Psychology
Background
Mary is a 24-year old African-American woman that seeks evaluation of her condition. She has been using heroin since she was 19 years old. Mary is pointed out her boyfriend Max as the person that introduced her to heroin after she moved in with him. She has a history of family dysfunction and grew up seeing her father as an alcoholic and her mother undergoing an alcoholic recovery phase. Mary reported that she never received any substance or professional help before and that would justify any hesitation on her part to undergo evaluation. Another crucial part of her situation is her being an alcoholic as well because she reported drinking four to five bottles of beer every night before going to work. She wasn't able to finish high school and that limited her choices when it comes to the line of work that she could get. As a result, she ended up working as a prostitute to finance her drug addiction, rent and other necessities. However, the most important part of the problem is the unconfirmed pregnancy. It could be possible for her to be pregnant, despite the fact that she demanded her clients to wear condoms during intercourse. But she also reported that she and her boyfriend never uses condom during sexual intercourse.
The fact that there are instances of absence of protection during sex there is a possibility of occurring pregnancy. Her lack of menstruation for the last 12 months could also be an indication as well as the reported physical changes such as her breast that she described as swollen and tender. However, her constant use of heroin could bring harm to the developing baby if it is positive that she is pregnant. Mary is confused about what to do because she appears to be having trouble whether to choose pregnancy or to using heroin and drinking alcohol. In a clinical point of view, there is no way that she will continue using the illegal substance and be pregnant at the same time because it would have a negative implication to the growth of baby inside her. This situation will be evaluated accordingly and all aspects of the issue would be addressed in order to provide an accurate diagnosis and recommendation.
DSM-IV-TR Diagnosis
In order to provide an accurate assessment and recommendation for Mary's situation, there should be an evaluation of causes of her behavior particularly with heroin and alcoholic use. First, looking back in her childhood there is an emotional trauma involved in her process of development that led to her current situation. It was mentioned that her father was an alcoholic and her mother obviously has the same issue because of the fact her mother is on a recovery phase. Such behavior from the parents created a barrier in their family relationship, which resulted to disruption in family role and functions. The problem even got worse when Mary's father left the family and that possibly triggered depression on Mary due to the stressful life event. It could have been corrected when diagnosed with adjustment disorder under DSM-IV-TR Axis 1. However, the situation was neglected and it escalated to a higher depressive episode on Mary.
The depressive episode possibly showed symptoms of significant distress and impairment in occupational, social and other related functions (Bhatia and Bhatia, 2007). The significant impairment manifests in her lack of interest to education, she dropped out of high school and engaged to physically and mentally damaging activities. Her emotional imbalance caused her to turn to substance abuse for relief of depression, it was justified by Mary's report that she began drinking alcohol and smoking marijuana at the age of 12. However, the problem was still not rectified and there were no presence of concurrent treatment on depression and substance use disorder on Mary at that point (Bhatia and Bhatia, 2007).
When Mary turned 19 years old, her condition was still not addressed, as she mentioned the visit for evaluation is her first. Therefore, her previous condition further escalated, she was introduced to heroin by her boyfriend Max and Mary has been exposed to the use of the substance for five years and is a frequent user. Her condition at this point appears in DSM-IV-TR under Axis IV because of the indicating factors that contribute to her substance abuse. This includes psychosocial problems, inadequate support system, educational problems and social issues. Her marijuana and alcohol abuse evolved into heroin abuse, which is classified as an Opioid drug. This is a type of drug composed of both synthetic and natural substances, heroin on the other hand is the most abused opioid derived from synthesized opium, thus the name of the drug classification suggests. Since Mary has been using heroin almost every day for five years, therefore, she has a substance use disorder as classified in DSM-IV-TR code 305.50. In these criteria, opioid abuse specifies that the use of the substance plays a role to either interfere or enhance the user's ability to fulfill work, home or school obligations (DSM-IV-TR Classification, 2009, p. 3). In Mary''s case, she mentioned that the kind of high she is getting from the drug allows her to feel comfortable and function properly.
