Practice Midterm
Client is an 18 year old biracial male who lives with his mother and father in Worcester MA. His mother identifies as Caucasian and his father is an immigrant from Puerto Rico. Client presents with cannabis dependence and alcohol abuse. Client began using substances at age 16, his usage progressed from only using when THC was available to him to starting to use it daily from ages 16 to 18. He is currently in treatment for substance abuse disorder. Client’s substance abuse has led to major strain in his family, which has led to a few days of homelessness where he would break into cars to sleep and a difficult relationship with his parents. His substance abuse has also hurt his educational career because he was asked to leave his High school due to a breaking and entering charge, which he attributes to happening because he was “too high.” While he claims no damages were done to the school, the client triggered a silent alarm that led to his arrest. Client reports experiencing no traumas or family conflicts while growing up, however he does say that most of his family members smoke marijuana and that is not seen as a stigmatizing thing. He reports that only his dad does not use drugs and that he has a cousin who struggles with homelessness because he was kicked out due to his substance abuse. Client went to substances because “all his friends and family were doing it.” He reports not wanting to feel left out so he started to partake with his friends and his family to fit in. Client presents are strong willed, optimistic, and cooperative. Not only is he willing to contribute to treatment he is willing to listen to other clients and try to help them through their difficulties while being here. Barriers to recovery are client’s friends and certain family members. He does not think they will respect his decision to be sober. Client is in the presents as being in the action stage of change. I chose this particular process recording because it was one of the first times that the client had opened up to me as a clinician. Client would often joke around or have regular conversation with me but it took us a while to get to a place where he was comfortable sharing things with me and the only reason he did was because he was writing his feelings in a journal and letting me read them. He still has a hard time with verbal communication around his drug use and struggles. I also chose this piece because it was challenging for me to receive so much information in written form because I ended up feeling totally overwhelmed because there were so many different subjects that I could address I just did not know where to start. So I think the session was difficult for both of us trying to figure out how to have a serious conversation, which was so much different than the joking conversations we had been having before. I have been trying to make a therapeutic connection with him since he got to the program but it just did not seem to be working that well, but when he came to me with his journal I was so happy for him because I knew it took a lot for him to get to that point and I was glad to start to make that sort of relationship with him. I believe that the client came to me with so much information at once because he was starting to feel guilty about some of the things he had done while he was high. It also seems that my client is confused as to why his family relationships are so strained. Looking at his family dynamic, it seems that almost everyone he surrounds himself with smokes marijuana. So it is extremely confusing to him for all of these people whom he loves and idolizes to be smoking but when he does it, he gets sent to rehab. There seems to be disconnect with his behaviors and that of the families. (Rowe, 2012) For example, in our session he discussed showing up high at a younger cousin’s birthday party and no one was upset with him about it and how his aunts used to take him on burn cruises. He knows now that these are not the best choices for him but they have been supported in the past by his family members so when he was talking to me I could sense the confusion coming from him. He seems to be very conflicted with why they can handle smoking weed and he cannot and it seems that he cannot have that discussion with his family. He told me that he cannot tell people how he feels because he thinks that he will be viewed as stupid and that no one would listen to his feelings. So it is my assumption, and I will have to confirm this with him in a later session that he has had to have this conversation with either friends or family, and been shut down in doing so, which may be why it was so difficult for him to have the conversation with me. In terms of his strengths the client is so positive and overall has an extremely hopefully view of life and has a strong desire to make the most of the life he is living. I think that will be a huge benefit in his road to recovery and I also think that if he can foster that he will be able to have discussions with his family about their substance use and how it affects him. If the conversation can open up around this topic the client can learn how to be around his family without getting high and maybe his family can respects his wishes to be sober. Aside from their smoking history, the client loves his family very much and wants to be back in their good graces. However the client will have to learn to open up, which seems to be his biggest barrier. He is concerned what they will think of him and how they will react. I have made offers for a family meeting but the client says he is not willing to do so yet. It is my thought that if we can get the family into the same room with a mediator the client will have enough strength and esteem to address his issues and confusion