addiction case study examples

Module 9: Substance-Related and Addictive Disorders

Case studies: substance-abuse disorders, learning objectives.

• Identify substance abuse disorders in case studies

Case Study: Benny

The following story comes from Benny, a 28-year-old living in the Metro Detroit area, USA. Read through the interview as he recounts his experiences dealing with addiction and recovery.

Q : How long have you been in recovery?

Benny : I have been in recovery for nine years. My sobriety date is April 21, 2010.

Q: What can you tell us about the last months/years of your drinking before you gave up?

Benny : To sum it up, it was a living hell. Every day I would wake up and promise myself I would not drink that day and by the evening I was intoxicated once again. I was a hardcore drug user and excessively taking ADHD medication such as Adderall, Vyvance, and Ritalin. I would abuse pills throughout the day and take sedatives at night, whether it was alcohol or a benzodiazepine. During the last month of my drinking, I was detached from reality, friends, and family, but also myself. I was isolated in my dark, cold, dorm room and suffered from extreme paranoia for weeks. I gave up going to school and the only person I was in contact with was my drug dealer.

Q : What was the final straw that led you to get sober?

Benny : I had been to drug rehab before and always relapsed afterwards. There were many situations that I can consider the final straw that led me to sobriety. However, the most notable was on an overcast, chilly October day. I was on an Adderall bender. I didn’t rest or sleep for five days. One morning I took a handful of Adderall in an effort to take the pain of addiction away. I knew it wouldn’t, but I was seeking any sort of relief. The damage this dosage caused to my brain led to a drug-induced psychosis. I was having small hallucinations here and there from the chemicals and a lack of sleep, but this time was different. I was in my own reality and my heart was racing. I had an awful reaction. The hallucinations got so real and my heart rate was beyond thumping. That day I ended up in the psych ward with very little recollection of how I ended up there. I had never been so afraid in my life. I could have died and that was enough for me to want to change.

Q : How was it for you in the early days? What was most difficult?

Benny : I had a different experience than most do in early sobriety. I was stuck in a drug-induced psychosis for the first four months of sobriety. My life was consumed by Alcoholics Anonymous meetings every day and sometimes two a day. I found guidance, friendship, and strength through these meetings. To say early sobriety was fun and easy would be a lie. However, I did learn it was possible to live a life without the use of drugs and alcohol. I also learned how to have fun once again. The most difficult part about early sobriety was dealing with my emotions. Since I started using drugs and alcohol that is what I used to deal with my emotions. If I was happy I used, if I was sad I used, if I was anxious I used, and if I couldn’t handle a situation I used. Now that the drinking and drugs were out of my life, I had to find new ways to cope with my emotions. It was also very hard leaving my old friends in the past.

Q : What reaction did you get from family and friends when you started getting sober?

Benny : My family and close friends were very supportive of me while getting sober. Everyone close to me knew I had a problem and were more than grateful when I started recovery. At first they were very skeptical because of my history of relapsing after treatment. But once they realized I was serious this time around, I received nothing but loving support from everyone close to me. My mother was especially helpful as she stopped enabling my behavior and sought help through Alcoholics Anonymous. I have amazing relationships with everyone close to me in my life today.

Q : Have you ever experienced a relapse?

Benny : I experienced many relapses before actually surrendering. I was constantly in trouble as a teenager and tried quitting many times on my own. This always resulted in me going back to the drugs or alcohol. My first experience with trying to become sober, I was 15 years old. I failed and did not get sober until I was 19. Each time I relapsed my addiction got worse and worse. Each time I gave away my sobriety, the alcohol refunded my misery.

Q : How long did it take for things to start to calm down for you emotionally and physically?

Benny : Getting over the physical pain was less of a challenge. It only lasted a few weeks. The emotional pain took a long time to heal from. It wasn’t until at least six months into my sobriety that my emotions calmed down. I was so used to being numb all the time that when I was confronted by my emotions, I often freaked out and didn’t know how to handle it. However, after working through the 12 steps of AA, I quickly learned how to deal with my emotions without the aid of drugs or alcohol.

Q : How hard was it getting used to socializing sober?

