Running head: SCHOLAR PRACTITIONER PROJECT
Scholar Practitioner Project
Brookes Davis
Walden University
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Narrative Case Study
Identifying Information
The client in this case is Marge C. Marge is a forty-one-year-old, Caucasian female.
Marge is married to Ken. Marge and Ken are parents of three children, ages sixteen, twelve, and
ten. Marge has a background in education and has previously been employed as a teacher
(Laureate Education, 2014a).
Presenting Problem
Marge was brought into the residential treatment program by her husband, Ken. Prior to
their arrival, Marge’s family and friends held an intervention in the home. Marge’s family and
friends are concerned about Marge’s alcohol use. Marge’s physical appearance is described as
disheveled. Her eyes are red, and she appears to have been crying. Marge is without makeup and
her face shows a black eye and other facial abrasions. Marge is possibly experiencing alcohol
withdrawal, as evidenced by her unsuccessful attempts to control the visibility of her trembling.
Upon entering the facility, it became clear that Marge does not want to be here. Marge is
defensive and blames her husband for bringing her into the treatment facility. Marge’s body
language also shows resistance, as she avoids eye contact with therapist and sits with her arms
closed (Laureate Education, 2014a).
Assessment
The clinical interview is a critical portion of the screening process. The screening process
seeks to detect unhealth use and should lead to further assessment if the findings indicate a risk
for substance misuse or abuse (Doweiko, 2019). Self-reports from the client and her husband at
intake can explore the family’s purpose for visiting the facility and provide another perspective
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on Marge’s substance use. Use of brief verbal screening aids such as the TWEAK questionnaire
may be useful with Marge. The TWEAK questionnaire is brief and may be more effective
considering Marge is not happy to be at the treatment facility. The questionnaire can also provide
insight into the intensity of Marge’s alcohol use, which can further inform assessment efforts
(Laureate Education, 2014a; Doweiko, 2019). Marge also verbalizes “constant depression.”
Administering Beck’s Depression Inventory will help to identify if the client is at risk of
depression. Ongoing assessment consists of standardized tools such as the Drug Use Screening
Inventory- Revised (DUSI-R) to explore domains of drug/substance use, psychiatric and
behavioral concerns, adjustment concerns in school and work, impact on health and relationship
with peers, social competencies, and leisure. Exploring these domains align with
recommendations from Frances’ on elements of better assessments (Laureate Education, 2014a;
Doweiko, 2019). Finally, the initial week of treatment will introduce use of the Structured
Clinical Interview for DSM to fully explore the client’s mental health symptoms and lead to
diagnosis. The clinician can also gather information from interviews with families and blood
screenings to assess for comorbidity (Laureate Education, 2014a; Doweiko, 2019).
Addiction History
According to Marge’s self-reports, Marge’s use of alcohol began at least sixteen years
ago. She reported initially having a glass of wine after work several days out of the week and
progressed to having a drink daily, which eventually turned into drinking every morning to get
her day started and “feel normal.” Marge reported hiding her drinking from her family, friends,
and co-workers and admits to becoming “horribly ill” if she doesn’t have alcohol. Marge also
reports hallucinations and recalls seeing the same symptoms in her father and uncle (Laureate
Education, 2014a). Marge’s use of alcohol led to termination from employment, a DUI, and
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drastically impairs her roles of wife, mother, friend, and sister. Marge has attempted to stop
drinking on her own and has abstained from alcohol for “a month or two”, citing participation in
AA and visits to a counselor in the community. In the initial contact, Marge admits that she has a
problem drinking but believes she has been unsuccessful in stopping use of alcohol because she
hasn’t exerted maximum efforts. Eventually Marge expresses willingness to undergo treatment as
a means of restoring her usefulness to her family (Laureate Education, 2014a).
Co-Occurring Disorders
Marge reports being depressed since a teenager, expressing that she could not recall a
happy moment in her childhood. Marge reported constantly feeling stressed, angry, and
depressed. Marge reported daily symptoms of depression that impact her functioning and trigger
use of alcohol (Laureate Education, 2014b).
Medical History
Marge reports a prior history of diabetes and expressed her health has been complicated
by her use of alcohol. Marge admits she has “totally ignored her health.” (Laureate Education,
2014b).
Educational/Vocational History
Marge appears to be well-educated. Marge has previously been employed as a teacher.
However, Marge was terminated after her superiors smelled alcohol on her. She admits to
drinking daily before work. As a result of the termination, Marge has no income and her husband
has adapted to working two jobs to support the family (Laureate Education, 2014a; Laureate
Education, 2014b).