about his family smoking pot while he cannot. For the client I have been trying to implement motivational interviewing and psychodynamic theory. In terms of motivational interviewing, it seems to be the best studied approach to use with addicts. The client I am working with is determined to change his drugs habits and the behavior that have some with it, so when we are speaking or discussing his journal I always try to ask open ended questions, so it allows room to explore. During our session, I think I did an okay job of doing so and even though he may not have been overly engaged in my questions, at least he could sit with it and it can be readdressed later. I try to provide affirmations and reflect what he said back to him client but I am not sure it is something that was done well in this particular session. (Fox, Towe, Stephens, Walker, Roffman, 2011.) I was so overwhelmed by all the information that I had read in the journal I lost a sense of what I was trying to do. Overall, I am happy with the session and the implementation of motivational interviewing because judging from his appearance and responses, he was at least thinking about the questions I was asking him. I tried to be non-judgmental and non-confrontational and I believe that the client did not feel as if I was judging him or combating his feelings, but rather it seemed as though he could tell I was trying to empathize and get him to think and explore some of his choices. Another method I am going to explore with this client is psychodynamic theory. From what he has told me it seems like his past has a lot of influence over choices he has made and I think it will be valuable to explore that with him. The client has been surrounded by drugs his whole life so it seems natural that he would do the same types of things as his family. For him using also became a coping mechanism, which is a defense he has seen other family members use before. When the client started to get legal action and do hurtful things to his family, he has said that is when he starting using more so it became a way for him to cope. He has a cousin who went through a similar process, except until the client, his cousin is homeless and without family support. So for my client what I can gather from his stories is that coming from a family of people who use, it was a natural thing for him. However, when his behaviors got out of control in the eyes of his family, rather than get sober, my client started to use more, because it was a way of coping that he has seen used over and over again. Since there are so many unresolved conflicts within his family, it seemed to intensify that desire to use drugs. (Gedo, 2011) So I would like to explore those conflicts with him and his drug use as a coping strategy to see how it has shaped his behaviors. Since the client has said multiple times that he has trouble verbally communicating so the way I judged my responses and reactions during our interaction was by how much he responded to me. He responded to me and my thoughts differently than he had before. We had a good relationship personally, but the therapeutic one had not been going as well. So for him not to really make jokes or try and make me laugh but rather sit with me and think about what I was asking him was huge for the client. I was so surprised myself with his reactions and the honestly he showed me in his journal it was hard for me to sit with. I think I did a good job at asking open ended questions. While I was speaking with him I was trying to really focus on what he was saying and how I could make him think deeper. Although he did not always respond to my questions I could see that he was thinking about them. I would not be surprised if he were to write about them later since it is what he has been doing since he got to rehab. I think I should have tried to reaffirm what he was saying more and try to offer more reflection. I was so focused on trying to ask him open ended questions that did not come off as judgmental that I kind of jumped from topic to topic. When rereading our session and thinking about it, I see a lot of opportunity where I could have tried to reflect with him about a lot of the things he was saying but missed the opportunity to do so. I also wish our session had gone on longer. The client tends to get distracted very easily and tries to change subjects when he starts to feel uncomfortable, so when he heard another staff that he has a good relationship he jumped at the opportunity to go see her. At first I thought he did that because he did not think our conversation was going well, but when I think back on it and read it again, I realize that it was the deepest conversation we had ever had and it was visually difficult for him to have a conversation that was serious. It was probably easier for him to revert to that goofy teenager and jump at the opportunity to end the session rather than continue to have a difficult conversation, and I am going to try to bring it up again with him to see if my suspicions are correct. I think overall it was a very successful session and I think it is going to be a good starting point for us to start to have that therapeutic relationship in addition to the fun one we already have.

References
Fox, C. L., Towe, S. L., Stephens, R. S., Walker, D. D., & Roffman, R. A. (2011). Motives for cannabis use in high-risk adolescent users.Psychology Of Addictive Behaviors, 25(3), 492-500.

Gedo, P. (2011). An Island in a Sea of Madness: The Uses of Theory for In-Patient Adolescent Treatment. Clinical Social Work Journal, 39(2), 132-138. doi:10.1007/s10615-011-0341-6

Rowe, C. L. (2012). Family Therapy for Drug Abuse: Review and Updates 2003-2010. Journal Of Marital & Family Therapy, 38(1), 59-81. doi:10.1111/j.1752-0606.2011.00280.x