The following case study is connected to the questions below: Please assist with answering the following questions in a synopsis format related to case study:

Your assignment is to include the following:

Title Page

Abstract (Optional)

Brief Overview of Client

DSM Diagnosis and rationale (Including code)

Approach to Treat Disorder (including assessment techniques or tools)

Treatment Plan (Minimum THREE goals with measurable objectives) with following format:

Goal 1:

Objective 1:

Objective 2:

Objective 3: (Complete for minimum three goals)

Anticipated discharge criteria (i.e., When is process complete?)

Additional Information (What more information about the client would need to be gathered to better understand the client?

What are the statistics for American high school seniors and their consumption of alcohol?

When did Randy’s drinking develop into pattern drinking?

Do you think Randy developed a tolerance for alcohol? Give a reason for your answer.

Why did Randy’s wife, Kelly, not think of Randy’s drinking as a problem?

When did Kelly begin to realize that alcohol use disorder and marriage don’t mix?

What prompted Kelly to realize that Randy needed professional help with his drinking problem?

Describe the SORC model that Dr. West decided to use with Randy and Kelly.

Why did Dr. West feel it was important for Kelly to participate in the therapy with Randy?

Describe the five components of the triggers sheet that Randy used.

What are some of the alarming statistics that result from alcohol use and abuse?

What are key areas under debate regarding the use of alcohol once a person has developed alcohol use disorder?

What are some of the activities necessary to keep a couple together during therapy, with one family member suffering from alcohol use disorder?

What are some of the key features for relapse prevention?

What was the final outcome for Randy?

Case Study:

Randy was a heavy drinker from the first time he tried alcohol. He began drinking as a freshman in high school and immediately consumed large amounts at parties with his friends. Throughout high school, he limited his drinking mostly to weekends. He and his friends would use their fake IDs to get a case of beer and bottles of cheap vodka or rum, and then drive to a wooded areas in the suburbs. There they would turn on music, sometimes make small fires, and sit outside or in the back of their pick-up trucks, drinking heavily into late hours of the night.

One-quarter of middle school children admit to some alcohol use. Around 29% of high school seniors drink alcohol in a given month and 2% report drinking every day (Johnston et al., 2020).

Randy generally returned home from drinking after his parents fell asleep, so they never fully appreciated the extent of his drinking. They themselves were weekly social drinkers, and it never occurred to them that their son’s drinking could be a problem. They would sometimes reason that they had drunk alcohol when they were younger, and they turned out okay. It was all socially acceptable for kids their age, his parents would tell themselves and their friends. Besides, Randy and his friends never got into any trouble as a result of their drinking — none, at least, that his parents knew about.

In college, Randy joined an off-campus fraternity known for partying, and he continued his high school drinking pattern. But without the structure of home and high school, and within the culture of the fraternity, Randy’s drinking became more regular. Almost every Friday and Saturday night, the fraternity brothers would hold keg parties where the booze would run heavy and long into the night, usually until the wee hours of the morning. Some of his fraternity brothers drank as much or more than Randy, helping him normalize his own drinking and leading him to conclude that at least he didn’t drink as much as they did.

When people consume 5 or more drinks on a single occasion, it is called a binge-drinking episode. Thirty-eight percent of full-time college students binge-drink each month, one-third of them 6 times per month (NIAAA, 2021a; SAMHSA, 2021, 2019).

Three years after graduation, Randy married Kelly, who he had met in college while she was in a sorority and used to come to his frat parties. Kelly herself enjoyed an occasional drink but always stopped at one, since she did not like the sensation of feeling light-headed or being out of control. She knew Randy drank heavily, but she assumed that all guys his age drank this much and expected his pattern would change as he got older and took on the responsibilities of a family and a career. The pattern did later change. But rather than drinking less, Randy began drinking more.

Randy had a good job in sales. His job was remote, allowing him to work from home and while on the road, affording him an opportunity to drink most days. When he traveled for work, he regularly drank during lunch meetings with colleagues and customers. In addition, he would “reward” himself after each workday by drinking expensive vodka and Venezuelan rum at home. Within a few years of joining the work world after graduating college, he was averaging 8 to 10 drinks daily. This pattern continued for the next 17 years.

