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Addiction in itself can be complex and there are a lot of different types of addictive disorders, such as alcohol use disorder, opioid use disorder, stimulant use disorder and many more and the descriptions can be found along with the diagnostic criteria in the DSM-5 manual (Black & Grant, 2014). When you are treating someone who has an ongoing issue with addiction and there is the possibility that they are also dealing with more than one kind of substance use disorder along with the possibility of a mental health disorder it becomes more serious, and when this happens it is known as a comorbid disorder. Comorbid disorders are defined as multiple disorders that occur at the same time, such as two or more substance use disorders and mental health disorders all happening at the same time (Avery & Barnhill, 2018). The case which is being reviewed is that of David who is a thirty-nine-year-old man who was recently divorced and fired from his job for stealing money. In the initial interview with his therapist, it was discovered that he has been dealing with excessive drinking since he was a teenager which began to become worse as he got older because he also began using other substances as well. To have a better understanding of what led to David stealing money from his job and his addiction spiraling out of control it is important to complete a Biopsychosocial Assessment, complete a Risk Assessment, Diagnose David using the DSM-5 manual, create a harm reduction plan; and create a treatment plan which included two long-term and short-term goals, talk about the possible ethical issues which may arise, explain the etiology of co-morbid addiction and personality disorder, and explain the model of dual diagnosis as it pertains to David’s case.
David is a recently divorced thirty-nine-year-old man whose wife recently file for a divorce because he is unable to stop drinking and using drugs. In his initial interview with his therapist, he stated that he was only there because his ex-wife believes that he has a problem, but he believes she is the one with the problem. David’s ex-wife believes that he is an alcoholic I and when examining his past there is, in fact, a pattern of excessive drinking which began when he was a teenager. In his eyes, he believes that she just cannot see how amazing he is and that she should not have a problem with him continuing this behavior, and he also states that his parents were the only people who knew that he was special and what he was capable of and that he would be successful. He began drinking as a teenager and only did so on the weekends, but when he got to college he began drinking more. Among these things occurring in his teenage years, he also reports to having the feeling of not wanting to be alive but that nothing bad ever happened to him, so it wasn’t a big deal. He graduated from college with his degree in business and obtained a job at a bank as the assistant manager where he began to receive promotions quickly and he continued to drink while also beginning to use cocaine on a regular basis. During this period his drinking slowed down, but his cocaine use increased, and this is also around the time that he met his wife and they would party together. They were both twenty-nine-years-old when they met and David reported to his therapist that this was the best time of his life because his wife worshiped the ground that he walked on, and that all of his co-workers admired his for his work and that the amount of money he was making continued to increase as time passed. David becomes angry when expressing that after his ex-wife gave birth to their first child she no longer wanted to go out and party with him which did not bother him at first because she focused on their daughter and took care of all of her needs. He reports that nothing changed for him and that he even became friends with his drug dealer. Once their second child came along, they began to argue all the time and David did agree to stop drinking but blamed their fights for continuing and was even fired for showing up to work drunk. He quickly regained employment as his owns a pet store and made him the manager, and to David, this job was better because his friend did not care if he drank before work or even while he was on the job, and this is because as long as the job is completed that is all that matters. The feeling of not wanting to be alive resurfaced and drinking more did not help him to feel better so he began hanging out with his drug dealer more along with staying out for days at a time just to avoid fighting with his ex. David talks about how he couldn’t take it and that his ex is the one with all of the problems and he states that she was lucky to have him. Recently he was caught stealing from his job because he owed his drug dealer money, but that he was entitled to the money because he did a lot of extra work which he was never paid for, so he earned it. When you take into consideration all the factors leading up to David being sent to counseling you might conclude that he has a problem with drugs and alcohol, but therein another issue as well. David feels a sense of entitlement and that he is special, and that people should see that and understand, but what he is not taking into consideration is how his actions are affecting others. He has lost his wife, children and job yet he sees nothing wrong with the way he has been living his life and sees no reason to change his behavior.
