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CASE STUDY: JEFF
Case Study: Jeff
Elise Y. Schultheis
School of Behavioral Sciences, Liberty University
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CASE STUDY: JEFF
Case Study Jeff
Client Concerns
Symptoms Behaviors Stressors
Hangovers Drinking daily, if on site 4-8
beers after work. If off, 6-8
beers along with multiple
shots of liquor.
Fear of losing his job
Recent divorce and his ex-
wife getting remarried soon.
Depression Drinking has increased due to
wanting to drink to
intoxication.
Has received four violations
at work for his blood alcohol
content being above the
maximum allowed on-site.
Resulting in suspension
without pay.
Fatigue Drinks with friends on days
he is off work.
In the last 18 months, it has
taken longer to recover from
a night of drinking, causing
the client to be late for work.
Resulting in being written up.
Lack of appetite Domestic violence against
ex-wife on three separate
occasions during their
marriage.
Has received two DWIs once
in his mid 20's and again in
his early 30's.
Assessment
Jeff displays increasing indications of both Major Depressive Disorder and Alcohol Use
Disorder. Employing the Beck Depression Inventory (BDI-II) would be advised for assessing his
condition. The BDI-II, as described by Moore et al. (2016), is a self-report questionnaire
consisting of 21 items designed to gauge the presence and severity of depressive symptoms.
Each item is rated on a 4-point scale, indicating the severity experienced by the individual over
the previous two weeks (Moore et al., 2016). Major Depressive Disorder is closely intertwined
with substance use disorders, which can either alleviate or exacerbate specific depressive
symptoms (Moore et al., 2016).
Diagnostic Impression
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CASE STUDY: JEFF
Signs and Symptoms
DSM-5-TR Diagnostic Criteria: Alcohol use
disorder (F10.20 Severe)
Client’s Signs/Reported Symptoms:
Criterion A: A problematic pattern of alcohol
use leading to clinically significant
impairment or distress, as manifested by at
least two of the following, occurring within
12 months.
A1. Alcohol is often taken in larger amounts- The
client has increased the number of beers he drinks
each day to become intoxicated.
A2. There are unsuccessful efforts to cut down or
control alcohol use- Received counseling and
attended AA in the past both efforts were
unsuccessful.
A3. Craving, or a strong desire or urge to use
alcohol- The client leaves work and as soon as
returning to the hotel room begins to drink.
A4. Recurrent alcohol use resulting in a failure to
fulfill major role obligations at work, school, or
home- The client has four violations at work for
alcohol levels resulting in suspension.
A5. Continued alcohol use despite having
persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of
alcohol- The client reports his drinking was the
reason for divorce, and drinking has continued to
increase.
A6. Recurrent alcohol use in situations in which it
is physically hazardous- The client has reported
coming to work hungover.
A7. Tolerance: A need for markedly increased
amounts of alcohol to achieve intoxication or
desired effect- The client has reported an increase
to 6-8 beers along with shots of liquor.
Major Depressive Disorder (F33.1 Moderate
and Recurring)
Criterion A: Five (or more) of the following
symptoms have been present during the same
2-week period and represent a change from
previous functioning.
A1. Depressed mood most of the day, nearly
every day, as indicated by either subjective report
(e.g., feels sad, empty, hopeless)- The client
reported that he has a sad episode that lasts 7-8
months. Reported feeling sad since he was 15
years old. Reported feelings of hopelessness.
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CASE STUDY: JEFF
A2. Significant weight loss when not dieting or
weight gain-Client reports losing 25 to 30 pounds
during sad episodes.
A3. Markedly diminished interest or pleasure in
all, or almost all, activities most of the day, nearly
every day- Client reports pulling away from
friends and family during sad times. Reported,
"losing all interest in activities that he normally
enjoyed and feeling hopeless about his life in
general."
A4. Insomnia- the client reports symptoms of
trouble sleeping and fatigue during sad episodes.
