This case study took place at an Alcohol and Addiction Counselling Practice. This service offers people with drug or alcohol related problems an opportunity to increase their quality of life by: providing advice and information, one-to-one counselling, a gender specific alcohol and drug user group, a support group for people who have stopped drinking or using drugs and a family and friends support group.
The first interview with Claire took place in October 2000. Her psychiatrist referred Claire to our practice. His first contact with Claire was in August of the same year. She was referred to him by a hospital that had treated her for an attempted suicide. Although the psychiatrist is treating Claire for severe depression it has become apparent to him that she has a problem with alcohol. She is 30 years old and was divorced two years ago. She has no children. There is no partner in her life now or since her divorce and she lives in a rented one bed roomed house. She is unemployed and is currently in receipt of Income Support. Claire has requested a counselling programme that will help her to abstain from alcohol. She has not drunk any alcohol for two weeks prior to her appointment at this service, but she is on prescribed medication: tranquillisers and anti-depressants for depression.
The main objective of this interview is to gather information in order to assess which of our services will best benefit Claire to aid her with abstinence from alcohol. At the beginning of the interview it was explained to Claire that anything she told me would be confidential unless she disclosed anything that I felt was harmful to herself or to anyone else. It was then explained that in order to assess her situation, details of her background would be needed. info
Claire was born in 1970 and has two brothers, one older and one younger. Her father was a lieutenant commander in the navy until Claire was eighteen years old. As a consequence of his naval career he was on occasions drafted to sea for durations of one and a half years. Claire loved her father and had a good relationship with him until he became aware of her alcohol abuse. Her relationship with her mother is strained and as a child Claire was very fearful of her and felt that she emotionally neglected her. This was not the case with her brothers and from an early age Claire came to the conclusion that her mother loved her brothers but not herself. She has never been able to sustain any real friendships with her peers and as a teenage Claire was three stone overweight.
At the age of seventeen Claire became involved with a group who abused drugs. Her drug intake eventually progressed from smoking cannabis to taking speed orally. Eventually at the age of nineteen Claire was experiencing physical and psychological withdrawal symptoms as a result of drug abuse. During this time she was employed as a Civil Servant and had a demanding job as personal assistant. Claire's parents did become aware of her drug abuse but she feels that due to their inability to cope with the situation they chose to ignore it. Claire eventually decided to disconnect herself from her 'drug' acquaintances and immediately started to abuse alcohol. She said that the alcohol was better than the drugs as it enabled her in social situations to feel less inhibited and shy.
For a few years Claire's alcohol consumption was confined to weekends when she would get very drunk. During the week she would feel very low and depressed. After a serious relationship had ended and resulted in Claire seeking an abortion she felt that her drinking had crossed over some imaginary line. Claire had no counselling before or after her abortion and as a Catholic she suffered deep feelings of guilt and felt that she had committed a murder. She hide this feelings from her parents and felt that it was then that she commenced to use alcohol to kill pain and emotions that she felt unable to deal with. Approximately a year after this abortion Claire was admitted to a psychiatric hospital suffering from a nervous breakdown. This was her first experience of being prescribed tranquillisers and anti-depressants. Other than prescribed medication no other psychiatric help was given to her. On her discharge from the hospital Claire then mixed the tranquillisers and alcohol to alleviate her depression and her ongoing negative feelings and emotions. info
Claire married her ex-husband in 1995. She described him as a cold and unemotional man. During her marriage to him Claire spent three more periods in a mental institution having been diagnosed with depression. She was still at this time abusing alcohol. Claire eventually divorced her husband and moved to Twickenham in 1998. Within two weeks of moving, Claire was admitted to an alcohol treatment centre and was treated for alcoholism and not depression. On her discharge from hospital Claire was given an appointment to see the psychiatrist who is treating her for depression. This is the first time Claire has had weekly sessions with a psychiatrist and she had talked at length with him about her alcohol dependency.
Her family live in the south of England and she has no contact with them. It is apparent that Claire is seen as a social outcast as her family and her friends have shunned her. Claire is a bout drinker which means that she will drink for weeks, months and then will not touch any alcohol for one or two months. Due to a social phobia Claire feels very isolated and alone. Her day-to-day routine, when she is not drinking never varies as she will spend most of her day indoors cooking, cleaning or reading. She tries to avoid people as much as possible as this causes her tremendous anxiety.
