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Final Project Case Study: Lisa

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1 Final Project Case Study: Lisa
This presentation was prepared as the final project by Evette Rowley for Dr. Parson’s Counseling , Substance Abuse Therapies class. Evette Rowley August 21, 2011

2 Case Study: Lisa Thirty-two years old
Single mother of 8 year old twin boys Mexican-American Heterosexual Referred by attorney Meet Lisa. She is a 32 year old Mexican-American single mother of 8 year old twin boys. She identifies as heterosexual and is currently in a relationship with her boyfriend Charlie. Since middle school she has been affiliated with a gang and continues to associate with them at this point in her life. Lisa was referred to substance abuse counseling by her attorney after receiving her third citation for driving while intoxicated. This presentation will explore Lisa’s current situation as it relates to her past and present substance abuse, explore biological and cultural considerations leading to or stemming from her usage, and recommend a substance abuse treatment plan and interventions based on Lisa’s assessment and diagnosis.

3 Substances (Valdez, Mikow, & Cepeda, 2006; SAMHSA Treatment Episode Data Set [TEDS], 2007)
Marijuana (12 years old) Alcohol (12 years old) Cocaine (14 years old) Heroin (16 years old) Current methamphetamine use Lisa has been using alcohol and drugs for over half her life – twenty years. She began using marijuana and alcohol at 12 years old, followed by cocaine at 14 and heroin at 16. Research indicates that substance use among Hispanic females occurs both at an earlier age and at higher rates as compared to other racial/ethnic females (Valdez, Mikow, & Cepeda, 2006). The National Coalition of Hispanic Health and Human Services Organizations (1999) has found that Hispanic girls are more likely to use marijuana and alcohol before 13 years of age as compared to their White or Black peers (Valdez, Mikow, & Cepeda, 2006). Among Hispanic females, the most commonly reported primary substance used is methamphetamine (SAMHSA Treatment Episode Data Set (TEDS), 2007). While Lisa claims that she hasn’t used heroin in over five years she does admit to current alcohol and methamphetamine use.

4 Implications (Smith & Capps, 2009)
Alcohol Poor judgment – multiple DUI, jeopardy of losing children Danger to self & others – violence Methamphetamines “Fight or flight” response Aggression – rage and blackouts Hallucinations – hearing fathers voice Lisa’s current substance use includes alcohol and methamphetamines. After a recent night of heavy drinking and using meth, Lisa and her boyfriend Charlie began arguing. The argument escalated into threat of violence when Lisa drew a knife and told Charlie she would kill him. He was able to lock himself in a bedroom where he called the police. Lisa continued to stab at him under the door and when that didn’t work, she attempted to cut through the door. After the knife became lodged in the door she left the apartment in frustration and drove away in her car. She went several blocks when she was stopped by the police and arrested for driving while under the influence, her third incident. Her children were staying with her mother at the time of her arrest and in addition to charges for driving while under the influence of drugs and alcohol, she is now in jeopardy of having her children taken from her. Alcohol in prolonged and heavy use leads to poor judgment and becoming a danger to self and others (Smith & Capps, 2009). Lisa’s night of heavy drinking coupled with her meth use altered her judgment so that she became a danger to her self, exhibiting a “fight or flight” response and getting behind the wheel, resulting in another DWI. She obviously was a danger to Charlie as evidenced by her violence and aggression. Throughout her daily use of drugs and alcohol over a twenty year period, Lisa says she experiences blackouts during the most extreme times of rage but she cannot state whether or not the blackouts correlate with her substance abuse. Lisa’s father was a chronic heroin abuser and she spent the majority of her childhood witness to her father beating her mother. Lisa’s father insisted that she grow up “tough” and forced her to box with her brothers and male cousins. To survive Lisa realized she needed to be aggressive and fight so she joined a gang. She said during the argument with Charlie the only things she remembers is that she acted just like her father did to her mother and hearing her father’s voice grow louder and louder, despite the fact that he has been dead for ten years. Auditory hallucinations may be attributed to her drug abuse or evidence of a psychiatric disorder which will be explored later in the presentation. Despite being referred by her lawyer, substance abuse treatment was not mandated for Lisa so the fact that she is seeking help shows initiative but may also be a strategic move in order not to lose custody of her children.