The criteria also stipulates that a span of use of 12 months is already classified under the said DSM-IV-TR code (305.50). Therefore, the five-year long use of the drug is clearly an addiction and can be evaluated as a "severe" condition of opioid abuse. In Mary's case, code 305.50 is also in combination with code 305.00 or alcohol abuse. The DSM-IV-TR criteria when it comes to alcohol abuse includes, recurrent intake of alcohol to satisfy obligations at work, home or school. In Mary's case, alcohol was her boosting agent before going out to work as a prostitute. It only takes a consecutive 12 months continuous intake to qualify under these criteria. However, it appears that Mary has been drinking alcohol since 12 years old.
Mary's continued use of heroin also qualifies her under the opioid abuse criteria. DSM-IV-TR code 304.00 is a maladaptive pattern of use of opioid substance causing impairment of distress. Stressors accumulated from childhood triggered distress leading to several patterns of maladaptive use of both alcohol, marijuana and heroin for the purpose of relieving stress. Tolerance, time spent significantly to obtain heroin (explained by her working as a prostitute to earn money to buy heroin) and continued use despite the threat to both physical and mental health are the obvious indications of dependence to opioid (Emedicine.medscape.com, 2012). The criteria in which Mary falls under suggests a strong manifestation of several problems categories described under DSM-IV-TR Axis 1 namely, substance related disorder and adjustment disorder evaluated as "severe" (Hartnell.edu, 1970, p. 1-5).
These problems branches out to DSM-IV-TR Axis IV under the category of problems related to access on health care services. This is because of the fact that Mary never had a chance to seek help regarding her mental condition and on top of that is the fact that she is suspecting to be pregnant, but cannot have a pregnancy check-up due to lack of healthcare insurance. This problem is related to Mary's suspicion that she is pregnant due to the absence of menstrual period and physical changes. Because of her unconfirmed pregnancy, Mary cannot make a decision between her baby is she is indeed pregnant and giving up using heroin. She is adamant in cutting off her heroin use, but also considering her pregnancy. Mary cannot make a decision, however, in order for her to make good judgement her current condition should be addressed first. This is because of the reasons that Mary cannot make a clear decision is due to her addiction and dependence to heroin and alcohol, which disrupts concentration and decision making.
Recommended Treatment
Beforre administering help or any action to correct the problem, a plan should be drafted first to address the prevailing disorders one at a time. A treatment plan utilizing ASAM PPC-2 or the American Society of Addiction Medicine (Patient Placement Criteria 2) is the widely accepted and comprehensive guidelines for placing, discharging and continued stay of patient with substance abuse disorders. There is a six dimension of treatment settings based on the determined appropriateness of the patient's disorder. However, not all of the six dimensions will be applied because there are certain areas in Mary'c condition that needs focus. Considering dimension three should be the first step, addressing the cognitive, behavioral and emotional aspects of the patient's condition. Influencing factors identified in adjustment disorder will be treated first in a psychiatric unit to eliminate stressors and reduce severity of the condition.
The next step is detoxification of dimension one, it can be done through an out-patient facility, Opioind agonist will be administered such as Clonidine, Buprenorphine or Methadone to flush out residues of the substances left in the body. There are instances of withdrawal symptoms, which would be very uncomfortable for Mary, but it will guarantee complete detoxification. However, since Mary is also alcoholic at the same time, the effects of dimension one approach would be extremely crucial to the patient. Therefore, potential withdrawal and detoxification should be done in an in-patient care level. Since there is a suspicion of pregnancy, pregnancy test is highly recommended first before administering any detoxification procedures.
Special consideration have to be evaluated in Mary's case, she is a high risk patient especially if it is found that she is indeed pregnant. This is because detoxification would induce premature delivery and labor. Certain medications applicable for pregnant women should be used during the whole duration of the pregnancy. In this case, Mary has to be placed in the Enhanced Program because of her pregnancy and call for detoxification. The program is a coordinated effort among behavioral health providers, psycho-pharmacology, counseling and clinical experts.
