PSYC 305
Case Study Assessment and Treatment Recommendations
Department of Psychology,
Liberty University
PSYC 305-D03: Overview of Theory & Treatment of Substance Abuse
Chemical Use Assessment/History and Treatment Recommendations
Name: Teresa
DOB/Age: 28
Dates of Interviews: 5-03--10-2021
Evaluator: Wendy L. Bates, Liberty University
Reason for Assessment
Teresa is an adopted female of unknown Asian heritage, and comes to us today presenting
all aspects of the TWEAK and CAGE acronyms used to reference one’s substance use severity,
as well as their alternative paper and pencil screenings [ CITATION Libnd \l 1033 ]. Intake
staff has identified these markers as consistent with the DSM-5 [ CITATION Ame13 \l 1033 ]
definition of Alcohol Use Disorder (AUD), markedly seven to eight markers out of ten of the
standard diagnosis guidelines. The client is experiencing mental discord and social conflict due
to her alcohol use habits and has requested our assistance in guiding her toward the necessary
changes to recognize and understand her illness, with the hopes of behavior extinction and
interpersonal stability [ CITATION Unk11 \l 1033 ].
Sources of Information
Teresa is our single source of information at this time. Because she is the only available
resource during this assessment, attempts to urge Teresa’s participation in the suggested case
management methods is key to creating rapport and trust with her [ CITATION Are08 \l
,1033 ]. This connection is to enable her to feel understood and secure enough to effectively
communicate her perspectives, which in turn fosters commitment to the treatment process
[ CITATION Mil16 \l 1033 ]. Active listening, paraphrasing, recognizing and confirming her
feelings in all areas will stimulate increased contributions (Aronson, Wilson, & Sommers, 2019;
NIDA, 2020; Substance Abuse and Mental Health Services Administration, 1999). Further
review of her relationships is necessary to discover if additional information can be gathered
from outside persons that might be useful in tailoring her treatment plan [ CITATION HED15 \l
1033 ].
Background Information
Teresa began her use of alcohol at age 14, and also confirms promiscuity and urging
others her age to drink, and maintains that her use of alcohol has been “natural” and consistent
for at least the past 10 years. She has a very high tolerance for the substance’s intoxicating
effects, and it continues to be the center of her daily life and social relationships [ CITATION
Aro19 \l 1033 ]. Her adolescent support system would have consisted of a family dynamic based
on a Korean culture and a strictly disciplined educational construct with no indications of club or
group activities. She recalls instances that tell us her school friends also illustrated the same
types of alcohol use and risk-taking behaviors. More information is needed regarding her mental
health [ CITATION MKe20 \l 1033 ], genetic background [ CITATION NID20 \l 1033 ],
cultural beliefs (Aquilino, 2005; Price, 2008), spirituality [ CITATION May06 \l 1033 ],
sexuality
[ CITATION Bjo17 \l 1033 ], traumatic experiences of discrimination [ CITATION Nol20 \l 1033
], and other social factors to make a complete evaluation of the causes of her sickness (Arriaga,
2015; Atieno Okech & Geroski, 2015; Hendrickson, 2013; Labella & Masten, 2018; National
Institute on Alcohol Abuse and Alcoholism, 2006; Wadman, 2018).
, Current Status
Teresa is actively a binge drinker, consuming alcohol heavily in a set amount of time, and
has evolved into heavy drinking patterns, otherwise known as patterns of binge drinking for an
extended amount of time (Center for Behavioral Health Statistics and Quality, 2015; Doweiko,
2015; National Institute on Alcohol Abuse and Alcoholism, 2006). Teresa is eliciting signs of
precontemplation and contemplation within the addiction recovery stages, and hints of
preparation phases concerning her current treatment-seeking behaviors [ CITATION Sub991 \
l
1033 ]. It is my agreement that Teresa has progressed into the DSM-5 definition of AUD
[ CITATION Ame13 \l 1033 ], or the next phase of severe alcohol abuse and prolonged addiction
[ CITATION HED15 \l 1033 ].
