1. What would your initial assessment of Laura be?

1. Substance Abuse Dependency. Laura exhibits all the classic symptoms of addiction/dependency
as outlined in the textbook.
a. Cravings: The psychological need to have a drink to calm her down, relieve her stress and
unwind. i.e. Drinking for emotional / psychological relief.
b. Loss of Control: Once Laura begins drinking. Intending to have just one glass of wine with
dinner, she unintentionally finishes the bottle. Laura is aware of her loss of control. She is becoming
more isolated and avoiding social events unless they are absolutely necessary. She is avoiding her
social life in order to be at home were she can drink without risking her
relationships with friends and business associates.
c. Tolerance: Laura is aware that her consumption of these drugs has increased and that she is no
longer able to control her drinking or her antianxiety medication Xanax?
. In combination, alcohol and a benzodiazepine can have a synergistic effect on the CNS. This creates
an increase in tolerance and also pushes the user closer toward a potentially lethal drug overdose.
d. Continued Use Despite Negative Consequences: Despite Laura’s awareness that she has
been increasing her drug use and that it was getting out of control for her, she continued to use. This
cost her a valuable client and possibly her job. It was only at her boss’s insistence that she contact the
company’s EAP program that Laura is even in your office at this time. Given the above information, it
seems fairly certain that Laura has moved from the habitual stage of this disease and is now in the
abuse/dependency stage of alcoholism.

2. What would you say Laura’s main drug of choice is and do you think she will need to be placed in a
detoxification program to address this problem?
2 From the medical / drug history Laura has given you it would appear that she has become
dependent on alcohol and benzodiazepines and in all likelihood will need a medical detox. You
would always want to get a medical evaluation to confirm if your assessment is correct. A
referral to a physician certified in addiction medicine should be a routine part of any substance
abuse assessment. Ruling out any other medical information at this point, it seems that the
safestcourse of action to treat Laura would be to place her in an in-patient hospital detoxification
program. Failing this arrangement, then an outpatient medical detoxification and recovery program
would be a second option. However, because this is Laura’s first attempt at detoxification, and her
statements on her previous inability to stop her drug use on her own, the counselor would be advised
to set up a contingency contract with Laura before placing her in an out-patient program. This contract
would acknowledge that should Laura fail to achieve stability in the out-patient program she would
then seek treatment in an in-patient program. Laura is also taking a fair amount of stimulants too.
Prescription diet pills for weight control, caffeine, and nicotine. These may or may not complicate the
treatment picture and you would want to get a medical opinion on these medications as well. It would
be prudent to also alert her treating physician about your concerns. It would also be important that
Laura be counseled as to the potential that she may experience some weight gain while going through
the detox process. Reassure her that this is normal out come at first and that controlling her weight will
become easier when she is not taking in all the alcohol. Recommend a good nutritional program with
exercise based on the recommendations of her doctor and /or nutritionist.

3. Based on Laura’s emotional situation and the medications she is taking, what if any dangers do you
need to be aware of?
3. The danger is the potential for an accidental overdose. You will need to educate the client as to the
synergistic effects of alcohol and benzodiazepines. The purpose of the detoxification is to slowly and
safely withdraw her from these medications and lower the risk of such an event occurring. The other
danger is intentional suicide. Laura is facing what may seem to her some overwhelming life tasks.
Loss of an important client, possible loss of her job, embarrassment in being referred to an employee
assistance program, the stigma of being an alcoholic, and needing treatment, and unresolved grief
over the death of her father. All these and other issues may appear to Laura, at this point in time, just
too much and she may toy with the possibility of suicide. Also, depressant medications and drugs will
skew her view of her situation making it appear more hopeless than it really is. The counselor or case
worker needs to constantly monitor Laura’s statements and affect for clues that she may be
contemplating suicide.

