Dbarclay_02-10-2024-Case Study Jeff

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CASE STUDY: JEFF 1 Case Study: Jeff Daniel Barclay School of Behavioral Sciences, Liberty University Author Note Daniel Barclay I have no known conflict of interest to disclose. Correspondence concerning this article should be addressed to Daniel Barclay Email: dsbarclay@liberty.edu

CASE STUDY: JEFF 2 Case Study: Jeff Client Concerns Symptoms Behavior Stressors Persistent Sadness Dismissive Inconsistent Work Schedule Alcohol Dependence Excessive Drinking Might Lose Job Avoidance Apathetic Family Problems/Divorce Recklessness/Apathy Social Partying Feeling Forced to Get Treatment Domestic Violence Suicidal Thinking (Jeff Case Study Data, 2024) Assessment Jeff is showing signs of excessive alcohol use and persistent sadness. While he stated that both of those have been present for most of his life, they seem to have been exacerbated by his divorce from his wife and subsequent estrangement from his children. Since Jeff seems to understand that he drinks excessively, an assessment for alcoholism is not necessarily required. However, something like the CAGE questionnaire, a brief screening tool consisting of four questions that assess problematic alcohol use could be beneficial. Each letter in "CAGE" corresponds to a question related to cutting down, annoyance by criticism, feeling guilty, and needing a drink in the morning. Some reports state that while this questionnaire is easily applied in clinical settings, it would be wise to utilize standardized diagnostic tools to determine a diagnosis (Dhalla & Kopec, 2007). The added benefit of this questionnaire could also help in generating conversation around Jeff’s annoyance regarding others telling him that he has a problem. Diagnostic Impression Jeff is exhibiting symptoms of severe Alcohol Use Disorder (AUD), the ICD-10 code of which is F10.20. The symptoms that Jeff is exhibiting that align with the diagnoses of severe

CASE STUDY: JEFF 3 AUD are persistent desire or unsuccessful efforts to cut down or control alcohol use; craving, or a strong desire or urge to use alcohol; recurrent alcohol use failing to fulfill major role obligations at work, school, or home; continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol; continued alcohol use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol; and tolerance, as defined by either needing more alcohol to achieve the desired effect or experiencing diminished effect with the same amount of alcohol (American Psychological Association, 2022). Additionally, his family has widespread alcohol use to the extent that one sibling has nothing to do with his family, and alcohol use disorder has a strong genetic component (Gupta et al., 2020). Signs and Symptoms DSM-5-TR Diagnostic Criteria: Severe Alcohol Use Disorder (F10.20) Client’s Signs/Reported Symptoms: Criterion A: Tolerance “…it takes more liquor for him to get drunk, about 4-6 shots more than 18 months ago.” Criterion B: Work Dysfunction “…if his alcohol consumption continues in this manner, they will not be able to employ him any longer.” Criterion C: Persistent Interpersonal Problems “She has recently threatened to get all visitation stopped if she finds out he has been drinking with the children in his care.” Criterion D: Alcohol-Worsened Depression “Even if the drinking's making me feel a little bit sad, those episodes come and go…” Criterion E: Unsuccessful Attempts to Stop “He briefly remained in treatment but ended up terminating when the counselors suggested he was an alcoholic.” Criterion F: Craving “This results in him leaving the site and immediately going to his hotel room to have a few beers before joining his coworkers…” (Jeff Case Study Data, 2024)

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CASE STUDY: JEFF 4 Other DSM-5-TR Conditions Considered Various diagnoses were considered while reviewing Amara's case, including mood disorders, eating disorders, and other cognitive disorders. The client reported some signs of social anxiety disorder such as increased concern with how others were perceiving her, but they did not appear to be distinct from her already present excessive worrying. The client also reported three symptoms associated with major depressive disorder (MDD) (insomnia, fatigue, and sadness), but since a minimum of six symptoms is required for a diagnosis of MDD, the diagnosis was ruled out. Additionally, panic disorder was contemplated; however, as the client did not exhibit any symptoms of panic disorder such as avoiding situations and events that trigger panic, it was dismissed as a potential diagnosis. Developmental Theories and/or Systemic Factors The Erikson Psychosocial Development Theory would describe the life stage that Amara is in as the final stage or “integrity vs. despair.” Integrity pertains to one’s understanding of self and life satisfaction whereas despair concerns one’s feelings of wasted opportunities and chances (Wong et al., 2021). A recent study on older populations in Switzerland found that the density of conflict in a family system and the extent to which an individual is the central connector of their family are directly correlated to that individual’s quality of life and health-related issues (Widmer et al., 2017). Given the existence of so much dysfunction in Amara’s family system, it is not surprising that she is experiencing so many feelings of worry and existential despair. As a result of the loss of her husband and her choice to retire, Amara appears to be experiencing anxiety that is related to her inability to move from a place of despair to a place of equilibrium

