Introduction: Presenting Problems
The client, Dante Williams, is a 56-year-old African American heroin addict diagnosed with bipolar disorder. Dante works as a mail carrier for the U. S. postal services. Although he has a son, he does not maintain any relationship with him, and his son does not try to communicate with Dante. The client’s father was a drug addict and died from an overdose fifteen years ago, while Dante’s siblings have substance abuse disorders. Dante’s elder brother and younger sister do not use drugs but consume strong alcohol. Among other relatives, the client has the closest relationships with his mother, and they communicate every week. Dante has received care for hypothyroidism and also has high blood pressure.
The client’s bipolar disorder is manifested through major depressive episodes that may last for several weeks and even months. The client had hypomanic episodes that lasted up to a week, but these episodes have not occurred lately. The client underwent detoxication procedures and received pharmacological treatment to address his addiction. He was recommended to undergo addiction psychotherapy to ensure his full recovery. Dante displayed readiness and willingness to participate in the counseling program, and he acknowledged the problem he had.
During counseling sessions, it was identified that the client was concerned about his current health conditions, which contributed to his depression. Dante’s relationships with his parents caused distress and psychological discomfort as well. His communication with his mother had mixed effects as it could cause certain emotional discomfort. First, the client did not address this aspect and was unwilling to talk about his son. Later, he acknowledged that his relationship with his son made him feel uncomfortable and contributed to the development of depressive symptoms. The client also reported vocational problems related to his psychological state.
Dante reported strong cravings for heroin twice during the therapy. Once, he failed to effectively address his cravings and used alcohol. He was proud he did not use heroin but consumed strong alcohol instead. The other time, he effectively avoided using any substance.
Short- and Long-Term Treatment Goals
Short-Term Treatment Goals
- dispose of drug-related items;
- identify the exact issues related to addiction;
- identify the particular triggers (events, ideas, emotions, and thoughts) leading to cravings for drugs;
- try new things;
- self-control strategies development.
Long-Term Treatment Goals
- end completely the client’s use of the substance (drugs or strong alcohol);
- restore and build positive relationships;
- self-control strategies development;
- commit to positive actions;
- form a positive life agenda.
Theoretical Framework and Specific Techniques
Substance abuse has been approached differently depending on the idea regarding the nature of addiction. Diverse models have been developed, ranging from biological to social learning theories (Cavaiola & Smith, 2020). Some models are based on the assumption that psychological traits shape people’s behaviors leading to the development of addiction. Other frameworks are rooted in the belief that social factors are instrumental in the formation of people’s behavioral patterns.
The present counseling process is guided by the attachment theory. This theoretical paradigm is associated with the focus on people’s relationships. Attachment is referred to as a behavioral and motivational system providing security to a child and regulating the distance of parents (Schindler, 2019). Children develop a feeling of security during early attachment experiences, which ensures the development of their own coping strategies when facing negative events and feelings.
Four attachment styles have been identified, including secure, anxious-avoidant, anxious resistant, and insecure attachment. These styles are formed during a person’s early childhood depending on their relationships with the primary caregiver (Cavaiola & Smith, 2020). When the caregiver displays predictable behavioral and emotional patterns, is available in diverse situations, and provides guidance and support, a secure attachment style in the offspring is developed. The child manages to develop healthy coping strategies that enable them to develop appropriate relationships (and attachments) in their adulthood. They can handle diverse situations autonomously without depending on others.
Insecure attachment is on the other end of the spectrum and is associated with dysfunctional emotional and behavioral patterns. Insecure attachment is believed to develop when the primary caregiver (usually the mother) is unable to satisfy the diverse needs of the child (Schindler, 2019). The mother’s reactions are often unpredictable or inadequate. In simple terms, the child wants to escape the caregiver (who does not satisfy their needs or hurts them) but cannot do it due to their complete dependence on the caregiver (Schindler, 2019). The person who develops insecure attachment tends to block traumatic experiences.
Numerous studies show that people with this attachment style are more likely to develop an addiction later in their lives as compared to people with other attachment styles (Schindler, 2019). Insecure attachment is associated with the use of the substance as a self-medication strategy.
This framework is the most appropriate theoretical model for the present case as the client has a family history of addiction and turbulent relationships with family members. During the first sessions of the counseling process, it became clear that Dante is likely to have an insecure attachment style. His father was a drug addict who died from an overdose. The boy had to live in a family characterized by unhealthy emotional and behavioral patterns displayed by its members. The fact that the siblings do not support close relationships serves as a justification of this assumption. Dante, as well as his siblings, tend to escape from the traumas of the past by avoiding communicating with each other and using the substance as a coping strategy. The client has no proper relationships with his own son, which is common for people having an insecure attachment style.
The use of this theoretical framework is instrumental in choosing the most appropriate treatment strategies. It is clear that the client needs to improve his relationships with his family and other people. Dante should acquire the skills necessary for the development of healthy relationships based on trust and autonomy. The client needs to develop effective coping strategies as well because his dissatisfaction and, as a result, cravings for drugs are to a considerable extent associated with his inability to interact with people, especially close ones.
Evidence-Based Practices Used to Address the Treatment Goals
Cognitive behavioral therapy (CBT) is a common practice used in counseling. It has also proved to be effective in treating substance addiction and bipolar disorder, as well as a combination of these two conditions (Cavaiola & Smith, 2020). This approach implies the discussion of thoughts, ideas, emotions, and attitudes to understand the client’s behaviors and the development of strategies to shape their behavioral patterns making them more appropriate.
