Case Study: PTSD and Alcohol Dependence Treatment Plan

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 and 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 had startled him out of sleep and he reacted as though responding to a threat. Frank did not see his alcohol use as relevant to his current situation. In fact, it was the first caseworker's early inquiries about alcohol use that alienated Frank and prompted the referral to the second caseworker.

Emotional, Behavioral, and Mental Status

When the caseworker of record first met Frank, he saw a tall, thin man who seemed worn, tired, and older than his 33 years. In conversation, Frank was reserved and polite but came out of his shell when complimented on his cowboy boots, which were noticeably elegant in comparison with his otherwise 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 that he experienced nightmares dating 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 his having shot his wife when she startled him out of an uneasy sleep. His several drunken driving arrests form part of a history of behavioral problems and, although not acknowledged as such by Frank, they suggest alcohol abuse and/or dependence. The shooting of his wife is the current and acknowledged presenting problem.

Substance Use and Psychosocial History

Frank's family history included a sister with 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."

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 approximately twelve bottles of beer 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 morning shakiness that he addressed by adding alcohol to his coffee. 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, been jailed, or had his driver's license revoked — receiving only probation and mandatory attendance at drunken driving school — because his attorney, who specialized in drunken driving offenses, argued that Frank earned his living as a truck driver.

Frank lived with his wife and 2-year-old twin daughters, but after the shooting he moved to a hotel, despite his wife's desire that he remain 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 likely disapprove even more after the shooting.

Another schism in the family existed between Frank and his older sister. Frank stated that he was too angry to speak to her because of her drinking, drug use, 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 parents 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." His mother was a schoolteacher — a source of pride in the family — and deeply 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."

Frank's current environment was bleak: alone in a hotel room, 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, claiming that his wife and family were enough.

Finances posed a potential problem as well. Frank was paying a lawyer, not working, and paying to stay in a hotel, while house payments or rent still had to be met. He also risked losing his job if incarcerated.

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

Frank's experiences in combat in Vietnam and their psychological effects are of pressing concern, above and beyond the concern over alcohol dependence. The possibility that Frank has posttraumatic stress disorder is addressed in the diagnosis section below.