Reporting cannot seem to get enough sleep.
A5. Diminished ability to think or concentrate, or
indecisiveness, nearly every day- The client
reported having trouble concentrating at work
during sad episodes. Co-workers have shown
concern during these times.
Criterion B: The symptoms cause clinically
significant distress or impairment in social,
occupational, or other important areas of
functioning.
The client has reported being passed up for
promotion due to symptoms interfering with
normal work habits. The client is generally seen
as a good worker, but during sad episodes cannot
seem to concentrate.
Criterion C: The episode is not attributable to
the physiological effects of a substance or
another medical condition.
The client reports some use of marijuana in
the past but does not currently use nor has any
medical conditions.
Criterion D: At least one major depressive
episode is not better explained by
schizoaffective disorder.
The client reports no signs or symptoms of
schizoaffective disorder.
Criterion E: There has never been a manic
episode or a hypomanic episode.
The client reported he has never had any
psychotic or manic-like symptoms.
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CASE STUDY: JEFF
(American Psychiatric Association, 2022)
Other DSM-5-TR Conditions Considered
Other potential disorders that merit consideration and exclusion include Persistent
Depressive Disorder and Substance/Medication-Induced Depressive Disorder. Persistent
Depressive Disorder was assessed due to its hallmark feature of persistently enduring symptoms
for a year or longer (i.e. such as poor appetite, insomnia, and fatigue) (APA, 2022). However, it
was excluded from Jeff's diagnosis as his symptoms did not persist continuously for the required
duration. Similarly, Substance/Medication-Induced Depressive Disorder was scrutinized due to
the possibility of depressive symptoms being linked to alcohol consumption (APA, 2022).
Despite Jeff's increased drinking over the past two years, no major depressive episodes have
occurred, and he reports experiencing sadness regardless of alcohol intake. Thus, this disorder
was also ruled out.
Developmental Theories and/or Systemic Factors
Considering Jeff's family background, he is likely navigating Erikson's psychosocial
stage of "Intimacy vs. Isolation" in the context of familial influences (Gilleard, 2020). Jeff's
position as the fourth of six children suggests that he has experienced significant familial
dynamics and interactions throughout his life. His parents' long-standing marriage of 45 years
and regular contact with Jeff indicates a stable familial environment, one possibly influenced by
his father's daily drinking habits and his mother's sadness. Jeff's relationships with his siblings,
particularly his two brothers who drink similarly to him and his father, highlight the familial
normalization of alcohol consumption. However, his estrangement from one brother due to their
differing views on alcohol underscores potential conflicts within the family system regarding
drinking behaviors. Jeff's early exposure to alcohol at the age of seven, in the company of his
father and older brothers, further emphasizes the familial acceptance and normalization of
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CASE STUDY: JEFF
drinking behaviors within his upbringing (Gilleard, 2020). These familial dynamics may
contribute to Jeff's current functioning and behavior, impacting his attitudes toward alcohol use
and interpersonal relationships (Gilleard, 2020).
Multicultural and/or Social Justice Considerations
Given Jeff's Baptist background and the cultural context of his family, his lived
experience and perception of his symptoms and situation may be influenced in several ways.
From a cultural standpoint, Jeff may view mental health issues as taboo or stigmatized topics, as
they were not openly discussed within his family. This cultural norm could lead Jeff to minimize
or downplay his depressive symptoms, as seeking help for mental health concerns might be
perceived as a sign of weakness or failure. Instead, Jeff may attribute his symptoms to external
factors or stressors, such as his recent divorce, without recognizing the underlying mental health
implications (Wlodarczyk, 2017). Additionally, Jeff's cultural background may instill traditional
values related to masculinity and emotional expression, which could further inhibit his
willingness to acknowledge or seek help for his depressive symptoms (Wlodarczyk, 2017).