In spite of his high level of drinking, Randy received positive work evaluations and promotions throughout the 17 years. He had no legal problems due to drinking. Although he regularly drove with a blood alcohol level over the legal limit, he had not had any accidents or arrests. He was a high-functioning alcoholic with a good career and family. What Randy could not ultimately avoid was the toll his drinking took on his marriage. For the first several years, Kelly tolerated her husband’s drinking, not recognizing it as a problem. A man with a serious drinking problem, to her way of thinking, was someone who couldn’t hold a job, got into fights, stayed out all night in bars, or beat his wife while drunk. Randy, however, talked to her every night when on the road traveling, and when in town working he had a quiet dinner with her either at home or at a restaurant. Sure, he always drank one or two at dinner and a nightcap after, but he seemed to be able to be one of those people who could hold his alcohol without having any problems. Or at least this is what she told herself for many years, until the problems began.

During the first 5 years of their marriage, Kelly worked full-time in a consulting firm. She worked long and hard hours but felt fulfilled and enjoyed the high salary. They were able to save for their future, and she was proud to make more money than her husband at such a young age. However, when she gave birth to their daughter, she worked part-time from home and made significantly less money. After several years like this, their son was born, and Kelly stopped working full-time to focus on raising a family. She had helped them save a lot of money during her time as a consultant, and Randy was happy to see her take less time to work and more time to take care of the young children and the home.

When their children both entered school full-time, Kelly began to work remotely in consulting again. Although it was demanding, she enjoyed the work, and the infusion of extra money felt great. However, after a while, she began to feel the effects of Randy’s drinking, as he was unable to provide much companionship or assistance in the evenings. She realized it had been this way for the past few years, but she had attributed this to the kids and the need to attend to their needs every night. By the time they were both in bed, Kelly was exhausted most nights and would go to sleep before Randy. Now, with more routine and less stressful days at home, she wanted to connect with him at night after the kids went to bed. But he wasn’t emotionally available. He would sit in his basement “man cave” watching sports while responding to e-mails and drinking. Kelly didn’t feel welcomed in Randy’s man cave. She always felt ignored when she tried to join him. As a way to have more social contact, Kelly began joining volunteer organizations in her community. Before long, she was going out some weeknights and weekends with new friends to attend volunteer functions. Randy told her it didn’t bother him but responded by withdrawing into his drinking even more. At age 40, Randy seemed to be the picture of success — on the surface. The father of a 9-year-old daughter and a 5-year-old son, he was vice president in charge of sales for his company, earning a high salary and regular bonuses. He had worked for the same company for a long time and worked his way up from sales associate to manager and now to an executive role. He was near the top of the organizational chart and was respected by his colleagues. He arrived at work consistently before 8:00 a.m., rarely missed an important meeting, and usually met his deadlines and sales quotas.

At the same time, Randy was continuing his long-term pattern of daily drinking, mostly vodka or rum, but sometimes bourbon or whiskey too, along with a few beers. He usually took his first drink of the day at lunch, when he went out to eat with colleagues or clients. To start off, the businessman would have a couple of vodka and waters while waiting for his meal. When his food arrived, he would order a beer to go with the meal. Longer meals meant another round of beer. Randy was under the impression that he was drinking no more than his lunch companions. However, he was actually doubling their consumption — not that they took special notice of his drinking. Although outgoing and gregarious at these lunches, Randy’s general behavior didn’t differ much from that of the others. His heavy drinking over the years had caused him to develop a tolerance to alcohol, so his three or four drinks over lunch affected him no more than one or two drinks might affect someone else.

DSM-5-TR does not have separate diagnoses of substance abuse and substance dependence. Rather, the separate criteria for abuse and dependence found in past diagnostic systems have been collapsed into one set of criteria in DSM-5-TR (APA, 2022, 2013).