Indicators of Use/Abuse/Dependency
Teresa self-reports aggressive, and significant violent incidents, blackouts, tolerance,
insubordination, and loss of self-preservation following her bouts of alcohol consumption
(Doweiko, 2015). She describes a desire to eliminate the “chaos” in her life, however, she is
reluctant to correlate the entirety of these consequences to her progressive drinking habits
(American Psychiatric Association, 2013; Doweiko, 2015). When she drinks, she often loses
track of the amount she consumes, and it frequently results in disorientation and risky behaviors [
CITATION HED15 \l 1033 ]. This loss of control, regardless of its effects, is reflected in her job
absenteeism, memory loss, and diminished physical health following binges, and is an end result
of connecting her learned associations with binge drinking and its environmental triggers
Case Study Assessment and Treatment Recommendations
Department of Psychology,
Liberty University
PSYC 305-D03: Overview of Theory & Treatment of Substance Abuse
Chemical Use Assessment/History and Treatment Recommendations
Name: Teresa
DOB/Age: 28
Dates of Interviews: 5-03--10-2021
Evaluator: Wendy L. Bates, Liberty University
Reason for Assessment
Teresa is an adopted female of unknown Asian heritage, and comes to us today presenting
all aspects of the TWEAK and CAGE acronyms used to reference one’s substance use severity,
as well as their alternative paper and pencil screenings [ CITATION Libnd \l 1033 ]. Intake
staff has identified these markers as consistent with the DSM-5 [ CITATION Ame13 \l 1033 ]
definition of Alcohol Use Disorder (AUD), markedly seven to eight markers out of ten of the
standard diagnosis guidelines. The client is experiencing mental discord and social conflict due
to her alcohol use habits and has requested our assistance in guiding her toward the necessary
changes to recognize and understand her illness, with the hopes of behavior extinction and
interpersonal stability [ CITATION Unk11 \l 1033 ].
Sources of Information
Teresa is our single source of information at this time. Because she is the only available
resource during this assessment, attempts to urge Teresa’s participation in the suggested case
management methods is key to creating rapport and trust with her [ CITATION Are08 \l
,1033 ]. This connection is to enable her to feel understood and secure enough to effectively
communicate her perspectives, which in turn fosters commitment to the treatment process
[ CITATION Mil16 \l 1033 ]. Active listening, paraphrasing, recognizing and confirming her
feelings in all areas will stimulate increased contributions (Aronson, Wilson, & Sommers, 2019;
NIDA, 2020; Substance Abuse and Mental Health Services Administration, 1999). Further
review of her relationships is necessary to discover if additional information can be gathered
from outside persons that might be useful in tailoring her treatment plan [ CITATION HED15 \l
1033 ].
Background Information
Teresa began her use of alcohol at age 14, and also confirms promiscuity and urging
others her age to drink, and maintains that her use of alcohol has been “natural” and consistent
for at least the past 10 years. She has a very high tolerance for the substance’s intoxicating
effects, and it continues to be the center of her daily life and social relationships [ CITATION
Aro19 \l 1033 ]. Her adolescent support system would have consisted of a family dynamic based
on a Korean culture and a strictly disciplined educational construct with no indications of club or
group activities. She recalls instances that tell us her school friends also illustrated the same
types of alcohol use and risk-taking behaviors. More information is needed regarding her mental
health [ CITATION MKe20 \l 1033 ], genetic background [ CITATION NID20 \l 1033 ],
cultural beliefs (Aquilino, 2005; Price, 2008), spirituality [ CITATION May06 \l 1033 ],
sexuality
[ CITATION Bjo17 \l 1033 ], traumatic experiences of discrimination [ CITATION Nol20 \l 1033
], and other social factors to make a complete evaluation of the causes of her sickness (Arriaga,
2015; Atieno Okech & Geroski, 2015; Hendrickson, 2013; Labella & Masten, 2018; National
Institute on Alcohol Abuse and Alcoholism, 2006; Wadman, 2018).
, Current Status
Teresa is actively a binge drinker, consuming alcohol heavily in a set amount of time, and
has evolved into heavy drinking patterns, otherwise known as patterns of binge drinking for an
extended amount of time (Center for Behavioral Health Statistics and Quality, 2015; Doweiko,
2015; National Institute on Alcohol Abuse and Alcoholism, 2006). Teresa is eliciting signs of
precontemplation and contemplation within the addiction recovery stages, and hints of
preparation phases concerning her current treatment-seeking behaviors [ CITATION Sub991 \
l
1033 ]. It is my agreement that Teresa has progressed into the DSM-5 definition of AUD
[ CITATION Ame13 \l 1033 ], or the next phase of severe alcohol abuse and prolonged addiction
[ CITATION HED15 \l 1033 ].
Indicators of Use/Abuse/Dependency
Teresa self-reports aggressive, and significant violent incidents, blackouts, tolerance,
insubordination, and loss of self-preservation following her bouts of alcohol consumption
(Doweiko, 2015). She describes a desire to eliminate the “chaos” in her life, however, she is
reluctant to correlate the entirety of these consequences to her progressive drinking habits
(American Psychiatric Association, 2013; Doweiko, 2015). When she drinks, she often loses
track of the amount she consumes, and it frequently results in disorientation and risky behaviors [
CITATION HED15 \l 1033 ]. This loss of control, regardless of its effects, is reflected in her job
absenteeism, memory loss, and diminished physical health following binges, and is an end result
of connecting her learned associations with binge drinking and its environmental triggers
