Cassidy is at high-risk of alcohol dependency. She finds it to difficult to cope in crisis and often turns to alcohol to calm her nerves. These high-risk have to do with coping or daily functioning skills, in which risk increases with weakness. (Sneidman, 1985). Cassidy's alcohol dependence may result in emotional or cognitive overload, which in turn became unbearable for her (Shneidman, 1985). Therefore, being mindful, not only to a leading causes or stressor, but looking at her life conditions that may push her towards drinking (Clark, 1995). Unless the psychosocial influences changed, her drinking patterns will remain.
Would you take abstinence or harm minimisation approach? Why? (Make sure you define harm minimisation).
Harm minimisation approach (Bellak & Seigel, 1983; Fujimura, Weis, & Cochran, 1985) is the recommendation for Cassidy. The primary aim is to help Cassidy to reduce her use of alcohol and the impact associated with her drinking. This approach accepts that she make choices whether to drink alcohol or not (Shand & Gates, 2003).). The focus remains on preventing harm while she continues to drink. Therefore, the aim is not to pressure Cassidy into abstinence, rather the goal of harm minimisation is to increase coping mechanisms and social supports, so that she can reduce alcohol consumption to the right level.
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Harm minimisation control social functioning during in-balance to ease immediate effect of difficult stressful events and it is a way of reducing the stressful effects of drinking and strengthens her coping throughout her crisis (Mariatt & Witkiewitz, 2002).
Therefore, I will strongly recommend to her as an immediate action to engage drinking only light to moderate alcohol. She should drink not more than two standard drinks per day, which is 20 grams of alcohol (Shand & Gates, 2003) Engaging in this modified controlled drinking behaviour, to start will give some excellent results to her health and lessen the chance of getting other disease.
What psychosocial intervention(s) if any would you select for this person? Why? Ensure that you include (1) an outline of the theoretical underpinnings or framework of the intervention e.g. motivational interviewing's theoretical underpinnings include Stages of change and the Transtheoretical Model) and (2) a brief review of the study
"Cognitive Behavioural Therapy" focusing on coping skills and healthy behaviours (Longabaugh & Morgenstern, 1998) will be useful for Cassidy. Other techniques such as controlled drinking strategies may also be useful (Miller & Caddy, 1977). Applying respectful listening and empathy are effective for people in Cassidy's situation (Roger & Farson, 1957).
"Cognitive Behavioural Therapy" focuses on changing two main types of thoughts: unhelpful (automatic) thoughts that occur day to day and the core beliefs that drive these thoughts (Beck, 1995). CBT shows to have the same effectiveness to pharmacotherapy and may add protection to Cassidy against relapse or recurrence after the treatment end.
CBT aims to make the process of therapy more understandable to Cassidy. Cassidy will feel more comfortable when she knows what to expect from the session. She will clearly understand the role that she is expecting to do. What she does outside the therapy is an essential part of the CB. This is referring to the between-session practices or homework. CBT will help Cassidy become better at helping herself in her everyday lives (Egan 2002). CBT will help her asks and answers for her self's questions like; problems, issues, concerns, or opportunities that should be working. CBT will help her clarify the key issues on calling for change. It also involves identifying her expected results from treatment, like solutions that make sense, what does she want her life to be, or changes that would make her happier. In addition, help her develop strategies for carrying out goals. Goals such as how will she get what she need and want, or plan to get where she wants to go.
Building a trusting link is when she and I cooperate in planning and carrying out the intervention (Egan, 1998). CBT give support in which Cassidy can actively work towards change, and reduce her fear and distrust of treatment programs, and by it encourage her to continue attending treatment and follow-up appointments (Ashley et al, 2003).). Providing a non-threatening and kind environment in which she can address sensitive issues (Mattick, & Jarvis, 1993).
Motivational Interviewing is an evidence-based treatment for assisting people with behaviour change (Miller and Rollnick, 1991). The principles of motivational interviewing are to have Cassidy; voice the argument for change and her statements provide the reasons for change. As Cassidy talks about her drinking and her current situation changing during a conversation, changes are likely to occur. Counselling that is performing in a reflective, and encouraging manner, resistance goes down while change talk increases (Miller and Rollnick, 2002). MI applies these stages of change with the aims to explore and identify feelings of ambivalence, and highlight differences and discomfort surrounding current behaviour to increase motivational for more positive health changes. Cassidy must make a decision for her self-make these changes happen.
