Clinical Mental Health Counseling

Instructions:
1) Read the following case study. Address all questions completely. Incomplete responses will result in a deduction of points. The exam is worth a total of 300 points.
2) Exam must conform to APA style, including the cover page and reference section.
3) Groups are required to use journal articles and book citations beyond those listed for the course. Grades will be based on the extent to which reference materials beyond those used in the class were integrated into your responses. You are permitted to use class notes, handouts, course readings, and class discussion materials to help answer the questions; however, these sources should be used sparingly.
4) Each group will submit one paper and should be no more than 30 pages of text (the cover page and references do not count toward the 30 pages–you do not need an abstract). References must be properly cited in the paper in accordance to APA 7th edition.
5) Headers must be used for each question.
6) Exams not received by the due date will be deducted one full letter grade (10%) and will lose an additional full letter grade for each 24-hour period beyond the due date.

Case Study

Rachel is a 26-year-old, divorced, African American female who was referred to you for counseling by her probation office after she recently failed a drug test for cocaine and opiates. Rachel has been on probation for the past three months following her second DUI in the past two years. At the time of her arrest, her blood alcohol concentration (BAC) was .26%. In the referral, it stated that Rachel told the arresting police officer that she drank two beers in the two hours prior to her DUI (Rachel is 5’7” and weighs 156 lbs.). Her BAC for her first DUI was .12%. Except for the DUIs, she has no prior legal history. Rachel first started drinking at age 13 when she stole beer and wine from her parents’ liquor cabinet. She also obtained alcohol from friends and siblings. Her parents both identify as alcoholics. She has been drinking steadily since her senior year of high school. Over the past year, she has been drinking a six-pack and five shots of liquor daily following her divorce. In addition, Rachel first began using powder cocaine at age 16 but has avoided providing any history of usage other than saying she “has dabbled in it.” Her probation officer informed you that when she was pulled over for her second DUI, she was caught with several grams of cocaine, which she claimed was “a friend’s.” Two years ago, she was prescribed Percocet following a back injury resulting from an accident associated with her first DUI. Within a short time, she started abusing them and eventually switched to OxyContin. Her opiate use has become more progressive consuming over 80 mgs of OxyContin illicitly a day. Within the last four months, she also reported using 1-2 bags of IV heroin 1-2 times a week (a bag contains approximately 50 mgs). She is very defensive and evasive when discussing her opiate and cocaine use and minimizes the significance of her alcohol use. Rachel has no previous experience in counseling, yet she does not believe it will be helpful. She feels counseling is confrontational and no one is going to understand her let alone help her. In addition, she is adamant that “no one is going to tell me what to do.” Further, she is concerned about having to “spill my guts to some stranger.” Rachel has never attended AA/NA and she knows nothing about meetings.

Rachel has two children from her marriage. Her son Lee, age 7, and daughter Cynthia, age 5 have been living with her sister Hillary and brother-in-law Bill since the divorce. Hillary often cares for Rachel’s children. Rachel loves her children but feels a great deal of sadness that she has been unable to care for them recently. Hillary is aware of Rachel’s substance abuse issues and other issues but does not confront her. She feels she can best help Rachel by taking care of her children. Hillary is concerned about Rachel but will buy alcohol for her at times. Hillary also avoids asking for rent or household expenses and gives Rachel money to help buy clothing for the children. Rachel’s children are exhibiting behavioral problems at school and at home.

Rachel has been unable to maintain gainful employment. Prior to her divorce, she worked part-time as a food server and did other seasonal work. Her work history has been sporadic. She often worked in establishments that sold alcohol. In the last year, she had three jobs all of which she was fired from due to her substance use and poor work performance. Rachel has a high school diploma. After high school, she enrolled at Bowie State University where she completed two semesters toward a baccalaureate degree in Accounting. Others in her support system did not see school as a priority even though she was doing well academically. She never completed her degree due to financial problems, pressure from family to quit, and a growing substance abuse problem.

Rachel’s parents divorced when she was 16. She is the youngest of four siblings. Her parents’ relationship was often acrimonious and they would fight a lot, especially when they drank. Rachel’s mother was physically and emotionally abusive toward her. Rachel’s father was distant and struggled with undiagnosed depression and anxiety. After her parents divorced, she went to live with her father. Rachel lived with him until she married John. Rachel is closest to her sister Hillary. Rachel confided in Hillary growing up and saw Hillary as her protector. Hillary has been an important part of Rachel’s support system. Rachel’s brother died of a heroin overdose two years ago, which still causes her a lot of pain. Her ex-husband used drugs and alcohol and they divorced after he admitted to an affair with another woman. He currently pays $350 per month in child support.

At age 22, Rachel was diagnosed with bipolar disorder and was prescribed Seroquel but she has not maintained her medication protocol or psychiatric appointments. She claims the medications did not help after a few weeks, so she stopped using them. In addition, she feels overly burdened and at times worries about her situation. She has been anxious all her life, especially in social situations. Alcohol helps with anxiety.