5 Biological Predispositions (Faulkner, 2009; Edwards, Svikis, Pickens, & Dick, 2009; Prescott, Madden, & Stallings, 2006) Genetic predisposition Father - chronic heroin user Children at risk Risk factors High tolerance Stressful life situations While no genes have been known to cause substance abuse, genetic predisposition for drug and alcohol addiction varies depending upon substance, population, age, and sex (Faulkner, 2009; Edwards, Svikis, Pickens, & Dick, 2009). The genetic linkage studies done demonstrates that heritability estimates for alcoholism consistently range from 50% to 60%, based on U.S. population studies (Edwards, Svikis, Pickens, & Dick, 2009). There is less research done on the genetic linkage of illicit substances such as heroin between parents and children because only recently as data become available where both generations have been compared but the familial connection has been investigated through the use of twin and adoptive studies that supports the presence of a genetic predisposition, anywhere from 25% to 80%, with the majority being in the range of 50% to 70% (Prescott, Madden, & Stallings, 2006). Lisa’s father was a chronic heroin user for most of Lisa’s life and died from an overdose however she mentioned nothing regarding her father’s alcohol use. Alcoholism is believed to be inherited based on gender and type, with Type I alcoholism transmitted cross-gender (from mother to son) and Type II alcoholism being transmitted same gender (from mother to daughter) (Faulkner, 2009). The characteristics of each type are different whereas Type 1 alcoholics tends to have less criminality, less dependent personalities, and less violence during drinking binges (Faulkner, 2009). Type II alcoholics exhibit much more aggressive and violent behaviors coupled with compulsive drinking signs such as blackouts (Faulkner, 2009). Lisa’s alcohol use shows clear characteristics of the Type II variety so additional information regarding her mother’s alcohol use might be helpful in determining if a biological predisposition played a role. Of course, environmental influences cannot be dismissed and during her childhood Lisa definitely experienced trauma, pain and unhappiness which followed her into adulthood. Biological predisposition and environmental risk factors make Lisa’s children at an increased risk for substance abuse. Genetic factors may also play a role in manifesting certain risk factors such as a high tolerance for alcohol or other drug use and coupled with stressful life situations, heavy drug and alcohol stemming from a high tolerance can lead to addiction (Faulkner, 2009).

6 Cultural Considerations (Wadsworth, Raviv, Reinhard, Wolff, Santiago, & Einhorn, 2008; Whiting, Simmons, Havens, Smith & Oka, 2009; Caballero, Ramos, González, & Saltijeral, 2010; Valdez, Mikow, & Cepeda, 2006; Harris, 1994) Abject poverty Domestic violence Witness to her mother’s abuse Gang affiliation Fighting = survival Sense of belonging Identity Power While biological predispositions are a consideration it is more likely that Lisa’s culture and background played a much more significant role in fueling her addictions. Lisa grew up in poverty in a part of San Antonio where access to drugs and alcohol was plentiful and easy. Growing up in persistent poverty is detrimental to a child’s psychological, physical, and educational well-being (Wadsworth, Raviv, Reinhard, Wolff, Santiago, & Einhorn, 2008). Children who are poor are more likely to engage in behaviors that cause serious psychological and physical damage such as substance abuse, crime, and early pregnancy (Wadsworth, Raviv, Reinhard, Wolff, Santiago, & Einhorn, 2008). Living in poverty creates a constant state of chronic stress and exposes children to violence, hunger, poor health, and daily economic worries that have a cumulative effect on children and families (Wadsworth, Raviv, Reinhard, Wolff, Santiago, & Einhorn, 2008). The poverty Lisa’s family experienced no doubt contributed to the violence and substance abuse she witnessed as a child. The domestic violence Lisa’s mother endured clearly had a significant and long-lasting impact on Lisa’s psyche and well-being. Research has shown that experiencing violence as a child not only predisposes one to an increased likelihood of being in a relationship where violence occurs but that victimization was the most common predictor of substance use and abuse (Whiting, Simmons, Havens, Smith & Oka, 2009). The tendency is for domestic violence victims to use substances in order to self-medicate for trauma and psychological disorders like depression and anxiety (Whiting, Simmons, Havens, Smith & Oka, 2009). It is clear that experiencing violence, particularly during childhood, demonstrates a strong relationship with the subsequent use of drugs and alcohol, very often at a much earlier age and corresponding to the severity of exposure (Caballero, Ramos, González, & Saltijeral, 2010). Gang affiliation has been cited as one of the reasons Hispanic females are more likely to be involved in legal and illegal substances (Valdez, Mikow, & Cepeda, 2006). Lisa’s home life was fractured beyond repair so she turned to a gang in middle school as a way of creating that sense of identity and belonging she craved. Her father taught her through the boxing matches with her brother’s and male cousins that fighting and being tough was the only way to survive. Gang membership allows the core participants to develop power, self-esteem and a strong sense of identity (Harris, 1994). The most active membership for Hispanic females is between the ages of 13 and 16 while older members decrease active gang membership but still maintain identity and connection to the gang in adulthood (Harris, 1994). Lisa’s drug use and aggression was most likely encouraged by her gang membership because these behaviors demonstrated that she could not only take care of herself but take care of her gang members as well (Harris, 1994).