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Legal History
Marge is currently facing charges for Driving Under the Influence after a one-car,
alcohol-related accident a few days ago. Based on reports from Marge, this is her first legal
infraction. Marge is not optimistic about having to address this incident when she returns home
from treatment (Laureate Education, 2014a).
Social/Cultural Status
Socioeconomic status can be determined by considering the individual’s education
attainment, occupation, and income levels. Higher educational attainment often influences
occupation and income levels, increasing comfort and status in life (Holosko, Dulmus & Sowers,
2013). Marge’s employment as a teacher suggests she has at least a bachelor’s level education.
Little information is presented on Ken’s vocational training or education. However, it is
documented that he works two jobs. Marge described the family’s finances as “a mess.” As a
teacher, Marge may have a high level of respect in the community and share connections with
others in the profession as well as within the community. American culture views alcohol use as
an acceptable social activity but also encourages control of consumption. Before seeking help at
the facility, Marge attempted to hide her drinking to appear in control. This is a direct reflection
of the culture’s influence on Marge’s alcohol use. Moreover, advertisements glamourizing
alcohol use are rampant today. These cultural factors may further influence Marge’s use of
alcohol (Laureate Education, 2014b; Doweiko, 2019). Marge shares no information on any social
or leisure activities outside of the mention of a few close friends.
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Family/Relationship Status
Like any other system, the slightest change in the family environment can influence other
members in the family (Doweiko, 2019). Marge and Ken have three children: twelve-year-old
Roger, sixteen-year-old Carla, and ten-year-old Scotty. Ken reported their youngest Scotty may
be less influenced by Marge’s alcoholism; however, Scotty’s attempts to bring laughter to the
family may be an effort to reduce conflict in the home. Roger’s behaviors seem to concern both
Marge and Ken. The only unified efforts to address Roger’s behavior or give him attention occur
when he gets into trouble at school, confirming that Roger’s behaviors may be attention-seeking
efforts. Marge and Ken’s sixteen-year-old daughter Carla appears to have assumed parenting
roles in the absence of her parents. Carla makes good grades, is involved in sports, and is popular
in school. (Laureate Producer, 2014c). Carla’s assumption of parenting responsibilities has
reduced responsibility for both of her parents, further delaying addressing Marge’s alcoholism
and contributing to ongoing substance use and development of codependent patterns of
behaviors. Carla is at risk of self-esteem issues because there is a likelihood that she will
determine her own value by the effectiveness of her attempts to maintain the family unit
(Doweiko, 2019. Laureate Producer, 2012; Margasinski, 2017).
Models of Addiction
The Sociocultural Model of Addiction
The Sociocultural Model of addiction seeks to identify and likely intervene to address the
systemic issues that might influence an individual to drink. This perspective asserts culture,
environmental factors, and even elements of the individual’s family system can either contribute
to the development of a substance use disorder or be useful in helping the individual to build a
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resistance against substance use disorders (Doweiko, 2019). The Sociocultural Model also
focuses on the role of culture in development of addictions. The model recognizes that culture
can encourage use of chemicals to alter an individual’s perception of reality and factors such as
the drug of choice, expectations for use and current state of mind, as well as the context of use
can contribute to ongoing substance use (Doweiko, 2019). In short, the social perspective places
more emphasis on the interactions within the environment of the individual struggling with
addiction.
Strengths and Limitations of the Model
As with any model, there are specific strengths and limitations to use of the Sociocultural
Model of Addiction. The model’s systemic approach to addiction empowers individuals dealing
with addiction to accept responsibility for some of society’s norms and expectations for human
behavior (Doweiko, 2019; Winters, 2012). The model’s focus on the influence of environmental
factors is useful for identifying populations that may be considered at risk of developing
substance use disorders and informs prevention efforts in the addiction field. Finally, the
Sociocultural Model can help to increase cultural competency in clients by increasing their
awareness of cultural norms, impacting their relationships and interactions with others across
systems in their ecology (Doweiko, 2019; Winters, 2012).
Rationale for Use
Marge’s reports to the clinician suggest a need for further assessment of the client’s use of
substances. Marge reported that her father and uncle were alcoholics, and while many may
believe this statement is evidence of a genetic influence, the statement also suggests that Marge’s
use of alcohol may be a result of social learning (Laureate Education, 2014; Doweiko, 2019).
Moreover, Marge’s expression of the escalation of her drinking from its’ socially acceptable use
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after work to drinking through the day to deal with negative factors such as caretaking and
hopelessness suggests Marge’s alcohol use is largely influenced by sociocultural factors
(Laureate Education, 2014: Doweiko, 2019). Use of the sociocultural model will help to increase
positive or protective factors, counteracting factors contributing to substance use.