Rachel has few friends, and she thinks about going back to school but is uncertain if it would make a difference at this point. She has never contemplated suicide but feels helpless and hopeless at various times. She finds little joy in hobbies or interests. She recalls periods in her life where she enjoyed playing sports to escape from the tension at home.

Exam Questions and Issues

1) As you prepare to work with Rachel, what are the primary and secondary issues? Give a rationale for each response. (CACREP Clinical Mental Health Counseling Standards A.6. Recognizes the potential for substance use disorders to mimic and coexist with a variety of medical and psychological disorders; C.2. Knows the etiology, the diagnostic process and nomenclature, treatment, referral, and prevention of mental and emotional disorders; K.3. Knows the impact of co-occurring substance use disorders on medical and psychological disorders)

2) Regarding the substance use reported, discuss what you know about each of these substances. Make sure you include in your response what category each drug falls into, the dependency potential for each substance, main and long-term effects of each substance, and potential health or medical issues. You should also discuss concerns about tolerance and withdrawal.

3) Discuss what theoretical model(s) of addiction should be considered when working with Rachel. Explain the model(s) and your rationale for using each. In addition, explain which model(s) may not be appropriate when working with Rachel and why.

4) During the first session with Rachel, briefly describe what you believe are important factors that must be considered in preparing to work with her. Also, briefly discuss what counseling skills you think would be most beneficial during the beginning stages of counseling and why? How would you go about addressing her resistance toward treatment? (CACREP Clinical Mental Health Counseling Standards D.8. Provides appropriate counseling strategies when working with clients with addiction and co-occurring disorders)

5) Explain the significance of conducting D&A assessments. What do you see as your role during this phase? What are some key issues to remember about assessment measures? What type of assessment tools/measures, risk assessment, screening instruments, and diagnostic instruments might you consider incorporating and why? What other concerns or issues do you have with this client or when working with the client that should be considered during the assessment process? (CACREP Clinical Mental Health Counseling Standards C.2. Knows the etiology, the diagnostic process and nomenclature, treatment, referral, and prevention of mental and emotional disorders; G.4. Identifies standard screening and assessment instruments for substance use disorders and process addictions; H.3. Screens for addiction, aggression, and danger to self and/or others, as well as co-occurring mental disorders)

6) Based on the information you have been presented, develop a treatment plan that is based on the primary and secondary issues outlined in question 1. Make sure you clearly state the goals and objectives, show evidence that they are measurable, establish a realistic timeline for addressing the goals, and demonstrate that the plan is consistent with her SOC (treatment plan should be based on the content presented in this case). As the client progresses through SOC, identify how the treatment plan will be revised to reflect these changes. Prior to devising a treatment plan, explain what components are important when developing an effective treatment plan. Discuss how you would structure treatment based on what you believe are the primary and secondary issues. Use a table format for the initial treatment plan that shows the goals/objectives, if it is addressing primary/secondary issues, timeframe for completion, and approach(es) used to achieve the goal. (CACREP Clinical Mental Health Counseling Standards H.4. Applies the assessment of a client’s stage of dependence, change, or recover to determine the appropriate treatment modality and placement criteria within the continuum of care)

7) Various treatment approaches/techniques have been shown to be efficacious in treating clients with substance abuse issues. Discuss which treatment approaches/techniques you would incorporate into your counseling work with Rachel given the information presented and provide rationale/empirical evidence for these approaches. Provide a brief description of the theoretical approaches and treatment techniques to be integrated into treatment. How will these approaches change as her motivation to change improves? (CACREP Clinical Mental Health Counseling Standards H.4. Applies the assessment of a client’s stage of dependence, change, or recover to determine the appropriate treatment modality and placement criteria within the continuum of care)

8) Rachel’s sister Hillary appears to be an important “support.” Based on the information presented, discuss any concerns you have about this relationship. In addition, discuss why it is important to work with Rachel’s family and address potential problems that may surface within the family and with her children in particular. What type of support system do you see as benefiting Rachel and why?

9) One of the most difficult issues to manage in substance abuse treatment is relapse. Assume that Rachel engages in treatment and makes progress toward maintaining abstinence. You are concerned, however, that she is still at high risk for relapse. Discuss any applicable relapse theories that may explain why she is at risk for relapse. How would you structure treatment and aftercare to account for a potential relapse scenario? Discuss which strategies or prevention treatment approaches you would integrate into treatment and provide a rationale for why.

10) From a multicultural perspective, identify cultural factors/issues/concerns that must be considered during assessment and treatment. How does race, ethnicity, gender, being a single parent, etc. factor into your work with her? What other factors must be taken into consideration (integrate multicultural counseling competencies into this response).