CASE STUDY: JEFF 5 and integrity, which is in turn contributing to increasingly more dysfunction in her family system. Ultimately, this results in even more feelings of worry, anxiety, and uselessness. Multicultural and/or Social Justice Considerations Asian Americans naturally experience life differently than many other groups in America, particularly in the ways that they develop and deal with mental pathologies. For example, caregivers for older adults in the Asian American community are typically older and experience poorer health compared to individuals who are not caregivers (Miyawaki et al., 2022). In the case of Amara, this has relevant implications regarding the caregiving role she has continued to play in her mother’s life amid an already tumultuous period. Although Amara did not explicitly discuss instances in her history of discrimination or marginalization linked to her religious identity, it is nonetheless still crucial to consider the potential adverse impacts of cultural bias or preconceptions on her mental well-being. Her cultural background could be a source of discrimination or microaggressions, contributing to underlying feelings of discomfort or distress. Treatment Recommendations Key Issues for Treatment  Persistent anxiety  Existential confusion  Dysfunctional family communication Recommendations for Individual Counseling

CASE STUDY: JEFF 6 One recommendation would be cognitive-behavioral therapy (CBT). CBT would be beneficial to Amara for several reasons. Firstly, cognitive behavioral therapy has the benefit of eliminating avoidant and safety-seeking behaviors (Nakao et al., 2021). Both safety-seeking and avoidance behaviors are symptoms of anxiety disorders like GAD (Petwal et al., 2023). CBT also frequently integrates mindfulness techniques to enhance individuals' awareness of the current moment. Mindfulness assists in observing thoughts without judgment, fostering a non- reactive and accepting approach to anxious thoughts and feelings. All these effects could be beneficial to Amara’s ability to resist excessive worry and rumination over imagined problems. Another type of therapy that could be helpful for Amara is existential therapy. Existential therapy is a philosophical and therapeutic approach rooted in existentialism, emphasizing a dynamic and concrete engagement with life's challenges, focusing on the inherent "givens" of human existence, such as death, freedom, isolation, and meaninglessness (Heidenreich et al., 2021). The existential approach in therapy promotes a collaborative exploration of life dilemmas, acknowledging the therapist and client as fellow travelers in the human experience. Amara could benefit from this therapy because it could help her process her feelings of uselessness and fears about her future. Additionally, taking a collaborative approach with elderly individuals helps them feel that they have a say in what happens to them. Ultimately, this collaborative approach to counseling will help Amara maintain a sense of dignity and control over what is happening to her, which is vital not only to aging individuals but also to their caregivers (Hung et al., 2023). Specific Considerations

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CASE STUDY: JEFF 7 Amara expressed her Hindu faith and indicated a desire to incorporate the principles of her religion into the counseling process, so that should be considered for more than one reason. One recent study discovered that engagement in religious activities provided older adults with a means to manage stress, strengthen support networks, and maintain cognitive activity (Hosseini et al, 2021). Integrating her Hindu religion into counseling sessions could provide her with comfort and guidance regarding her existential confusion. Additionally, there may be specific practices used by those in her religion that could assist her in dealing with many of these symptoms. Yoga, for example, is a practice that originated in India and is widely known for its potential to help in managing anxiety (Cramer et al., 2018). Medication Considerations Amara shared that she has been taking Paxil as prescribed by her doctor, but she has yet to feel any significant changes. She stated that she is aware that it may take time for the effects of the drugs to be noticeable. Ideally, Amara should follow through with this treatment until the effects of the drugs are either noticeable or the drug needs to be changed. However, Henssler and their colleagues (2019) reported in one study that it is best to gradually reduce the dosage of antidepressants like Paxil over a period exceeding four weeks if that time should arise so that negative side effects can be avoided. Another option for Amara would be a class of drugs called benzodiazepines. Benzodiazepines such as alprazolam are effective in clients suffering from generalized anxiety disorder (Bounds & Nelson, 2023). Benzodiazepines are also widely used for those suffering from sleep issues and have the added benefit of muscle relaxation, all of which Amara is dealing

CASE STUDY: JEFF 8 with. However, they do have the potential to become addictive, so it is typically advised to use the minimal effective dose necessary when utilizing them for that reason. Unique Client Considerations The role of cultural background is important in this case. Primarily because those who come from Asian cultures often feel a larger obligation to care for their older parents (Miyawaki et al., 2022). Amara could somewhat be expecting this felt sense of obligation from her children who could quite possibly not share that cultural sentiment. It would be wise to gather additional information from her regarding which traditional values typically found in Asian cultures she feels connected to so that they can be addressed and implemented into the sessions with her counselor. As a Christian, I may not see eye to eye with her Hindu-based belief system. Extra effort should be made on my part to learn about this religion which I may not know enough about to integrate into counseling sessions with her. Additionally, supervision and talking with peers may assist me in dealing with the differences in both age and cultural background.

CASE STUDY: JEFF 9 References American Psychiatric Association. (2022). Anxiety Disorders. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787.x05_Anxiety_Disorders Dhalla, S., & Kopec, J. A. (2007). The Cage Questionnaire for Alcohol Misuse: A Review of reliability and validity studies. Clinical & Investigative Medicine, 30(1), 33. https://doi.org/10.25011/cim.v30i1.447 Gupta, I., Dandavate, R., Gupta, P., Agarwal, V., & Kapoor, M. (2020). Recent advances in genetic studies of Alcohol Use Disorders. Current Genetic Medicine Reports, 8(2), 27– 34. https://doi.org/10.1007/s40142-020-00185-9 Wong, D., Hall, K. R., & Hernandez, L. W. (2021). Counseling individuals through the lifespan . SAGE.

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