A risk assessment helps to identify the issues with an individual’s behaviors which may be causing harm to themselves or others and/or has the potential to cause more harm to the individual and those who are close to them (Avery & Barnhill, 2018). In David’s case, he has been partying and drinking since he was a teenager and has never seen a problem with it as up until now there have been no severe consequences to his actions. He admitted to having thoughts of no longer wanting to be alive as a teenager and that these thoughts recently resurfaced due to all the issues he was having with his wife due to his drinking and partying. This is a serious risk factor that could lead to him making a bad decision, such as ending his life. Another problem is that he was caught stealing from his job because he owed his drug dealer money. It is unknown if the police were called but this is a serious risk factor as well because the issues in his life have escalated to being able to get in trouble with law enforcement. He has already hurt his wife and she has considered taking him to court to ensure that his access to their children is restricted. David is nothing of how his actions are affecting others because he believes that everyone else has the problem and that he is fine. He has harmed those who love him the most which are what led to him being asked to seek out counseling. Though nothing serious has happened there is a major risk that David will suffer from medical complications because of his alcohol and drug use along with legal consequences as his bad behavior is increasing. The risk associated with his behavior is high and it is important to ensure he can see not only what he is doing to himself but those who are closest to him as well.
David has been dealing with drinking alcohol since he was a teenager and though it started out as only two days a week it increased as he got older to an everyday occurrence and the amount, he was drinking increased as well. Aside from the drinking, he began using cocaine on a regular basis as well which also increased when he started going through issues with his wife because she no longer wanted to party when their first child was born. He has this belief that he is not the one with the problem because it is not his fault that no one can see how special and great he is. There is a lot going on with him and it is important to diagnose the issues he is having individually so that he can be treated properly to ensure that he is getting all of the help he needs so that his healing process can begin. According to the DSM-5 manual you must present with at least two of the symptoms within a 12-month time period to be diagnosed with alcohol use disorder (Black & Grant, 2014). Two of the items which are listed include alcohol often being taken in larger amounts along with over a longer period than was originally intended and alcohol use that is recurrent which results in a person failing to meet the obligations of their major role regarding their job, school, or home (Black & Grant, 2014). With the descriptions provided in the DSM-5, it can be determined that David does, in fact, have alcohol use disorder. David also uses cocaine which is a stimulant and in order to be diagnosed with stimulant use disorder an individual must present with at least two symptoms on the list in the DSM-5 manual, and two of the symptoms that are listed include the stimulant being taken in larger amounts along with over a longer period of time, and stimulant use that is persistent regardless of having consistent or repetitive social or inter-personal issues that were caused or exacerbated by the effects and/or use of the stimulant (Black & Grant, 2014). Being that David lost his wife and children due to being unable to stop partying and using stimulants it is can be determined that he also has stimulant use disorder. On top of losing these things, he was also fired from stealing fifteen hundred dollars from his job because he said that he owed his drug dealer money. The issues in David’s life seen to be escalating so it has been determined that he has stimulant use disorder as well. The last and final thing which seems to present an issue for David is that he has a belief that he is special and that he does not have a problem but that it is everyone else who has the problem. He feels he should be allowed to do what he wants and that people should understand and see how great he is. It seems as if David has a personality disorder and it is most likely that has Narcissistic Personality Disorder but in order to be diagnosed with this disorder according to the DSM-5 manual an individual must present with at least five of the items listed and many would have presented since early childhood (Black & Grant, 2014). A few of the items listed which pertain to David include having a grandiose belief of self-admiration (which means that he believes he should be recognized regardless of his achievements), an individual becomes preoccupied with a fantasy of brilliance of ideal love, has a belief that they are special and should only be around those who are of equal status, must be admired consistently, and feels as they are entitled to things and are not required to earn them (Black & Grant, 2014). David has exhibited many of these behaviors most of his life and the diagnosis of narcissistic personality disorder is accurate in his case. Now that David’s diagnosis has been completed a plan to reduce these types of behaviors must be put in place.
Harm Reduction Plan
Harm reduction plans can be implemented before treatment and can be found useful in helping to reduce harmful behaviors, such as drinking alcohol too frequently or abusing substances (Smith & Marshall, 2016). In David’s case there is behavior which needs to be focused on reducing and a plan put into place such as this:
- The client will see a physician to have tests ran to check his health and blood levels for any long-term damage that may have been caused.
- The client must find a job to pay back the money he stole and settle the debt in order to avoid legal trouble.
- The client will reserve drinking alcohol for the evening time once work hours have passed for a period of one month.
- Using cocaine will cut down to two days a week and obtaining from all drugs and alcohol while the children are around for a period of one month.
- The client will work on not being around the friend who also supplies him with cocaine and refrain from being around others who wish to partake in these activities.
- The client must continue to attend weekly counseling sessions and see a psychiatric doctor in case medication is recommended.