Furthermore, the normalization of alcohol consumption within Jeff's family may contribute to his
acceptance of his drinking habits and his reluctance to recognize the negative impact they may
have on his mental health (Wlodarczyk, 2017). Overall, Jeff's cultural identity may influence his
perception of his symptoms and situation, potentially hindering his ability to recognize the need
for mental health support and treatment.
Treatment Recommendations
Key Issues for Treatment
Depression
Substance use Alcohol
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CASE STUDY: JEFF
Fatigue
Recommendations for Individual Counseling
In Jeff's case, the recommended treatments for individual counseling offer tailored
approaches to address his complex needs and challenges. Cognitive Behavioral Therapy (CBT)
provides a structured framework to help Jeff identify and challenge negative thought patterns and
behaviors contributing to his depression and alcohol use. Through CBT, Jeff can learn practical
skills to cope with depressive symptoms, such as cognitive restructuring techniques to challenge
distorted thinking and behavioral activation strategies to increase engagement in enjoyable
activities (Clark & Holttum, 2022). Additionally, CBT can assist Jeff in developing effective
coping mechanisms to manage triggers for alcohol use and address underlying psychological
factors contributing to his drinking habits (Clark & Holttum, 2022). Additionally, Motivational
Interviewing (MI) takes a collaborative and client-centered approach to enhance Jeff's intrinsic
motivation for change regarding his alcohol use and mental health. Through MI, Jeff and his
counselor can explore his values, goals, and concerns related to drinking and depressive
symptoms in a non-confrontational manner (Pace et al., 2017).
By fostering a supportive and empathetic therapeutic relationship, MI can help Jeff
resolve ambivalence and build confidence in his ability to make positive changes (Pace et al.,
2017). Furthermore, MI techniques such as decisional balance exercises and exploring the pros
and cons of behavior change can empower Jeff to take ownership of his recovery journey and
work towards his goals at his own pace (Pace et al., 2017). By integrating both CBT and MI into
Jeff's individual counseling sessions, he can benefit from a comprehensive and collaborative
approach that addresses his unique needs while respecting his autonomy and cultural
background.
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CASE STUDY: JEFF
Specific Considerations
Medication Considerations
As Jeff exhibits escalating symptoms of both Major Depressive Disorder and Alcohol
Use Disorder, medication may be considered as an adjunct to psychotherapy to alleviate his
symptoms and support his recovery. Medication evaluation may be warranted if Jeff's depressive
symptoms are severe and significantly impairing his daily functioning or if he has not shown
significant improvement with psychotherapy alone. Antidepressant medications, such as
selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors
(SNRIs), are commonly prescribed for Major Depressive Disorder and have been shown to
effectively reduce depressive symptoms in numerous studies (Compagner et al., 2021). SSRIs
and SNRIs work by increasing the levels of neurotransmitters such as serotonin and
norepinephrine in the brain, which can improve mood and alleviate symptoms of depression
(Compagner et al., 2021). Additionally, medications such as naltrexone or acamprosate may be
considered for Alcohol Use Disorder treatment (Palpacuer et al., 2018). These medications can
help reduce cravings for alcohol and decrease the pleasurable effects of drinking, thereby
supporting efforts to abstain from alcohol (Palpacuer et al., 2018). However, it's essential to
consider potential risks and side effects associated with medication, as well as Jeff's individual
preferences and concerns. Collaborative decision-making between Jeff, his counselor, and a
psychiatrist or primary care provider is crucial in determining the most appropriate course of
treatment.
Unique Client Considerations
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CASE STUDY: JEFF
As a counselor, I recognize the complex nature of co-occurring disorders and the
importance of thoroughly assessing their interplay in shaping a client's overall well-being. I must
understand how each disorder influences the other and impacts the client's functioning daily
(Gutierrez et al., 2018). This assessment process involves considering factors such as the severity
of each condition, the client's readiness for treatment, and the potential risks associated with
addressing one disorder over the other (Gutierrez et al., 2018). In many cases, addressing both
disorders simultaneously may be necessary to achieve the most effective treatment outcomes.
