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Jane Smith is a 35-year-old white woman living in Providence, Rhode Island. She was born in a middle-class family and received a university degree in law. Currently, Mrs. Smith is a lawyer working for an advertising company. She is married to Paul Smith, a financial analyst. The couple lives in a suburb with their six-year-old daughter Michelle. Their total annual household income exceeds 100,000 USD, which makes the Smiths an upper-middle-class family.
Mrs. Smith is a supporter of the Democratic Party like most people in her family and among her friends and colleagues. She is interested in the life of her community. For example, she participates in events organized by local schools and community centers. Occasionally, Mrs. Smith volunteers for local community programs. Her parents live in the next neighborhood. She visits them with her husband and daughter regularly. Mrs. Smith’s two siblings often join the meetings. Spending time with her family is very important to Mrs. Smith. About twice a month, she also dedicates a night out to her college friends, with whom she is still close. Mrs. Smith identifies herself as Christian, although she does not go to church regularly. Neither do the members of her family.
Mrs. Smith decided to see a psychologist because she became worried that she was developing an alcohol addiction. During her first visit, Mrs. Smith explained why she thought so. Since college, she had been a social drinker, but drinking had never been an issue. Within six months before the visit, however, she noticed that it had been hard for her to unwind after a hard day at work without a few glasses of wine or a few whiskeys. Mrs. Smith started drinking almost every day.
Other “bad signs” that Mrs. Smith recognized was that she had started drinking strong drinks like vodka and tequila more often than previously, was getting grave hangovers, which had not happened before, had skipped several business meetings because she was drinking at the time they were scheduled, and had trouble controlling her behavior and emotions during intoxication. Mrs. Smith also confessed to having felt “something like withdrawal” on those days when she did not drink.
The particular incident that made Mrs. Smith seek psychological help occurred a few days before her visit. She came home from a drinking party. Her daughter was not asleep yet. Without talking to her mother, Michelle came up to Mr. Smith and asked, “Daddy, is mommy drunk again?” Mrs. Smith said that it had been very hurtful and humiliating to hear such words from her six-year-old child.
After describing her concerns, Mrs. Smith was asked what goals she wanted to achieve in the course of her treatment. From the very beginning, the client pronounced that she did not want to quit drinking altogether because that would be, according to her, “a little bit too extreme.” She said she wanted to be “a normal person” who can drink occasionally without feeling addicted. Thus, she defined her primary goals of treatment as reducing the desire to drink and reducing the amount of consumed alcohol.
Mrs. Smith explained that these two goals might be interconnected, but was, in fact, separate. The first goal, to reduce the desire to drink, is seen by the client as a necessity because, within six months, she has experienced a strong urge to drink almost every day, especially in the afternoon and in the evening. Mrs. Smith said during her visit, “I don’t want to want to drink that often.” The second goal, reducing the amount of consumed alcohol, refers to cases where Mrs. Smith does drink, e.g. at a social event. She has been feeling that, once she starts drinking, it is hard for her to stop until she is very drunk or until she goes to sleep.
So she wants to change it. She wants to be able to have one or two glasses of wine at a party and then “do fine without a drink for the rest of the night.” Again, Mrs. Smith emphasized that the goal is not achieved if she has to make herself refrain from drinking, i.e. if it feels like abstinence. Rather, she wants to attain a psychological state where having just a drink or two for the whole night would feel enough, and drinking more would not be desired.
Relevant Theoretical Constructs
There are many psychological theories on the causes of alcohol consumption and addiction. Within the range of concepts associated with alcoholism, researchers usually distinguish alcohol dependence from alcohol abuse. The former refers to psychological addiction, while the latter is associated with physical addiction (Johnson, 2011). Nowadays, however, both concepts are included in the diagnosis of alcohol use disorder.
There is no absolute agreement among researchers on what the causes of alcohol use disorder are. However, it is recognized that, like any addiction, alcohol addiction can be regarded as a symptom, not as a unitary disorder (West & Brown, 2013). This perspective emphasizes that the negative effects of alcohol abuse can be eliminated if treatment focuses on the causes of addiction.
When asked about her perception of the causes of her alcohol use disorder, Mrs. Smith said that she attributed it to the increasing amount of stressful situations at work. According to her, she had not had family-related or other issues that could have caused alcohol abuse. But when she started feeling that her job was becoming less and less fulfilling for her and caused more and more stress, she began to look for relaxation in alcohol.