4. Based on the information Laura has given you who would you need to contact to advise them of
Laura’s situation and what would you need from Laura to make these contacts?
4. Laura will need to sign several releases of information so counselors and other treatment providers
can contact one other. This allows for a freer exchange of information regarding Laura’s situation. It
would be necessary that Laura’s doctor(s), those prescribing her benzodiazepines and diet pills, to be
informed of her being placed in an alcohol treatment program. Since Laura is here at the request of
her employer, he or she, will also have a right to receive minimum information as to whether or not
Laura is in treatment compliance and keeping her appointments with the EAP program. With regard to
issues of patient confidentiality, two sets of rules usually apply. Those of state law, found in the civil
codes pertaining to business and professional standards of practice and professional codes of
conduct and ethics. A counselor must be especially aware of what the state laws are regarding a
patient’s right to confidentiality in the state where they practice. Another superseding body of laws that
pertain to a patient’s right to confidentiality when they are receiving treatment for substance abuse, is
the Federal Rules of Confidentiality. This set of laws apply to any federal moneys that support that
treatment program. It can even be a non-profit tax exempt organization. In these cases then, the
Federal Rules and Regulations will apply and take precedent over state laws. Be sure you know and
are familiar with these laws. In cases where the two sets of laws conflict, courts have consistently held
with the law that provides the greater protection to the confidentiality of the patient

5. If Laura’s boss calls your office to find out how Laura is doing how would you respond to his inquiry?
What are his rights to know if Laura did keep her appointment with you?
5. In the case of Laura and her employer, the employer has the right to know or obtain a limited
amount of information regarding Laura’s treatment compliance. The employer does not have the right
to more detailed personal information on Laura. That she is keeping her appointments when into a
treatment program, expected length of that program, and if she participated satisfactorily in that
program is all an employer needs to know. Laura is within her rights to refuse signing such a release.
But she should then be aware that by denying the right for her employer to receive this information
gives her employer the right to terminate her employment.

6. What possible dual diagnosis issue(s) might Laura have and how would you do to confirm this
possibility.
6. There is certainly the possibility that Laura may have several dual diagnosis issues. It would be
important to begin a process of ruling out both Axis I and Axis II diagnoses as she becomes more
stabilized in her treatment program. Medical physicians and psychiatrists split on when to begin
intervention regarding a dual diagnosis patient. Suggest beginning medications for major depression
or bipolar disorder as soon as there is a reasonable suspicion that this component exists and will
influence treatment outcome. i.e., if that antidepressant medication will help that person remain in
treatment longer, then why wait. Other equally experienced physicians feel it is necessary to wait to
get a clearer picture of the patient before beginning a trial of medications. It is vital that such decisions
be left to the medical experts. The therapist’s and counselor’s job would be to pass on any changes
they see in the patients affect or demeanor to the medical staff so they can do further evaluations or
tests, if necessary. In Laura’s case there are strong indications that she never had the time to grieve
the death of her father whom she was very close to. What can start out as uncomplicated
bereavement, if not processed properly, can move into depression. In Laura’s case this may have
occurred as she began self-medicating her grief with alcohol and benzodiazepines. There is also just
a hint that Laura’s father may have been an alcoholic. Getting a good family history and genogram
would be one way to explore this possibility. If this is true, then Laura may be genetically predisposed
to alcoholism. You also want to decide whether Laura is Bipolar (I or II), Cyclothymic, has Major
Depression or Dysthymia. Laura is using Xanax? for anxiety. Is this a panic disorder? She reports
having become less social in recent months. Certainly this can be part of the overall isolation that
occurs when a person moves into alcohol dependency. But, you would want to rule out whether she is
also suffering from Social Phobia, Panic Disorder with or without Agoraphobia, or Agoraphobia
without a history of Panic Disorder. Another question is “What part does her diet pill, caffeine, and
nicotine use and abuse play in this picture.” Regarding Laura’s sleep medication, several more
questions will need to be clarified. To what extent has her alcohol abuse and other substance use
caused her sleep disorder. Alcohol is known to suppress REM sleep and disturb the normal sleep
cycle. i.e. Substance-Induced Sleep Disorder. However, you would want to rule out other possibilities
such as; Insomnia, Sleep Terror Disorder, Parasomnia NOS, or Sleep Disorder Due to General
Medical Conditions. All the above will issues will certainly complicate the substance abuse treatment
picture for Laura.