However, due to the nature of the client’s psychological problem, the treatment was a combination of CBT and the elements of attachment-based family therapy (ABFT). The former encompasses sessions with family members that focused on relationships and ways to develop proper patterns (Diamond et al., 2016). Diamond et al. (2016) stress that the focus of ABFT is not on behaviors per se but on emotions and regaining trust. One of the major reasons for the issues arising in a family is the loss of trust (Schindler, 2019). Therefore, the therapist concentrates on helping family members to regain trust and create a positive emotional environment.
As far as particular tactics and techniques employed, psychoeducation, thought records, imagery-based exposure, and pleasant activity scheduling proved to be the most effective. Psychoeducation aimed at helping Dante to understand the nature of his cravings and peculiarities of psychological and emotional states he, as well as other substance users, may have (Secades-Álvarez & Fernández-Rodríguez, 2017). Dante noted that this knowledge helped him understand the exact mechanisms of addiction and its detrimental effects on his life. The client stressed that this understanding also helped him manage the cravings that still occurred.
Thought records facilitated the effect of psychoeducation. Dante proved to have an analytical mind and loved analyzing things. The analysis evolved from Dante’s contemplations on of his favorite movies. The client reported that he made numerous records that helped him cope with diverse situations. Imagery-based exposure encompasses the analysis of the scene associated with unpleasant memories. Dante described some unpleasant situations and provided detailed descriptions of the setting. He placed emphasis on smells and colors, which helped him in treating cravings and shaping his behaviors. Finally, the creation of schedules that included pleasant activities was also an effective tactic, although it was associated with certain challenges.
Progress Made and Challenges of the Case
As mentioned above, several tactics were used to help the client cope with cravings, improve his emotional state, and develop pro-active behavioral patterns. Dante made considerable progress as he stated he understood that drugs were an easy but deteriorating method to address problems with short-lived effects. The client also reported his interest in understanding himself and his responses better. He acknowledged the reasons for specific behavioral patterns and managed to develop effective strategies to avoid actions that would be harmful to him. Although Dante reported that he had cravings quite many times during that period, he managed to control them and remain sober.
As far as CBT techniques are concerned, some of the most notable challenges were associated with pleasant activity schedules. On the one hand, the client liked this activity and asked to do it. On the other hand, he tended to focus on things he could not do due to some objective or rather subjective reasons. At that, the client managed to develop schedules with pastimes that were eventually good for him.
One of the most challenging but quite rewarding components of the therapy was related to ABFT. The client had several sessions with his mother, and they achieved great progress in identifying some causes of the lack of trust between them. Those were quite emotionally loaded and effort-consuming discussions with blaming and tears. Although many things to discover and discuss remain, Dante and his mother learned how to address such sensitive aspects of their love and their relationship.
These sessions were instrumental in activating Dante’s inner resources to start developing relationships with his son. This proved to be an important aspect for the client, although he used to think that good families could not exist as people could only hurt each other. The man’s family life was an illustration and the cornerstone of his belief. The sessions with his mother helped Dante to understand some of the mistakes he made when treating his son. Importantly, the client understood that he placed a great value on his relationships with his son. The client understood that the absence of communication with his son is one of the reasons for his emotional issues.
The client had only three sessions with his son, but they contributed to Dante’s progress and growth. The first session was rather short and ended abruptly due to the two men’s unwillingness to really work and share. Although some activities to prepare Dante for the session involving his son were conducted, the client failed to cope with his emotional state and remain focused or utilize the tactics discussed during earlier sessions.
These mistakes were discussed during later sessions, which helped Dante be more functional during the second session with his son. The client was ready to accept some unpleasant facts and offer a new beginning to his son. Dante’s son reported that his family (his wife and two children) were the major stimuli to start communicating with his father. During the third session, Dante’s son was ready to consider further communication in the future.
As mentioned above, pleasant activities scheduling was characterized by certain difficulties as Dante tended to focus on why he could not engage in this or that activity. He often tried to concentrate on his financial limits, but it was inappropriate in the vast majority of cases as the suggested actions were affordable for him. His willingness to punish himself proved to be the primary obstacle to doing this activity properly. The discussion of this destructive attitude, along with other activities conducted during the sessions, helped the client build a positive agenda.
Conclusion
On balance, it is necessary to note that a combination of CBT and ABFT was used to help Dante Williams, a heroin addict with bipolar disorder. The client made considerable progress and managed to remain sober during the period of therapy. He is also determined to live a drug-free life in the future. The risk of his relapse exists, but the client is likely to be able to cope with the issues that may potentially lead to the use of drugs. Importantly, the client is ready to seek help, which was not the case before the treatment. Dante learned how to cope with cravings and build quite a clear picture of the nature of his addiction and coping strategies.
The client also improved significantly his relationships with his mother and his son. The lack of trust in these relationships caused a lot of distress for Dante. Hence, effective interactions with his mother and son resulted in the improvement of his emotional state as well. The client had communicated with his mother prior to the beginning of the therapy, but those interactions were not completely healthy. After the discussion and resolution of some of the most sensitive issues, Dante became closer with his mother, which helped him build relationships with his son. This case shows that addiction is often combined with psychological issues that are deeply rooted in clients’ family lives. This case is also another illustration of the effectiveness of the involvement of family members in therapy.
References
Cavaiola, A A., & Smith, M. (2020). A comprehensive guide to addiction theory and counseling techniques. Routledge.
Diamond, G., Russon, J., & Levy, S. (2016). Attachment-based family therapy: A review of the empirical support. Family Process, 55(3), 595-610. Web.
Schindler, A. (2019). Attachment and substance use disorders—Theoretical models, empirical evidence, and implications for treatment. Frontiers in Psychiatry, 10, 1-13. Web.
Secades-Álvarez, A., & Fernández-Rodríguez, C. (2017). Review of the efficacy of treatments for bipolar disorder and substance abuse. Revista De Psiquiatría Y Salud Mental (English Edition), 10(2), 113-124. Web.