Model of Treatment
Family/Marital Therapies
Family/Marital therapy is a generic term that applies to an umbrella of approaches that
focus on psychodynamics, structural and behavioral systems, and family systems. The family
disease model is one of the most common forms of family therapy (Doweiko, 2019). This
treatment model recognizes the family as a system and asserts that impacting any part of the
system can affect change in other parts. Family and marital therapies use family strengths to
encourage abstinence and recovery. Family therapies also helps to reduce the impact of chemical
dependency on the family unit by capitalizing on family strengths. In this respect, the individual
suffering from addiction negatively impacts the entire family system (Doweiko, 2019). There
may be unclear roles, ineffective communication, unbalanced hierarchies, and ongoing conflict
in families of substance users and these factors can contribute to problematic use of chemicals.
Therefore, family and marital therapies can involve the family while focusing on the individual
with substance use disorder as the client, providing psychoeducation and other interventions to
manage the family’s response the member’s substance use and plan for social supports through
the recovery process (Doweiko, 2019; SAMHSA, 2004).
Strengths and Limitations
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Family and Marital therapies presents specific strengths and limitations as it relates to
treatment of addictions. For example, the model of treatment is strength-based and promotes
self-efficacy by incorporating client/family/systemic strengths into plans for recovery (Doweiko,
2019; Freed, 2012). Including the family in therapy to address addiction can counteract barriers
to engagement and continued delivery of services, improves family functioning, and increases
effective use of natural supports which has been shown to reduce the likelihood of relapse
(SAMHSA, 2004). On the other hand, because the approach includes the family unit, there is
also a chance that additional problems may arise in the course of treatment. The family and
marital model of addiction also requires the clinician to develop an alliance with the family, but
there is a greater risk of triangulation and a need for attention to survival or basic needs over the
course of services (Doweiko, 2019; SAMHSA, 2004).
Rationale for Use
Marge’s statements to the clinician are evidence of her value of the family system, and
since she attributes her use to environmental factors mostly involving her husband and children,
it is appropriate to implement family and marital therapies to address Marge’s substance use
(Laureate Producer, 2014). Marge’s family may benefit from addressing the roles and
expectations for Marge as a caregiver while identifying ways the family can be more supportive
of Marge in her quest for recovery. Since Marge’s family prompted her visit to the clinician,
including her family in therapy can maintain engagement and follow through and increase the
likelihood of abstinence from alcohol use.
Models of Case Management
Minnesota Model of Substance Use Treatment
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The Minnesota Model is commonly used in treatment of addiction. The model
emphasizes in-depth and continuous assessment of all aspects of the client’s life. This model also
utilizes a combination of therapeutic approaches to improve the client’s holistic health. Use of
multidisciplinary teams offers a wide range of individualized goals for the client. The treatment
team approach may be most effective for Marge considering there are persistent struggles with
depression and negligence to her diabetes. Moreover, Marge’s family issues that contribute to
substance use can be addressed using the model. This will ensure a greater chance of support
through recovery and prepare Marge for relapse prevention. It is appropriate to note that the
model is heavily influenced by the philosophies governing Alcoholics Anonymous (AA) and
participation in AA is mandated by treatment programs applying the Minnesota Model
(Doweiko, 2019; Borkman, Kaskutas & Owen, 2007).
Strengths and Limitations of Minnesota Model
One obvious strength of the Minnesota Model is the use of multidisciplinary teams.
Commonly referred to as treatment teams, treatment teams encourage focus on the needs of the
client as a whole and allow for interprofessional collaboration in a timely manner. The model is
also compatible with concurrent treatment efforts such as family therapy and medication
management (Doweiko, 2019; Borkman et al., 2007). On the other hand, the model’s distinction
in treatment lasting twenty-eight days limits the length of stay in residential programs. Lastly, the
model’s reflection of AA philosophies could also be viewed as forcing individuals to embrace
spirituality in recovery (Doweiko, 2019; Borkman et al., 2007).
The Role of Spirituality
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While there are different understandings of spirituality, the modern concept of spirituality
suggests a spiritual transformation that shapes the life, personal identity, self-knowledge,
relationships and peace seeking activities of an individual, defining their purpose (Doweiko,
2019). Marge does not identify an affiliation to a religion. When asked to report on her faith,
Marge stated, “No, I try so hard to believe, but I feel so sinful. No God would have anything to
do with me” (Laureate Education, 2014b). Marge’s remarks suggest she attributes her perceived
isolation from a higher power to her sin, or alcoholism. Nevertheless, spirituality can also refer to
a heightened sense of self-awareness and usefulness, which would be beneficial for Marge. She
has attended twelve-step programs before but have not attended consistently (Doweiko, 2019;
Laureate Education, 2014b).