7 Therapy Model (Shorkey, Windsor, & Spence, 2008; Peregoy, 2009)
Underserved population Language barriers Lack of culturally relevant providers Confianza Limited linkage to community resources Terminate after one contact Detoxification Inpatient treatment program Disease model & recovery process Family Treatment Support groups Mexican-Americans dealing with substance abuse and addiction are a woefully underserved population because of language barriers, a lack of culturally relevant providers, a cultural mistrust of treatment (confianza), and limited linkage to resources within Hispanic communities (Shorkey, Windsor, & Spence, 2008). This may explain why they tend to terminate therapy after just one contact at a rate of more than 50% (Peregoy, 2009). Lisa’s poly-drug chemical dependence is chronic with use on a daily basis over a period of twenty years. The therapy approach for Lisa will need to be multi-faceted to include detoxification within an inpatient treatment program that emphasizes education about the disease model and recovery process (Peregoy, 2009). Family is the foundation for the Hispanic culture. It provides support, identity and security and is the first resource family members turn to for advice in times of crisis (Peregoy, 2009). Lisa will have an opportunity to include her family in treatment not only as a support system but also to help her mother and children deal with the years of exposure to repeated violence and substance abuse. Lisa can supplement her recovery with support groups such as Alcoholic Anonymous, Children of Addicted Parents, and psychoeducational groups that address aggression and violence.

8 Assessment & Diagnosis (Chamberlain & Jew, 2009; Smith & Garcia, 2009)
Chronic phase DSM-IV criteria – substance dependence Self-admission of dependence Extensive drug history Family/peer influences Related legal problems Dual diagnosis PTSD related to domestic violence Schizophrenia Substance abuse and dependence almost always occurs within the context of other problems and Lisa’s situation is no exception (Chamberlain & Jew, 2009). Despite being referred by her attorney, she withholds nothing about her substance abuse history and freely admits to her drug and alcohol use and life circumstances. Lisa is entering into the chronic phase of addiction which is characterized by a continuous use of substances for prolonged periods of time as evidenced by her own admission of daily use of both alcohol and meth and impaired judgment and irrational thinking as evidenced by her blackouts and violent tendencies (Chamberlain & Jew, 2009). It appears as though Lisa meets the DSM-IV criteria for substance dependence and although additional information is needed from Lisa to confirm the diagnosis, additional indicators include her self-admission to chemical dependence, extensive and prolonged drug history, family and peer influences, and her related legal problems (Smith & Garcia, 2009). Additional assessment is required to determine if Lisa may have a co-occurring psychological disorder such as post traumatic stress disorder stemming from the domestic violence she experienced as a child or possibly even schizophrenia, which can be better assessed once she has been consistently sober for a period of time.

9 Treatment Plan & Intervention Strategies (Smith & Garcia, 2009)
Substance dependence Concept of addiction Alter lifestyle 60-day inpatient treatment Weekly individual and peer support Daily AA & NA meetings Aggression & violence Gang affiliation Avoid people & places Legal problems Probation Regular urine specimens Remain crime-free Family therapy Lisa has several problems to tackle in her treatment plan, the most significant being her substance dependence. Given her prolonged poly-drug use of alcohol and methamphetamines, referral to a methadone clinic for self detoxification may not be enough so Lisa will have to engage in medical detoxification and stabilization on an inpatient level for a period of at least sixty days. She will need to address this by understanding the concept of addiction and undertaking major lifestyle changes that encourage abstinence from drugs and alcohol (Smith & Garcia, 2009). She will attend and successfully complete a 60-day inpatient treatment program as well as attend weekly individual and peer support group counseling sessions (Smith & Garcia, 2009). Daily Alcoholics Anonymous and Narcotics Anonymous meetings will also be required (Smith & Garcia, 2009). In these sessions she can also address her aggressive and violent behavior although this may decrease with sobriety after a period of time. Lisa will have to deal with the negative influences in her life such as the gang affiliation if she wants to maintain sobriety so avoiding people and places associated with harmful individuals is crucial (Smith & Garcia, 2009). The outcome of Lisa’s legal problems have yet to be determined but considering this is her third offense of driving while intoxicated, she will most likely have to deal with probation which includes regular submission of urine specimens and a stipulation to remain crime free (Smith & Garcia, 2009). Finally, Lisa and her family need to heal. Her treatment plan should include family therapy to deal with the family’s past, present, and future, her son’s futures.