Counsellor could help Cassidy to explore what the right things are about drinking. Example of this is to know if Cassidy is trying to avoid something or does drinking alcohol make Cassidy feel better.
In Motivational Interviewing counsellor asks Cassidy the reason behind her continues use of alcohol. Could be that alcohol offer Cassidy a sense of self, separate from parenting a way for Cassidy to assert her independence and freedom of choice? If so, to counsel Cassidy in her efforts to stop drinking alcohol, without exploring these identity issues, would continue to prove ineffective. Applying motivational interviewing is to recognise as well if other triggers and antecedents that may cause her to abused and dependent to alcohol. Before discussing changes, I will use reflection and would gather comment from her about how she is going? Examples of these are bringing-up children alone, and other significant reason that may contribute to her drinking. Identifying the right causes for alcohol dependence for the first time will bring light to her emotional, feeling, attitude, and behaviour states, and this give clues in the motivational change.
When behavioural changing is starting, I have to identify what change Cassidy's at, and this will help decide if she needs help to build her confidence, direction of importance, or both. A category that Cassidy may be the one least ready to change, and change as rather unimportant, and had little confidence that she would successfully make the change she needed. Or not motivated to change as she also sees the change as too hard. However, she does believe that she could change if she seriously wanted and tried. Also, she may consider the necessity of change, and she is prepare and willing to change. (Miller and Rollnick, 2002).
The stages of change model show that changing drinking alcohol behaviour takes place gradually. Once seeing the negative results of drinking alcohol in her life, Cassidy can develop making changes can begin. One-way of looking at making change is the stages of change model (Prochaska and DiClemente, 1984) of client's motivation which is use to assess and encourage their motivation to change. She may move from being not interested, not aware or not willing to make a change. This model help explains the basic role of exploring ambivalence in regards to motivation can have in changing drinking patterns. The strength of commitments to change first is the driving force to enable her to escape from being dependent or abused of alcohol. It is possible to track how ready Cassidy to benefit from treatment using the stages of change. Cassidy must progress through different stages of the change on her way to achieving the completed goal at the end. Her progress will pass through the stages at her own pace which may be unique to her needs (Connors, Donovan & DiClemente, 2004).
By applying the stages of change model, I would interview Cassidy at the contemplation stage. Expressing empathy, reflective listening, affirming, and providing support, and encouragement, which are necessary. When Cassidy struggle with ambivalence and doubt about her ability to carry out the change, a reasonable approach, is to ask her about possible strategies. Cassidy may have strategies to overcome barriers and then arrive on a joint decision to follow one strategy before the next visit. It is also productive to ask Cassidy about her previous methods and what she tries to change behaviour. Barriers and gaps in her knowledge can then surface for further discussion (Miller & Rollnick, 1991).
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At preparation and determination stage in Motivational Interviewing Cassidy's motivation may reflect in the statement by saying, "I've got to do something" or "What can I do to change?" Cassidy may begin to explore on her issue. Cassidy may look or phone for information centres such as clinics seeking advice from counsellors or relevant specialist. Cassidy will begin to find and put together list of information available that she is going to need. Like treatment needed with her drinking, and how Cassidy can find a solution to her emotional, feeling, attitude, and behaviour (Kern, 2008).
At the stage, of action Cassidy need to decide and initiate the required changes in her negative behaviour. At this stage, is when Cassidy need to become actively involved in taking the necessary steps to change by using a series of techniques she has chosen. During this stage, Cassidy is most at risk of relapse. She may review her commitment to her self. Develop plans to deal with her personal and other external pressures that may lead to relapse. Cassidy may tend to be more open to receiving assistance and is likely to seek support.
At Maintenance stage of change is the successful avoidance of any temptation to return to the negative habit. Cassidy arriving at this stage may remind her self of the effort it required to get her to this stage, and how much progress she had made.
Relapse is when Cassidy can analyse why and how the relapse occurred, and to use it as an opportunity to cope differently, and make relevant changes to her change process. When Cassidy face challenges she must think what to do straight away.
What relapse prevention strategies would you integrate the two treatment approaches?
Cognitive and behavioral strategies to prevent or limit relapse episodes is the best recommendation for Cassidy. Relapse prevention using CBT is changing drinking behaviours seen as a combination of extinguishing the connection between pleasure seeking and/or pain reduction. Helping Cassidy to build new coping skills behaviour so she can replace addictive behaviours (Marlatt et al, 2002).