At least 2 days a week, Randy had another work-related drinking opportunity. This was at a private club where his company entertained important clients. The club had an open bar, with waiters who took drink orders and automatically brought refills as soon as an empty glass was detected. It would be hard not to drink in such a place, Randy reflected. And of course he had no intention of making any such effort.

The purpose of the parties was to entertain visiting clients. The idea was to build relations with them on a personal as well as business basis. Randy’s company was looking for every edge possible, and if this meant spending several hundred dollars on a party that would help to secure accounts worth millions, it was considered well worth the investment.

Randy was acutely aware of the pressure to be friendly, jovial, and well-liked at these parties. In fact, the parties were a trial for him. There were high expectations for him to be entertaining, and each time, he was doubtful of his ability to carry it off. The alcohol took an edge off his anxiety, loosening him up and allowing him to mix freely. It took at least three drinks for him to reach this point and at least another two to keep the feeling going for the rest of the party.

Once home from work, whether on a party night or not, Randy felt the need to unwind. One Tuesday evening was typical. He came home and had a couple of rum and Diet Cokes before having dinner with his wife and their two children. He had planned to drink nothing more, aside from two beers with dinner, for the rest of the evening. But as usual, things went well beyond that. After dinner, Kelly had to go to a PTA meeting, and when she left, Randy felt bored. He knew that his wife would like him to do the dishes or entertain the kids while she was gone, but looking at the pile of pots and pans in the kitchen did not inspire him. Anyway, the kids seemed perfectly satisfied watching television in the living room. He made a half-hearted effort to ask them if they wanted to play a game or listen to a story, but they barely looked up from their show.

Feeling he had done his duty, Randy poured himself a drink and went out to the back deck to relax and listen to music. He sat there surfing the Internet on his phone for the next hour and a half, pouring himself another couple of drinks along the way.

When the concentration of alcohol reaches 0.09% of the blood volume, the drinker usually crosses the line into intoxication. If the level goes as high as 0.55%, the drinker will likely die.

When Kelly returned, she found a quiet house and felt resentful. The dishes in the kitchen were untouched, and the kids were still dressed and nowhere near ready for bed. And as usual, Randy was in his favorite spot in the basement drinking. Some nights, Kelly would just ignore the situation, get the kids ready for bed herself, and do the dishes. But that night she yelled at her husband, telling him he was lazy, irresponsible, and self-centered. Randy seized on the “self-centered” part and told his wife she should try applying the label to herself. She was the one who was out every night pursuing personal interests. Kelly asked what point there was in staying home to sit around doing nothing with a drunk. For his part, Randy denied he was drunk, saying he had every right to have a couple of drinks to unwind. What did she care anyway, since she wasn’t even home?

Then the phone rang and Kelly went to answer it. It was one of Randy’s colleagues. Kelly didn’t even consider turning the phone over to her husband; she carried out her usual policy of shielding him whenever he got calls this late in the evening and this deep into his drinking. She simply told the caller that he was out visiting a friend. After hanging up, she decided just to drop the whole matter and get on with things. Why waste any more time banging her head against a wall?

Spouses and other family members often shield problem drinkers from some of the negative consequences of their drinking. The spouses may, for example, make excuses for the drinker or fulfill the drinker’s social or business obligations. This is sometimes called enabling.

Arguments such as these left Kelly feeling increasingly unhappy with their life together. Indeed, she and Randy now barely had any life together. In the evenings, they went their separate ways. On weekends, they — mainly Kelly — did household errands. For recreation, she would attend activities tied to her volunteer work; he would watch sports on television or sit outside listening to music while looking at his phone and cooking meals on the grill, drinking himself into isolation. The children would either tag along on Kelly’s errands or hang around the house, receiving only limited supervision from Randy. Over time, Kelly began to consider leaving him. Randy and Kelly sat down one evening to do some paperwork for their taxes. As usual, Randy had been drinking throughout the evening, but he was still quite alert and had no problem in sorting receipts, organizing records, and carrying out calculations. It was a 2-hour project, and the couple actually worked effectively together, chatting and even joking throughout the task. It was one of their rare periods of togetherness; how ironic, Kelly thought, that it should come over an activity like taxes. They got the whole job done that night, and both went to bed in good humor.