This is the plan that David will start with and in necessary it will be altered along the way. The main goal of this plan is to get his drug and alcohol use under control while trying to figure out what the best course of treatment will be for him.
David started off drinking alcohol at a young age and though it decreased at one point he picked up another habit which was stimulant use. Both his alcohol use disorder and stimulant use disorder increased when he was having issues with his wife and it has gotten to the point where treatment is necessary. One long-term goal of David’s treatment will be to eliminate his drug and alcohol use, and another would be to get his personality disorder under control. These goals will be vital to his continued success. A short-term goal is to get David to recognize that he has a problem not only with drugs and alcohol but with his personality and the way he thinks as well. The second short-term goal that is most important for David is to start minimizing his drug use with the implementation of the harm reduction plan. Once David has recognized the short and long-term goals of his program it will be suggested that he undergo a medical detox for the purpose of safety. Once he has completed the medical detox it will be recommended that he be signed into a thirty-day rehab program to get his drug and alcohol use under control with the hopes of eliminating it altogether. While in treatment he will see his therapist on a weekly basis and take part in group therapy sessions. The group in which he will participate in will contain others who also struggle with Narcissistic Personality disorder and ongoing drug abuse. Once his thirty-day treatment has completed he will be instructed to continue with his individual and group therapy sessions every week. There are however a few ethical issues that could arise during this process, and the main concern in David’s case would be confidentiality. It is the counselors' job to uphold confidentiality and look out for their client’s best interest, but on the other hand, there are limits to what can be said without a counselor having to report what was said to the proper authorities (NAADAC, 2016). David has admitted to breaking the law by stealing and continuing to do drugs which could put his counselor in a compromising position. The other issue when it comes to confidentiality, in this case, is that David has admitted to not wanting to live anymore which is a threat to his own life. This makes his counselor bound to report this to the proper authorities. This is where informed consent comes which is an important part of the treatment process as it ensures that the counselor is upholding their ethical duties an informing the client of the treatment process (NAADAC, 2016). In many cases like David’s where there is more than one addiction along with a personality what is not know that this is a common occurrence, and this is because the personality disorder often goes undiagnosed which can lead to other issues like substance use disorder (Avery & Barnhill, 2018). For David, it looks like he has had a personality disorder since childhood that has gone undiagnosed, and as a result, he lived believing that his thoughts were normal. The other issue is that the people around him did nothing about it until years later which has led to more use of drugs and alcohol on David’s part.
Treating those who deal with addiction can be difficult at times but when there is more than on addiction, as well as a personality disorder can pose challenges that can make treatment more difficult. Every individual is different which is why it is important to ensure proper diagnosis and treatment plan on an individual basis. David’s alcohol use disorder started at a young age and has progressively gotten worse as time passed to the point where he acquired another disorder which is believed to have been caused by his personality disorder never being diagnosed until now. The good thing is that he is still at an age where treatment can be helpful in improving the quality of his life and helping to resolve the issues which have been continuous over the last few years, such as being unable to keep a job due to his addictions and losing his marriage and kids. To gain an understanding on how to help David it was important to conduct Biopsychosocial Assessment, conduct a Risk Assessment, properly diagnose David with the use of the DSM-5 manual, come up with a harm reduction plan; and design a treatment plan which includes two long-term and short-term goals, discuss the possible ethical issues which could come about, talk about the etiology of co-morbid addiction and personality disorder, and explain the model of dual diagnosis in regard to David’s case. After reviewing these things understanding the development of David’s substance use disorders is easier to comprehend and this is because there was an underlying personality disorder that went undiagnosed. On top of the disorder going undiagnosed but the behaviors he was exhibiting were validated for so long that when his wife changed, he did not understand why. Co-morbid disorders are complex but when properly diagnosed can be treated.
- Avery, J. D., & Barnhill, J. W. (2018). Co-occurring Mental Illness and Substance Use Disorders: A Guide to Diagnosis and Treatment. Arlington, VA: American Psychiatric Association Publishing.
- Black, D. W., & Grant, J. E. (2014). DSM-5® Guidebook: The Essential Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Vol. Fifth edition). [Washington, DC]: American Psychiatric Association Publishing.
- NAADAC, the Association for Addiction Professionals (2016). NAADAC/NCC AP Code of Ethics. Alexandria, VA: NAADAC.
- Smith, C. B. R., & Marshall, Z. (2016). Critical Approaches to Harm Reduction: Conflict, Institutionalization, (de-)politicization, and Direct Action. New York: Nova Science Publishers, Inc.
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