According to Doweiko, the likelihood of sustainable outcomes after participation in AA
or twelve-step programs is closely related to the frequency of attendance, the individual’s level
of participation, and adherence to the focus on “one day at a time” (2019). Other research shows
that twelve-step programs have obtained longer abstinence and recovery for participants, even
empowering individuals to address factors such as depression and physical illnesses that may
contribute to substance use. Attending twelve-step programs outside of churches present a higher
chance for anonymity and participation for the individual, especially in rural areas. Twelve-step
programs outside of churches tend to be more action-oriented rather than focusing on reading
and study of Biblical text (Dunnington, 2019; Worley, Tate & Brown, 2012). Given this
information, a twelve-step program delivered in a setting outside of a church would best benefit
Marge.
Course of Treatment
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Use of American Society of Addiction Medicine (ASAM) criteria will inform the
continuum of care provided to Marge. At intake, Marge most closely fits the criteria for Level III
Inpatient/Residential Treatment. Level 3.7, Medically Monitored Inpatient Programs are
effective for patients with biomedical, behavioral, or other cognitive conditions that are best
addressed through highly structured around-the-clock care. There is ongoing evaluation and
observation and use of team meetings. Individuals at this level do not present needs severe
enough for a recommendation at the highest level of care, which would be medically managed
instead of monitored (Doweiko, 2019; Medicaid.Gov, 2017). As it relates to Marge, her possible
depressive diagnosis, diabetes, current state of dysfunction within the family, and risks to her
safety if she continues to drive suggest a need for a medically monitored inpatient program
(Laureate Education, 2014b).
Ongoing assessment of biomedical needs as well as support systems and mental health
symptoms will determine the appropriate level of care for referrals. Upon completion of
residential treatment, the client’s biomedical and mental health needs will be stabilized, and the
client is better able to manage these needs in the home setting. Marge will then be referred to a
Level 2.1 Intensive Outpatient Program where she can have access to medical and psychological
support. She will also have access to services such as psychotherapy, family therapy, and
recovery enhancement building activities over the course of twelve months. Finally, Marge will
be stepped down to Level 1 services on an outpatient level to sustain skills and strategies
gathered in higher levels of care (Doweiko, 2019; Laureate Education, 2014b; Medicaid.Gov,
2017).
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Discharge Plan
Upon completion of the thirty-day residential treatment, Marge will still need services to
maintain recovery and abstinence from alcohol use. Marge will be immediately referred to
intensive outpatient programs such as Individual Outpatient Therapy/Medication Management
and Family and Marital Therapy for twelve and six months, respectively. Marge will
simultaneously participate in Alcoholics Anonymous to provide recovery support in the group
setting and increase positive social interactions. Marge’s participation in Medication
Management can help to ensure compliance with medication and evaluate the medicine’s
effectiveness.
Reflection on Personal Mission Statement
In order to effectively assess and address substance use in clients, the social worker must
be keenly aware of how their own personal experiences and values impact their views on
addiction. The social worker needs to take such actions to ensure ethical practice and reduce risk
of harm to clients (Doweiko, 2019). As a child of a recovering addict, my views on addiction
may be unique. Witnessing my father’s journey to recovery and abstinence inspires hope for
others suffering from similar conditions. Over the last eleven weeks, it has also become clear that
my approach to those battling addiction might have initially limited their autonomy. While
excessive use of chemical substances may impair thought and decision-making processes, there
is still a strong need for person-centered care planning. This course has also reiterated a need for
supervision and consultation to ensure ethical practice and collaborative-decision-making. My
understanding of addictions, its causes, symptoms, and treatment has substantially increased and
in turn, has increased my preparation for positively contributing to the field of addiction through
social work.
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Marge’s Treatment Plan
Long Range Outcome: Marge will achieve and maintain abstinence from alcohol and better
manage symptoms associated with other diagnoses.
Identified Strengths: Marge demonstrates help-seeking behaviors, cares about her children,
and has a family support system (husband, sister, best friend).
Identified Needs/Deficits: Marge admits alcohol dependency, is diabetic, show signs of a
depressive disorder, and is facing legal trouble for driving under the influence.
Short Term Goal:
Marge will complete the inpatient treatment facility detoxification program.