The next morning, however, Randy said something that floored his wife. He asked her when she wanted to get together to do the taxes. She stared at her husband in disbelief but soon realized he was absolutely serious; he had no recollection of having completed the paperwork the night before. Kelly told Randy that they had already done the taxes, and he didn’t believe her. “How could I forget doing taxes?” he asked. At this, Kelly ran to get the evidence, the paperwork from the night before. Randy was shaken. Kelly was right. He had done the taxes, but for the life of him he could not remember it. It was as if somebody else had done the whole thing for him.

Truly upset, Randy decided that from then on he would have no more than a couple of beers in the evening. However, after a few days, his determination broke down and he returned to his usual pattern of drinking.

After the incident with the taxes, Kelly took to quizzing Randy routinely about events from the day before, and it soon became clear that the tax affair was not an isolated event. There were many mornings when he could not recall details from the night before. Kelly finally persuaded her husband to seek professional help with his drinking problem. She had seen an advertisement describing a community clinic that specialized in treating alcohol use disorder and related marital problems through the use of marital therapy. Kelly called for information and then, with Randy’s agreement, arranged an appointment for them. While interviewing Randy and Kelly, it became clear to Dr. August West, a psychologist who had been in practice for over 20 years, that Randy had alcohol use disorder. The client had developed a tolerance to alcohol. He often drank larger amounts than he intended; he had a persistent desire for alcohol; he drank to intoxication on a daily basis and had done so for many years; he neglected household obligations because of his drinking; and he continued his drinking despite realizing that it was possibly causing memory difficulties.

When people develop tolerance to a substance, they need increasing amounts of it to keep getting the desired effect.

Dr. West was trained in cognitive-behavioral therapies and for problems with alcohol, he usually used a behavioral model, called the SORC model, as a framework for his interventions. The acronym SORC stands for the chain of events — stimulus, organism, response, consequences — that lead to a given pattern of behavior. In the SORC model of alcohol use disorder, stimulus refers to external situations that prompt drinking, such as being at a bar, being with certain friends, or having an argument with one’s spouse. Organism denotes events that take place within the individual, such as thoughts, emotions, or withdrawal symptoms. Response refers to the specific drinking behaviors prompted by stimulus events and organismic states. And consequence refers to the results of drinking behavior, such as the reduction of anxiety or reduction of productivity.

According to the SORC model, each instance of drinking is a response to stimulus events or organismic states, and drinking is maintained because the consequences are in some way reinforcing. Correspondingly, to eliminate excessive drinking and to help people develop more adaptive behaviors, therapists must try to change each element in the SORC chain.

Whenever a client’s drinking was destroying their marriage, Dr. West would conduct treatment within a couples’ therapy format, in which he would use a combination of cognitive and behavioral techniques, applying them in three stages. In the first stage, he would teach the drinker skills for reducing and eliminating excessive drinking. In the second stage, he would help the spouse to see their role in the partner’s drinking, both as a trigger and as a consequence. In the third stage, he would offer communication and problem-solving training to help improve marital functioning. Throughout treatment, he would use the language and principles of the SORC model.

Some of the most common problems to arise between partners when one of them abuses alcohol are marital conflict, infidelity, domestic violence, marital stress, jealousy, and divorce (NIAAA, 2021b; Watkins, 2021).

Session 1

After gathering a complete picture of Randy’s problems and of Randy and Kelly’s marital difficulties, Dr. West explained to them the logic behind his treatment approach. Specifically, he presented the SORC model, noting that drinking can be viewed as a behavior that an individual carries out in response to certain situations or feelings, which the psychologist labeled triggers. Sometimes the drinking may occur out of habit; other times it may be a means of coping with the triggers themselves. For example, the drinking may be a way of coping with feelings of anxiety, loneliness, or the need to be sociable. The psychologist explained that the goal of treatment was for Randy to develop alternative ways of responding to these triggers.

