fit -- especially given the third session in which Frank told of his traumatic experiences in Vietnam. Frank meets all of the criteria for a diagnosis of PTSD: an initial trauma (A);re-experiencing the original trauma(s) through flashbacks or nightmares (B); avoidance of stimuli associated with the trauma and numbing of general responsiveness (C); increased arousal, as indicated by difficulty falling or staying asleep and exaggerated startle response (D); duration of Criteria B, C, and D. more than one month (E); and significant impairment in social and other important areas of functioning caused by the disorder (F) (American Psychiatric Association, 1994).

On Axis IV, family problems include guilt over shooting his wife, irritation with messy, noisy 2-year-old twin daughters, disapproval by wife's parents, and discord with older sister). After moving out, Frank lived alone with little if any social support. Job loss and incarceration are possibilities, as are future financial difficulties.

A GAF score of 55 could represent Frank's moderately adjusted functioning when not in a half-awake delusional state. His removal of himself from the home takes away some of the risk to his family, but he could conceivably harm himself or others if he brought his gun to the hotel where he currently lives by himself, drinking all day. The continued risk of harming himself or others suggests a GAF score of 25. Because of this duality of scores, the writer chose a value, 40, between the two.

ASAM/PPC-2R Scoring Criteria

With regard to his drinking, Frank appeared to be in the precontemplation stage of change through his first session with the caseworker. He seemed to move from precontemplation to contemplation at the end of the second session. That is, Frank appeared to be experiencing ambivalence about his alcohol use and even asked the caseworker for his opinion on the subject. Frank seemed to consider that there might be a problem and that change might be necessary. So, beginning treatment should be focus on emphasizing awareness and environmental reevaluation.

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 use material from the Royal College of Psychiatrists (n.d.) and Banarjee, Clancy & Crome (2002).

The goals for Frank are as follows.

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