Although Claire knows that for a number of years she has had problems with alcohol the medical profession has seen this as secondary to her diagnosis of depression and she has not been offered any medical help for her alcohol dependency. However, Claire did say that she was never entirely open or discursive about just how much she was drinking due to self-disgust and the condemnation of her family, friends and society. info
Societal attitudes to drunkenness in women tend to be markedly different from drunkenness in men. According to Ettore (1997) society views women with alcohol related problems as 'alcoholics' and therefore as abnormal, deviant, sick, selfish, evil and promiscuous. Because of this harsh stigma it would appear that Claire has isolated herself from treatment for her alcohol dependency. This belief is held by McConville (1995) who states, 'to protect herself against public contempt and her own self-castigation the woman is likely to deny and disguise her alcohol dependency rather than seek treatment.' p 45
Ettore (1997) also recognised the importance of tackling some underlying difficulties in changing traditional assumptions, attitudes and approaches to women whose drinking is problematic in order to offer them suitable treatment. She has noted that several studies she has researched have shown that professionals even in the health and welfare services often hold negative, stereotyped attitudes towards drinkers which make them reluctant to identify drinking problems and are less likely to consider alcohol as a factor in the symptoms presented by women.
It is apparent that Claire uses alcohol as a result of negative cognitions associated with low self-esteem and depression. She said that the alcohol helped to alleviate her feelings of depression but she was not aware that heavy use of alcohol could have the reverse affect by worsening depressive states. Marx enveloped
It has been suggested that depression-like symptoms in patients with alcohol problems are transient, alcohol induced effects that neither predate alcohol nor persist beyond it. However, it is possible that depression could increase the likelihood of subsequent alcohol problems, which seems to be the case with Claire. Hesselbrock et.at. (1985) cited in Dixit et.al. (2000) found that depression precedes alcoholism in sixty five per cent of female patients in alcohol treatment. This was also the conclusion of Wilsnack et.al. (1986) in Dixit et.al. (2000) whose analysis of women's drinking patterns over time showed that heavy drinking tended to begin after, not before problems with depression. However, at some point women who self-medicated themselves with alcohol to relieve their depressive symptoms may find that their alcohol consumption intensifies their depressive states.
It is clear from previous psychiatric assessments of Claire that a history of her alcohol misuse has not been sought. For example, Hipwell et. al. (2000) found patients who were evaluated in emergency settings and on entrance to mental institutions, substance misuse was missed in eighty four per cent of cases. Clients in their research study on dual disorders were identified as having an alcohol disorder on only a minority of discharge summaries from a variety of hospitals. They also found that whilst patients would not freely volunteer information to establish their alcohol abuse, this information would be freely given if asked for by physicians. This essay from studentcentral.co.uk
The Department of health guide titled, 'Building Bridges - A guide to Arrangements for the Care and Protection of Severely Mentally Ill patients,' (1995) recognises the existence of a dual diagnosis. The guide says,
Drug and/or alcohol misuse can have a significant impact on the well-being and risk status of mentally ill people. People with a dual-diagnosis of mental illness may require treatment from both sets of specialist services and close links need to be maintained at provider level to insure that such care is properly co-ordinated. p42
However, there is no national strategy on dual diagnosis either at a political or professional level. Where mental health problems co-exist with an addiction problem, intervention strategies appear to be based on the assumption that until the mental health problem has been addressed there was little or nothing that could be done by a substance misuse service
to help the patient.
If people were referred to a service with a dual diagnosis they were assessed by these services as either substance misusers with minor mental health problems, or people with major mental health problems who also happened to have a substance misuse problem. Their dual diagnosis was not seen as a specific problem and therefore deserving of a planned and comprehensive response (Checinski et. al. 1996). It is therefore noted that Claire previously has failed to access adequate treatment for her alcohol misuse. This will now be rectified. The counselling will sense out influences that were already operating when Claire began to drink in order to go forward to understand the subsequent impact on her environment, life events, personal relations, mental state and other relevant factors. Also it will be useful to gain an understanding of the pressures and circumstances, which have caused, contributed, or shaped towards her drinking pattern.
As Claire is very anxious and nervous and also due to her social phobia it has been decided that in the first instance Claire will benefit from one-to-one counselling with myself. She will then be gradually introduced to the Women's group that takes place once a week. Initial work will be on establishing areas of Claire's life that would appear to have a high risk of relapse. Another important area is to improve Claire's self-perception of herself.
As she is handicapped by an underlying inability to function confidentially in social situations identification in this area will include aspects of assertive training. As Claire also attributed her alcohol misuse to extrinsic factors such as stress, cognitive restructuring will be used to help her interrupt the series of thoughts that would usually lead to drinking and to replace them with more positive thought. Also training in social skills will aim to help Claire develop alternative coping strategies for use in high-risk situations when she might be at risk of a relapse. When Claire feels confident enough she will attend the weekly women's group. In this group she will be able to share her personal experiences, and develop further skills to manage her problems and increase her confidence.
Although it may be obvious that the appropriate treatment goal for patients with dual diagnosis is to address both the substance misuse and the psychiatric symptoms this fact has many times in the past been overlooked in Claire's case. Thus, it is important that Claire's treatment requires dual goals: namely, abstinence from alcohol and stabilization of her depressive symptoms. It will therefore be important to liase with her psychiatrist, on a weekly basis, so that we are both aware of treatment outcomes and any underlying problems that could prove useful in the process of helping Claire to start living a 'normal' life.