Discussion

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Of the substance disorders, alcohol-related disorders are the most prevalent even though only a small percentage of individuals actually receive help. Recidivism in the substance treatment world is also very high. As research into treatment has developed, more and more evidence shows that genes for alcohol-metabolizing enzymes can vary by genetic inheritance. Women have been identified as particularly vulnerable to the impacts of alcohol. Native Americans, Asians, and some Hispanic and Celtic cultures also have increased vulnerability to alcohol misuse.

Even with these developments, treatment continues to spark debate. For many years, the substance use field itself has disagreed with mental health experts as to what treatments are the most effective for substance use disorders and how to improve outcomes. The debate is often over medication-assisted treatment (MAT) versus abstinence-based treatment (ABT). Recently the American Psychiatric Association has issued guidelines to help clinicians consider integrated solutions for those suffering with these disorders. In this Discussion, you consider your treatment plan for an individual with a substance use disorder.

To prepare: Read the case provided by your instructor for this week’s Discussion and the materials for the week. Then assume that you are meeting with the client as the social worker who recorded this case.

Post a 300- to 500-word response in which you address the following:

  • Provide the full DSM-5 diagnosis for the client. Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, and the Z codes (other conditions that may need clinical attention). Keep in mind a diagnosis covers the most recent 12 months.
  • Explain the diagnosis by matching the symptoms identified in the case to the specific criteria for the diagnosis.
  • Describe the assessment(s) you would use to validate the client’s diagnosis, clarify missing information, or track her progress.
  • Summarize how you would explain the diagnosis to the client.
  • Explain how you would engage the client in treatment, identifying potential cultural considerations related to substance use.
  • Describe your initial recommendations for the client’s treatment and explain why you would recommend MAT or ABT.
  • Identify specific resources to which you would refer the client. Explain why you would recommend these resources based on the client’s diagnosis and other identity characteristics (e.g., age, sex, gender, sexual orientation, class, ethnicity, religion, etc.).
Note: You do not need to include an APA reference to the DSM-5 in your response. However, your response should clearly be informed by the DSM-5, demonstrating an understanding of the risks and benefits of treatment to the client. You do need to include an APA reference for the assessment tool and any other resources you use to support your response.

Case of Jordan

Intake: June 2020

IDENTIFYING/DEMOGRAPHIC DATA:

Jordan (31) and Sheri (28) are a married Caucasian couple who live with their sons, Myles (10) and Levi (8), in a two-bedroom condominium in a middle-class neighborhood. Sheri has recently found out that she is pregnant with their third child. Jordan is an Iraq War veteran and employed as a human resources assistant for the military. Sheri is a special education teacher in a local elementary school.

CHIEF COMPLAINT/PRESENTING PROBLEM:

Jordan stated that he came to the VA for services only because his wife had threatened to leave him if he did not get help. Sheri was particularly concerned about his drinking and lack of involvement in his sons’ lives.

HISTORY OF PRESENT ILLNESS:

Jordan said that since his return to civilian life 10 months ago he had experienced difficulty sleeping, heart palpitations, and moodiness. He described being proud to join the army and deployed and described himself as upbeat and happy prior to his deployments. He felt that he had to “change” to stay alive there. Jordan continued that he and his wife had been fighting a lot and that he drank to take the edge off and to help him sleep, saying, "Nights are the hardest." Jordan noted that just keeping his intrusive thoughts at bay took all the energy he could muster. Jack noted that loud noises, open spaces, and green lights triggered intrusive memories.  He said he was exhausted from being always alert and looking for potential problems around him. He told me he always felt on edge and every sound seemed to startle him when he was not drinking. He shared that he often thinks about what happened “over there” but tries to push it out of his mind. The night is the worst time for Jordan, as he has terrible recurring nightmares of one particular event. He said he wakes up shaking and sweating most nights.

PAST PSYCHIATRIC HISTORY:

Jordan does not report any significant previous medical history.

SUBSTANCE USE HISTORY:

As a teenager, Jordan used marijuana and drank. He does not use marijuana now but still drinks.  Jordan admitted to drinking heavily nearly every day, drinking four to five drinks in the evenings during the week and eight to ten drinks on Saturdays and Sundays.  Sheri told Jordan his drinking had gotten out of control and was making him mean and distant.

PAST MEDICAL HISTORY:

Jordan is physically fit, but an injury he sustained in combat sometimes limits his ability to use his left hand.  Jordan had previously visited his primary care physician, Dr. Zoe, where he was given a prescription of Paxil to help reduce his symptoms of anxiety and depression. Dr. Zoe recommended that he get ongoing treatment.

FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC:

Jordan and Sheri identify as being Jewish and attend a local synagogue on major holidays. Jordan’s parents are deceased, and he has a sister who lives outside London. He and his sister are not very close but do talk twice a year. Sheri is an only child, and her mother lives in the area but offers little support. Her mother never approved of Sheri marrying Jordan and thinks Sheri needs to deal with their problems on her own. The couple has some friends, but due to Jordan’s recent behaviors, they have slowly isolated themselves.

CURRENT FAMILY ISSUES AND DYNAMICS (OPTIONAL):

Jordan reported that he was not engaged with his sons at all and he kept to himself when he was at home. He gave some examples of having a “hair-trigger temper” with his sons, especially if they surprised him inadvertently.  Jordan spent his evenings on the couch drinking beer and watching TV or playing video games.  Jordan’s expressed fear of losing his job and his family if he did not get help.

Jordan worked in an office with civilians and military personnel and mostly got along with people in the office. Jordan tended to keep to himself and said he sometimes felt pressured to be more communicative and social. He was also very worried that Sheri would leave him. He said he had never seen her so angry before and saw she was at her limit with him and his behaviors.

Sheri talked about wanting to be able to communicate with Jordan without feeling that she was “nagging him” or fearful that she was making him withdraw and that she would “trigger his anger.” She said that she avoided asking him things or talking to him for fear it would “set him off” and make him retreat to the basement on his own.

MENTAL STATUS EXAM:

Jordan was well-groomed but appeared somewhat guarded and anxious. He was coherent and articulate. Speech was at a normal rate, although the pace was noted to accelerate when he approached or discussed disturbing content. He denied depression but admitted anxiety and hyperarousal in situations, such as when strangers stand close to him in check-out lines. His affect was somewhat constricted but appropriate to content. His thought process was coherent and linear. He denied all suicidal and homicidal ideations but admitted that if startled “not much thought happens” between the event and his aggression responses. He had no psychotic symptoms, delusions, or hallucinations. He had reasonable insight, was well oriented, and seemed to have average intelligence.

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