Treatment Plan for Hypothetical Patient Vera: Addiction & Depression

Introduction: Vera's Presenting Concerns and Background

Vera is an individual in crisis. Although it is likely that she was predisposed to both addiction and depression through genetic inheritance — as both conditions are present in her immediate family — a number of environmental stimuli have exacerbated her underlying vulnerabilities. Several critical life events acted upon Vera at crucial developmental stages, ultimately resulting in the maladaptive psychopathology present at the time of her interview. These events include her parents' divorce, the development of an abusive relationship with her biological father, numerous dangerous and maladaptive behaviors, suicidal ideations, and substance abuse.

Within this client's history is perhaps the most concise illustration of the interaction between genetics and environment. Had the divorce and the subsequent harsh treatment by her father never occurred, it is possible that Vera might never have experienced depressive symptoms or turned to compulsive behaviors — such as substance abuse, self-harm, and compulsive shopping — to alleviate those symptoms. Similarly, had Vera's mother been less supportive or had the relationship with her stepfather been more strained, one of her intentional overdoses might have successfully ended her life, and she likely would not have been placed in therapy or completed either of the two rehabilitation programs she attended.

The reason for Vera's current interview is her addiction and increasing struggles with depression. Her drug use — which includes regular use of marijuana, cocaine, Percocet, and more recently Ativan and Xanax — has become extremely expensive, costing more than $700 per month, and is a constant source of anxiety and worry. Vera indicates that she thinks about her next drug use constantly and feels she is dependent on these substances. She also describes the sensation that her life is spiraling downward. Although she previously experienced suicidal ideations, she reports not having experienced them in the past year.

Beyond the symptoms related to her drug use, Vera experiences panic attacks, cries frequently, and sleeps more than normal as a means of escaping her symptoms. She has been hospitalized three times for intentional overdose. She is quite impulsive, which often results in feelings of guilt; she has chronically low self-esteem and often worries that others are talking about her. She has lost interest in things she used to enjoy and is largely unmotivated and sad. Despite these challenges, Vera was able to graduate with a bachelor's degree in psychology, though she is currently unemployed.

Family History and Differential Diagnosis

In the past, Vera has been diagnosed with borderline personality disorder. A more appropriate diagnosis would appear to be borderline personality disorder with a modifier of discouraged or self-destructive subtype, as her depressive, dependent, and masochistic features are quite prominent. Vera's immediate family provides important insight into her differential diagnosis, since the incidence of related disorders within first-degree family members greatly increases her likelihood of developing those disorders or related ones.

Vera's maternal grandparents both experienced depressive symptoms and may have had major depressive disorder, which significantly increases her own risk of experiencing depressive episodes. Her father had substance abuse problems with alcohol and impulse control issues that manifested primarily in uncontrollable outbursts of anger. Although limited information is available about the specifics of his condition, it is possible that he also suffers from borderline personality disorder.

The presence of this family history of related psychological disorders indicates that beyond simple intervention and talking strategies, Vera will likely require a pharmacological regimen to support her therapy. One troubling aspect of this case, however, is that Vera has been in professional treatment for four years and has participated in two rehabilitation programs, one of which was residential. Although she apparently likes her current therapist, her inability to identify what they are specifically working on is problematic. No information is provided regarding the medication she is currently taking, which may complicate the development of any new treatment plan. Working on the assumption that such records will be forthcoming, it will be important to establish a mutually agreed-upon treatment plan with clear goals and strategies.

The Role and Responsibilities of a Counselor

It is important at the outset of therapy to clearly establish goals and effective strategies to achieve them. When an individual knows what they are working toward — and that end goal is one they believe will help them lead a more effective and rewarding life — developing a useful therapeutic relationship becomes considerably more straightforward. In the first meeting, it is important to establish the groundwork for that developing relationship by clearly defining behavioral protocols and allowing the client to articulate what they expect from the counselor. Providing a comfortable space is essential, but so is offering a set of rules and guidelines that are consistently observed. A sense of stability in which achievement is possible and goals are clearly defined is often extremely useful in establishing a successful therapeutic regimen.

Counseling is a venue for professionally guided self-improvement. It is useful most immediately when maladaptive behaviors or identified disorders are present, but it would benefit most individuals. Counseling provides a consistent, safe space free of judgment where a person can focus on internal development and growth — a time and place where the many influential forces, expectations, and commitments of the outside world can be set aside, deconstructed, and examined. A plan to navigate them more successfully, or to remove them from a person's life entirely, can then be developed. Counseling is one of the few situations in which an individual can be completely vulnerable without fear or hesitation.

In large part, the relative efficacy of treatment depends on the counselor. A counselor must make their client comfortable while remaining professional, providing a venue for complete honesty without fostering unhealthy dependence. Most simply defined, it is the role of a counselor to help an individual develop a more adaptive state of mind encompassing thoughts, feelings, and motivations. There are a great number of therapeutic strategies, and different counselors adopt the approach or approaches they believe will best meet their client's needs. Although some counselors specialize in a specific technique, an evolving and adaptable style of counseling is likely to be most effective, since each client responds differently to different methods.

The position of a counselor is a perpetual balancing act. At all times, they must balance comfortable, easy interaction with the awareness that their client is someone who came to them for professional assistance. While many counselors turn first to medication — an effective but sometimes oversimplified solution — this approach alone addresses symptoms rather than root causes. Combined therapies incorporating cognitive behavioral therapy alongside medication, when appropriate, are essential for a client to make effective and lasting changes.

The relationship between a counselor and their client must be beneficial and safe above all else. If either party begins to feel the relationship is no longer helpful, or feels threatened in any way, the relationship must be terminated. Treatment should never be denied based on race, creed, religious belief, sexual orientation, or previous criminal history. The letter and spirit of confidentiality laws must be adhered to, and clients must be able to trust that information disclosed in therapy will not be used against them — with the explicit exceptions of a court-ordered subpoena or expressed intent to harm themselves or others. These exceptions must be made clear at the onset of treatment, presented not as a threat but as part of the counselor's legal and ethical obligation to fully inform the client of their rights before any private information is disclosed.

A therapeutic relationship must be professional, yet the nature of the profession means it will become highly intimate. It is very important not to become personally involved with the client beyond appropriate professional boundaries. Romantic involvement or personal friendship with a client is inappropriate, as the power dynamic within the relationship is heavily skewed in favor of the counselor. Ultimately, a counselor functions as a catalyst for change — and it is a primary tenet of psychotherapy that a counselor cannot affect change unless the individual desires to change themselves.