This includes Cassidy's recognising those particular high-risk that might lead to a relapse. This involves reviewing a list of common relapse, recognising any of those obstacles that can cause difficulty for her, and devising methods to either avoid these circumstances or manage any situations with no alcohol drink (Marlatt & Gordon, 1985). Example of high-risk situations is when Cassidy is angry after coming home from work and face with tasks looking after children and preparing a meal. Negative emotional states such as anxiety, depression, frustration and boredom are also high-risk factors for relapse. (Marlatt et al, 2002). "When Cassidy feels agitate with her children or other person" also result in negative emotions and can precipitate relapse. Marlatt (1996) suggest high-risk situation like Social pressure, including both direct verbal or nonverbal persuasion and indirect pressure (Example; being around other people who are drinking. Positive emotional states are also high-risk which includes like attending party. Stimuli or cues like seeing and advertisement for alcohol drinks, or passing by to her favorite bar and bottle shop. Cassidy would have to identify that some cravings can also precipitate relapse (Marlatt et al, 2002).
Another relapse prevention is cognitive coping skills strategies, which includes thinking certain health that will results not to drink, and damaging health and other effects of returning to harmful intake of alcohol. This includes any belief associated with drinking that may hinder and disrupt her change. Cassidy will have to monitor her drinking level, and behaviour, and her response to the situation that determines whether she will experience a lapse (e.g. begin using alcohol).
It is critical for Cassidy to learn how to identify early warning signs of relapse and seemingly irrelevant decisions, as this will help her to be mindful of high risk situations that could result in her returning to her current drinking levels. These high-risk situations need to be explored with her and a plan develop that will allow her, to manage these problems more effectively (Dimeff & Marlatt, 1995).
Any special considerations for the person's age/gender/culture?
Difficulties may arise due to differences and misunderstanding between Cassidy's culture (Australian) and mine as Malayan. Although in CBT, some primary aspects of the therapeutic relationship are the same. Like, caring, empathy, trust, and genuineness. There are other aspects, which are use in Cassidy's culture that can undermine her way or values, such as the heavy individualistic focus of Western therapies that I am used to. There are cautions where CBT or Motivational interviewing should not be involved; these include knowledge areas such as women's business and she might do in her private life. Counsellor should be responsive according to a variety of factors contained within Cassidy's issue. To work with Cassidy, first, counsellor need to establish networks within her community, in order to build cultural checks and balance. This will allow for cooperation and demystifies their role (Garvey, 1994). Intervention with Cassidy mean endeavouring to work in shared partnerships. If the situation arises, like in Cassidy's case, is to refer first to other more appropriate community people or elders in the community (Garvey, 1994).
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As Cassidy is female, she can suffer more adverse effects from drinking alcohol, because woman's body processes alcohol more slowly than a man's. Since woman's body contains less water and more fatty tissue than a man's, alcohol remains at higher concentration in woman's for longer periods of time, and exposing their brain and other organs to more alcohol. Women have lower alcohol dehydrogenase and aldehyde dehydrogenase enzymes that break down alcohol in the stomach and liver. As a result, Cassidy may absorb more alcohol into her bloodstreams than men.
Cassidy being a single mother of young children also has limited finances and limited supports. Marlatt, Parks, & Witkiewitz (2002) suggest that the amounts of stress in a person's daily life such as limited support, low economic status with limited finances (result in not eating properly), are situations that cause someone to relapse. In relapse prevention is to assess Cassidy's quality of life with a focus on looking at her lifestyle, and discuss this to Cassidy if any other intervention needed to assist her in approaching relapse minimization. Intervention can come from other agencies support group who are specialists in helping those people who lives in a remote community area.
Does Cassidy need pharmacotherapy intervention as well, like antidepressant naltrexone? This pharmacological agent is useful for helping people who are still drinking, and it is effective for reducing alcohol dependence in the short term.
My decision is not to incorporate pharmacotherapy. I believe that Cassidy's alcohol use needs to be addressed first through counselling using cognitive, behavioural therapy, as her drinking appears to be associated with her current situation as a single parent and her psychological problems (stress and possible depression). Cassidy's alcohol use is usually caused by physiological and psychosocial and can lead to mental problem (SAMHSA, 2011). Cassidy first need is develop and strengthened her social support networks.