10 Ethical & Legal ACA Code of Ethics (2005) Confidentiality
Avoid bias & stereotypes Support client independence & freedom of choice Confidentiality Harm self & others Child abuse & neglect The American Counseling Association Code of Ethics (2005) maintains that counselors must avoid bias and stereotypes when dealing with clients. Working with diverse populations can be challenging, especially if a counselor is not familiar with that client’s cultural norms. Understanding Lisa’s situation will require knowledge of not only the Mexican-American culture as it relates to domestic violence, substance abuse, and treatment of this population but also the gang culture. Given that 50% of Hispanic clients terminate treatment after one contact and Lisa is not mandated to attend counseling (yet) a counselor will need to support Lisa’s independence and freedom of choice to not continue treatment However in looking after the best interests of the client it would be helpful for Lisa if the counselor explained that undergoing substance abuse treatment before being required to do so will greatly improve her chances of not losing custody of her children. The ACA (2005) requires counselors to maintain the privilege of confidentiality in almost all situations revealed in counseling with the exception of harm to self, others and child abuse and neglect. Given Lisa’s volatile history with violence and aggression as well as her exposure to domestic violence, a counselor would need to advise Lisa of the potential to break confidentiality in these situations.

11 Case Study: Lisa Challenging & complex Protective factors Genetics
Trauma Domestic violence Poverty Gangs Surviving through fighting Protective factors Family Resilience & determination Lisa’s case has proven to be challenging and complex. Factors such as genetic predisposition, traumatic experiences such as experiencing childhood domestic violence, poverty, gang affiliation and the cultural influence of always being tough for survival have all contributed to Lisa’s drug and alcohol addiction. But Lisa does have her strengths, namely her mother and her two boys. She also has resilience and determination on her side. These protective factors have been proven to be extremely important in preventing relapse and no doubt will encourage Lisa in her recovery process.

12 References American Counseling Association (2005). ACA Code of Ethics. Alexandria, VA: Author. Caballero, M., Ramos, L., González, C., & Saltijeral, M. (2010). Family violence and risk of substance use among Mexican adolescents. Child Abuse & Neglect, 34(8), doi: /j.chiabu Chamberlain, L.L. & Jew, C.L. (2009). Assessment and diagnosis. In Stevens, P., & Smith, R. L. Substance abuse counseling: Theory and practice (4th ed.), (p ). Upper Saddle River, NJ: Pearson Education, Inc. Differences in Substance Abuse Treatment Admissions between Mexican-American Males and Females. (2010). Differences in Substance Abuse Treatment Admissions between Mexican-American Males and Females, 6. Edwards, A. C., Svikis, D. S., Pickens, R. W., & Dick, D. M. (2009). Genetic Influences on Addiction. Primary Psychiatry, 16(8), Faulkner, C.A. (2009). Etiological theories of- substance abuse. In Stevens, P., & Smith, R. L. Substance abuse counseling: Theory and practice (4th ed.), (p ). Upper Saddle River, NJ: Pearson Education, Inc. Harris, M. G. (1994). Cholas, Mexican-American girls, and gangs. Sex Roles, 30(3/4), Peregoy, J.J. (2009). Working with diverse cultures: Exploring sociocultural influences and realities in ATOD treatment and prevention. In Stevens, P., & Smith, R. L. Substance abuse counseling: Theory and practice (4th ed.), (p ). Upper Saddle River, NJ: Pearson Education, Inc. Prescott, C. A., Madden, P. F., & Stallings, M. C. (2006). Challenges in Genetic Studies of the Etiology of Substance Use and Substance Use Disorders: Introduction to the Special Issue. Behavior Genetics, 36(4), doi: /s Shorkey, C., Windsor, L., & Spence, R. (2009). Assessing culturally competent chemical dependence treatment services for Mexican Americans. The Journal Of Behavioral Health Services & Research, 36(1), Smith, R.L. & Capps, F. (2009). The major substances of abuse and the body. In Stevens, P., & Smith, R. L. Substance abuse counseling: Theory and practice (4th ed.), (p ). Upper Saddle River, NJ: Pearson Education, Inc. Smith, R.L. & Garcia, E.E. (2009). Treatment setting and treatment planning. In Stevens, P., & Smith, R. L. Substance abuse counseling: Theory and practice (4th ed.), (p ). Upper Saddle River, NJ: Pearson Education, Inc. Valdez, A., Mikow, J., & Cepeda, A. (2006). The Role of Stress, Family Coping, Ethnic Identity, and Mother-Daughter Relationships on Substance Use Among Gang-Affiliated Hispanic Females. Journal of Social Work Practice in the Addictions, 6(4), Wadsworth, M. E., Raviv, T., Reinhard, C., Wolff, B., Santiago, C., & Einhorn, L. (2008). An Indirect Effects Model of the Association Between Poverty and Child Functioning: The Role of Children's Poverty-Related Stress. Journal of Loss & Trauma, 13(2/3), doi: / Whiting, J., Simmons, L., Havens, J., Smith, D., & Oka, M. (2009). Intergenerational Transmission of Violence: the Influence of Self-Appraisals, Mental Disorders and Substance Abuse. Journal of Family Violence, 24(8), doi: /s This slide notes the references used in the creation of this presentation.

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