This approach acknowledges the relationship between co-occurring disorders, where one can
exacerbate or perpetuate the other (Gutierrez et al., 2018). For example, substance use disorders
often coincide with mental health disorders such as depression or anxiety, and addressing both
concurrently can enhance treatment effectiveness. However, I also understand that there may be
situations where prioritizing the more acute or severe condition is necessary.
Furthermore, I am mindful of the challenges posed by substance use disorders in the
diagnostic process. Substance use can mask or mimic symptoms of other mental health disorders,
leading to diagnostic uncertainty. Therefore, I prioritize conducting a thorough assessment that
includes screening for substance use to accurately identify any co-occurring disorders (Gutierrez
et al., 2018). This comprehensive approach allows me to develop an appropriate treatment plan
tailored to the client's unique needs and circumstances (Gutierrez et al., 2018). Additionally, I
recognize that substance use can influence treatment recommendations by necessitating
interventions such as detoxification and harm reduction before addressing other mental health
concerns. Collaboration between myself and the client is essential throughout this process to
ensure that interventions are aligned with their goals, preferences, and values (Gutierrez et al.,
2018).
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CASE STUDY: JEFF
References
American Psychiatric Association (2022). Diagnostic and statistical manual of mental disorders:
DSM-5 TR (5th ed. Text Revision). American Psychiatric Association Publishing.
Clark, C., & Holttum, S. (2022). ‘A life I can cope with’. an alternative model of cognitive
behavioral therapy (CBT) for CFS/ME. Health Expectations: An International Journal of
Public Participation in Health Care and Health Policy, 25(1), 91-102.
https://doi.org/10.1111/hex.13326
Compagner, C., Lester, C., & Dorsch, M. (2021). Sentiment analysis of online reviews for
selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors.
Pharmacy, 9(1), 27. https://doi.org/10.3390/pharmacy9010027
Gilleard, C. (2020). The final stage of human development? erikson's view of integrity and old
age. International Journal of Ageing and Later Life: IJAL, 14(2), 1-24.
https://doi.org/10.3384/ijal.1652-8670.1471
Gutierrez, D., Fox, J., Jones, K., & Fallon, E. (2018). The treatment planning of experienced
counselors: A qualitative examination. Journal of Counseling and Development, 96(1),
86-96. https://doi.org/10.1002/jcad.12180
Moore, A. A., Neale, M. C., Silberg, J. L., & Verhulst, B. (2016). Substance use and depression
symptomatology: Measurement invariance of the beck depression inventory (BDI-II)
among non-users and frequent-users of alcohol, nicotine, and cannabis. PloS One, 11(4).
https://doi.org/10.1371/journal.pone.0152118
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CASE STUDY: JEFF
Pace, B. T., Dembe, A., Soma, C. S., Baldwin, S. A., Atkins, D. C., & Imel, Z. E. (2017). A
multivariate meta-analysis of motivational interviewing process and outcome.
Psychology of Addictive Behaviors, 31(5), 524-533. https://doi.org/10.1037/adb0000280
Palpacuer, C., Duprez, R., Huneau, A., Locher, C., Boussageon, R., Laviolle, B., & Naudet, F.
(2018). Pharmacologically controlled drinking in the treatment of alcohol dependence or
alcohol use disorders: A systematic review with direct and network meta‐analyses on
nalmefene, naltrexone, acamprosate, baclofen, and topiramate. Addiction (Abingdon,
England), 113(2), 220-237. https://doi.org/10.1111/add.13974
Wlodarczyk, O., Schwarze, M., Rumpf, H., Metzner, F., & Pawils, S. (2017). Protective mental
health factors in children of parents with alcohol and drug use disorders: A systematic
review. PloS One, 12(6). https://doi.org/10.1371/journal.pone.0179140