The fact that stress increases alcohol consumption has been confirmed by scientific studies (Becker, Lopez, & Doremus-Fitzwater, 2011). However, another important theoretical aspect to be identified in this case is whether or not Mrs. Smith can return to “normal,” i.e. controlled drinking after her treatment. While some theories suggest that alcoholism is a chronic disease that causes brain changes and requires constant abstinence as part of the treatment, other theories, including psychoanalytical ones, consider alcohol abuse to be a purely psychological illness that can be cured, allowing a client to go back to controlled drinking (Johnson, 2011). Since Mrs. Smith had never complained about serious stress-induced difficulties before, her case can be regarded as an early-stage development.
The type of psychological intervention strategy that was chosen for Mrs. Smith is Motivational Interviewing (MI). It has been proven to be particularly effective in alcohol abuse treatment (Smedslund et al., 2011). Compared to other approaches to counseling, MI is more goal-centered. It means that, in a conversation with a counselor, a client needs to identify desired behavior changes, set goals, and come up with ways to achieve them. MI is a brief intervention that normally lasts 1 to 4 sessions. One of its specific characteristics is that the counselor is directive.
Four essential processes of MI are engaging, identifying, eliciting, and planning. It means that, first of all, a certain degree of trust and mutual understanding should be established between a client and a counselor. Then, particular actions or behavior aspects should be identified that the client wants to change. After that, the counselor should elicit the client’s motivation by stressing the positive effects of the implementation of proposed changes. Finally, the client and the counselor plan the ways, approaches, strategies, and particular objectives that will help achieve the goals.
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Research shows that, for substance abuse cases, including alcohol use disorder, MI is more effective than no intervention (Smedslund et al., 2011). It is particularly relevant to Mrs. Smith’s case because from the very beginning she defined the goals she wanted to achieve in the course of her treatment and expressed her preference to work with the psychologist on a goal-oriented basis.
The characteristics of Mrs. Smith’s alcohol use appear to present no obstacles or objections to the use of MI.
Besides the personal and individual characteristics of a client, cultural aspects should also be considered in counseling. Exploring the cultural background of a client can help obtain a better understanding of his or her issues and improve the strategies of psychological help. It is better to discuss the cultural aspects of a client before the intervention.
Mrs. Smith was offered to reflect on her background and environment from the perspective of her alcohol abuse and future treatment. She concluded that, in her upper-middle-class circles, being an alcoholic is embarrassing. She said, “In my world, alcoholism is a shame.” At the same time, she stressed that social life in those circles is strongly linked to drinking because alcohol is present at the majority of social events Mrs. Smith attends. That is why she did not want to quit drinking, which would mean that she is an alcoholic, but wanted to drink in a controlled manner, which is socially acceptable and even encouraged in her community.
This cultural consideration is important because it can affect the initially set goals. There is a possibility that, due to the fear of being stigmatized as an alcoholic, Mrs. Smith is afraid to explore her alcohol use issues profoundly and refuses to accept the seriousness of these issues. Analysis of cultural background also allows concluding that, for Mrs. Smith, alcohol consumption is a means of fitting in. It is an important consideration for further counseling.
Use of Technology
The treatment can be significantly improved through the use of technologies. First of all, the communication with the client can be expanded and reinforced. Mrs. Smith’s goals to change her behavior may require everyday commitment and constant modification of habits and routine practices. In case it is decided during sessions that Mrs. Smith needs extensive consultation from the counselor on different day-to-day issues and activities, she may ask to be able to contact the counselor outside of sessions. This is where modern tools of communication, like instant messaging services or email, can be helpful. However, Mrs. Smith mustn’t develop the need to consult the counselor on every decision she has to make. This issue should also be discussed during a session.
Another advantage of the use of technology is that it facilitates safer and more efficient storage and organization of the client’s personal and confidential information. However, the balance about the use of technology should be maintained. Face-to-face communication should not be sacrificed to technological aspects of counseling.
Becker, H. C., Lopez, M. F., & Doremus-Fitzwater, T. L. (2011). Effects of stress on alcohol drinking: a review of animal studies. Psychopharmacology, 218(1), 131-156.
Johnson, B. (2011). Psychoanalytic treatment of psychological addiction to alcohol (alcohol abuse). Frontiers in Psychology, 2(1), 362.
Smedslund, G., Berg, R. C., Hammerstrøm, K. T., Steiro, A., Leiknes, K. A., Dahl, H. M., & Karlsen, K. (2011). Motivational interviewing for substance abuse. Campbell Systematic Reviews, 2011(6), 1-126.
West, R., & Brown, J. (2013). Theory of addiction. Hoboken, NJ: John Wiley & Sons.