Recommended Referrals
There are several referrals that could be given to Mary, first of all her pregnancy has to be checked and confirmed with an appropriate pregnancy health professional. If the problem is the lack of healthcare insurance, she will be given a referral to a community health facility that provides free consultations and also to the social welfare office for assistance. Once pregnancy has been confirmed she would need to be conditioned first before undergoing treatment. First, is to have Mary join help groups such as Alcoholic Anonymous for community support as well as a visit to Pregnant Addicted Mothers for treatment assessment. They also accept out-patient, Medicaid and social welfare assisted patients. On top of that is recommendations related none government support groups for further assistance such as Women in Need and Women's Center for Substance Abuse.
Legal and Ethical Considerations
Dealing with cases like Mary's require adequate considerations to legal and ethical issues that may arise in the process. One of, which is on the issue of pregnancy, as a counselor providing professional advice there is no way that choosing a side in the issue is appropriate. As the adviser, I cannot tell Mary to abandon pregnancy (if confirmed) for the sake of argument that she cannot quit drug and alcohol abuse right away. It is because such advice constitutes legal responsibilities pertaining to the promotion of abortion, which is against the law of the land and of faith. Telling Mary to immediately quit using drugs and drinking alcohol for the sake of pregnancy is a bias conclusion because appropriate steps are needed for treatment, otherwise she maybe vulnerable to relapsing. Passing judgement over her lifestyle is also deemed unethical, the reason that assessment and evaluation is required is to capture all the factors that led to Mary's current condition.
Regulatory issues also apply as licensing is needed for placement. An example of that is the ambulatory settings requirement stipulating that there should be a stable telephone access at home in case of emergencies. Furthermore, some rehabilitation centers require a "drug-free time" period before admitting. However, since Mary's problems is consists of mental and physical health it is necessary that Mary should undergo detoxification together with her mental treatment on the problem of developed behavioral issues. Constant communication is needed in the process especially between the patient and the treatment providers, between provider and providers and between patient support system and providers.
Transference and Countertransference Tendencies
In a matter of psychotherapy session in which Mary has to undergo comes the issue of transference and countertransference. In a way the therapist and the patient must be open and honest with each other in order to achieve the anticipated results of treatment. In some cases, the therapist and the patient interacts in a manner that close attachment to each other eventually develops. Mary could somehow express transference reaction in the process because of the redirection of her feelings to the therapist. However, it would not be an intimate sort of reaction, but rather in a form of parentification or extreme dependence. This is because Mary's situation and history indicates lack of parental intervention. On top of that is the fact that is in the state of confusion about her situation. Therefore, extreme dependence maybe expressed towards the therapist because of her lack of judgement and rely on the therapist for encouragement. When it comes to countertransference, the therapist's emotional attachment to the patient is more likely depends of the therapist's attunement to his own circumstances. Strong emotional attachment often occurs when the therapist can strongly relate to the patient's situation in relation to his own life experiences. However, such kinds of attachment is critical in understanding the patient's situation, but therapists know that it is necessary in order to get valuable insights regarding what the patient is trying to elicit in them. On the other hand, professionalism is still crucial and the therapist should be well aware of it.
References
Bathia, M.D., S. K., & Bathia, M.D., S. C. (2007, January 1). Childhood and Adolescent Depression. American Academy of Family Physician. Retrieved August 4, 2012, from http://www.aafp.org/afp/2007/0101/p73.html
D S M - I V- T R Classification. (2009). Appendix DSM-IV-TR Classification, 3.
Emedicine.medscape.com (2012, July 5). Opioid Abuse Clinical Presentation. Medscape. Retrieved August 4, 2012, from http://emedicine.medscape.com/article/287790-clinical
Hartnell.edu (1970). Disorders of the DSM-IV-TR. American Psychiatric Association, 1-5. Retrieved from http:www.hartnell.edu/faculty/ymatsush/Psy22/FscanDSM0001.pdf