Objectives:
1. Marge will refrain from use of alcohol for the next thirty days as required by the
detoxification program.
Strategies:
a. Urinalysis and Blood Screenings will be administered daily
b. Ongoing contacts with substance abuse counselor will assess Marge’s motivation
for change.
c. Team members will implement monitoring plans to ensure Marge does not have
access to alcohol.
Expected Outcomes:
Marge will achieve thirty days without use of alcohol, as evidenced by urinalysis reports,
self-reports from client, and reports from treatment teams.
Short Term Goal:
Marge will complete the inpatient treatment facility detoxification program.
Objectives:
2. Marge will actively participate in individual and family therapy sessions over the
course of treatment to address substance use and other diagnoses.
Strategies:
a. Substance Abuse Counselor will provide individual therapy bi-weekly to
explore and assess the client’s substance use.
b. Substance Abuse Counselor will provide weekly family therapy sessions to
educate the family on addiction as well as Marge’s other diagnoses.
c. Substance Abuse Counselor will teach recovery/relapse prevention skills to
both client and social supports.
d. Substance Abuse Counselor will coordinate scheduling of a psychiatric
evaluation to further evaluate the client’s mental health needs.
Expected Outcomes:
Marge will identify at least two drivers/triggers contributing to substance use
before discharge.
Marge and family will identify and demonstrate use of at least two relapse
prevention skills
Marge and team will identify any other mental health needs contributing to
ongoing substance use before discharge.
PROJECT
Short Term Goal:
Marge will complete the inpatient treatment facility detoxification program.
Objectives:
3. Marge will increase use of services to aid in addressing challenges related to
diabetes and possible depressive disorder.
Strategies:
a. Treatment team will actively identify community resources available for the
diabetic.
b. Treatment team will actively identify community resources available to
increase management of symptoms related to depression.
c. Ongoing contacts with substance abuse counselor will further identify any
unmet needs.
d. An interdisciplinary team meeting will be held before discharge to coordinate
delivery of services.
Expected Outcomes:
Marge will be able to identify and participate in at least one supportive program
designed to meet the needs of individuals with diabetes and depressive disorders and will
schedule initial sessions with providers before discharge from detoxification/inpatient
treatment program.
Short Term Goal:
Marge will maintain abstinence from alcohol use for twelve-months beyond discharge.
Objectives:
1. Marge will utilize Individual Outpatient therapy for One year
Strategies:
a. Treatment team will link Marge to Individual OPT at discharge session
b. Provider will continue to build on relapse prevention plan and recovery
building skills.
c. Provider will coordinate scheduling monthly team meetings (providers,
family, supports).
d. Provider will address Marge’s vocational needs to prepare her to return to
work.
e. Ongoing use of assessments to identify any unmet needs warranting
additional referrals.
Expected Outcomes:
Marge will have enhanced the skills gained in residential treatment to sustain positive
outcomes as it relates to maintaining abstinence from alcohol use.
Short Term Goal:
Marge will maintain abstinence from alcohol use for twelve-months beyond discharge.
Objectives:
2. Marge (and family) will participate in Family and Marital Therapy
Strategies:
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a. Family will attend a minimum of twelve, hour-long sessions.
b. Ongoing use of structured/unstructured tools to evaluate family functioning and
effectiveness of services delivered.
c. Therapist will provide psychoeducation, conflict resolution, role enhancement,
and other services to prepare the family to support Marge’s recovery.
d. Therapist will coordinate referral to additional services if needs are presented.
Expected Outcomes:
Marge and family will increase family functioning, evidenced by increased role
fulfillment, reduced conflict, and effective support in Marge’s recovery.
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REFERENCES
Borkman, T., Kaskutas, L. A., & Owen, P. (2007). Contrasting the Converging Philosophies of
Three Models of Alcohol/Other Drugs Treatment: Minnesota Model, Social Model, and
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Doweiko, H. E. (2019). Concepts of chemical dependency (10th ed.). Stamford, CT: Cengage.
Dunnington, K. (2019). Small groups Anonymous: Why the best church small groups might take
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Laureate Education (Producer). (2014a). Counseling session 1. [Multimedia file]. Retrieved from
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Laureate Education (Producer). (2014b). Counseling session 2. [Multimedia file]. Retrieved from
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Margasiński, A. (2017). Psychological roles of young adults growing up in alcoholic and
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REFERENCES
Medicaid.Gov (2017). Overview of Substance Use Disorder (SUD) Care Clinical Guidelines: A
Resource for States Developing SUD Delivery System Reforms. Retrieved from
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attendance, depression and substance use in patients with comorbid substance