Dr. West also noted that sometimes the triggers themselves should be changed. That is, certain situations, be they marital or work situations, may have some undesirable features, in addition to promoting drinking. The psychologist pointed out that although it would be important for Randy to learn to respond to such circumstances without drinking, it might be equally important to eliminate or reduce some of the undesirable features themselves. For example, if Randy was drinking because he was lonely, it might be helpful to see what could be done to decrease his loneliness. If he was drinking because of habits in certain places every night, he could change his behavioral patterns to avoid those places or the things that served as cues to increase the chances that he drinks.

As they talked, Kelly voiced concern that she was being blamed for Randy’s drinking. She stated that if her husband were lonely, he had only himself to blame. It was hard enough dealing with Randy’s drinking — and for her to be considered responsible was the last straw. And she explained that she had tried to move any triggers for drinking before, but there simply too many of them in the house. She became incensed: “He has drunk so much for so long that to remove his triggers would mean we would have to literally move to a new home!” Randy put his head down and rubbed his temples in frustration. The therapist felt frustrated too, but with his experience he knew how difficult it can be to remove all triggers for alcohol use. This would only be one part of the overall cognitive-behavioral approach to treatment for Randy.

Dr. West clarified his point, explaining that the person with the drinking problem should be viewed as entirely responsible for their drinking. At the same time, the psychologist noted, it would be important for both Randy and Kelly to examine the changes that each was willing to make to help him avoid alcohol. Under no circumstances, however, would Kelly be asked to make changes that she felt were unfair.

Next, the psychologist explained the behavioral monitoring that would be used throughout treatment. Both Kelly and Randy would complete a monitoring record each day. Both Kelly and Randy had smartphones, and they agreed that the easiest method to do the monitoring would be to use a self-monitoring app that would provide a daily alarm prompt to complete the form. On his app, Randy was to record any urges to drink, the intensity of the urges (on a 1-to-7 scale), the type and amount of drinks consumed, and his marital satisfaction that day (also on a 1-to-7 scale). On her app, Kelly would record her perception of Randy’s urges to drink, the level of drinking she perceived that day, and her level of marital satisfaction.

Also, Dr. West instructed Randy to complete a trigger sheet (see Figure 10-1) during this first week, both to assess his drinking in SORC terms and to help him see the triggers and consequences of his drinking. Because Randy was so shaken by his memory lapses and concerned about his health in general, Dr. West felt that his motivation to stop drinking was strong. Nevertheless, he gave the client an additional homework assignment that involved listing both the advantages and disadvantages, as Randy saw them, of continued drinking versus abstinence.

Figure 10-1 “Triggers” sheet used by Randy (from McCrady et al., 2022; McCrady, 1990)

Session 2

Dr. West, Randy, and Kelly examined Randy’s drinking in detail, based on the records of the past week. The client’s trigger sheet indicated that there were three main circumstances in which his drinking occurred: business lunches, business parties, and watching television in the evening. During the business situations, the following thoughts often occurred:

“Everyone always drinks.”

“I need to drink or else I will stand out in a negative way.”

“If I don’t drink and others do I will feel left out.”

By the end of 15 sessions, Randy had not had a drink for more than 2 months, and he remained committed to abstinence. In addition, he and Kelly reported they were communicating better and working out their problems more effectively.

The rate of alcohol use disorder is three or more times higher in the close biological relatives of individuals with alcohol use disorder (Duncan, 2020; NIDA, 2020c, 2019).

Dr. West saw them four times over the next year. Randy continued to be abstinent throughout the year and reported having only a few urges to drink each week. Moreover, the couple’s marital satisfaction remained high. They continued to attend the couples group once a week as part of Randy’s relapse prevention strategy. Kelly was able to find meaningful and fun things to do outside of home each week, and Randy was supportive. Overall, life without alcohol was better than Randy ever could have imagined before beginning therapy. As Randy would often say, he had put the monster back in the bottle and along the way had rediscovered his wife, his children, and the many pleasures that life could bring.