Benny : It was very hard in the beginning. I had very low self-esteem and had an extremely hard time looking anyone in the eyes. But after practice, building up my self-esteem and going to AA meetings, I quickly learned how to socialize. I have always been a social person, so after building some confidence I had no issue at all. I went back to school right after I left drug rehab and got a degree in communications. Upon taking many communication classes, I became very comfortable socializing in any situation.

Q : Was there anything surprising that you learned about yourself when you stopped drinking?

Benny : There are surprises all the time. At first it was simple things, such as the ability to make people smile. Simple gifts in life such as cracking a joke to make someone laugh when they are having a bad day. I was surprised at the fact that people actually liked me when I wasn’t intoxicated. I used to think people only liked being around me because I was the life of the party or someone they could go to and score drugs from. But after gaining experience in sobriety, I learned that people actually enjoyed my company and I wasn’t the “prick” I thought I was. The most surprising thing I learned about myself is that I can do anything as long as I am sober and I have sufficient reason to do it.

Q : How did your life change?

Benny : I could write a book to fully answer this question. My life is 100 times different than it was nine years ago. I went from being a lonely drug addict with virtually no goals, no aspirations, no friends, and no family to a productive member of society. When I was using drugs, I honestly didn’t think I would make it past the age of 21. Now, I am 28, working a dream job sharing my experience to inspire others, and constantly growing. Nine years ago I was a hopeless, miserable human being. Now, I consider myself an inspiration to others who are struggling with addiction.

Q : What are the main benefits that emerged for you from getting sober?

Benny : There are so many benefits of being sober. The most important one is the fact that no matter what happens, I am experiencing everything with a clear mind. I live every day to the fullest and understand that every day I am sober is a miracle. The benefits of sobriety are endless. People respect me today and can count on me today. I grew up in sobriety and learned a level of maturity that I would have never experienced while using. I don’t have to rely on anyone or anything to make me happy. One of the greatest benefits from sobriety is that I no longer live in fear.

Case Study: Lorrie

Figure 1. Lorrie.

Lorrie Wiley grew up in a neighborhood on the west side of Baltimore, surrounded by family and friends struggling with drug issues. She started using marijuana and “popping pills” at the age of 13, and within the following decade, someone introduced her to cocaine and heroin. She lived with family and occasional boyfriends, and as she puts it, “I had no real home or belongings of my own.”

Before the age of 30, she was trying to survive as a heroin addict. She roamed from job to job, using whatever money she made to buy drugs. She occasionally tried support groups, but they did not work for her. By the time she was in her mid-forties, she was severely depressed and felt trapped and hopeless. “I was really tired.” About that time, she fell in love with a man who also struggled with drugs.

They both knew they needed help, but weren’t sure what to do. Her boyfriend was a military veteran so he courageously sought help with the VA. It was a stroke of luck that then connected Lorrie to friends who showed her an ad in the city paper, highlighting a research study at the National Institute of Drug Abuse (NIDA), part of the National Institutes of Health (NIH.) Lorrie made the call, visited the treatment intake center adjacent to the Johns Hopkins Bayview Medical Center, and qualified for the study.

“On the first day, they gave me some medication. I went home and did what addicts do—I tried to find a bag of heroin. I took it, but felt no effect.” The medication had stopped her from feeling it. “I thought—well that was a waste of money.” Lorrie says she has never taken another drug since. Drug treatment, of course is not quite that simple, but for Lorrie, the medication helped her resist drugs during a nine-month treatment cycle that included weekly counseling as well as small cash incentives for clean urine samples.

To help with heroin cravings, every day Lorrie was given the medication buprenorphine in addition to a new drug. The experimental part of the study was to test if a medication called clonidine, sometimes prescribed to help withdrawal symptoms, would also help prevent stress-induced relapse. Half of the patients received daily buprenorphine plus daily clonidine, and half received daily buprenorphine plus a daily placebo. To this day, Lorrie does not know which one she received, but she is deeply grateful that her involvement in the study worked for her.

The study results? Clonidine worked as the NIDA investigators had hoped.

“Before I was clean, I was so uncertain of myself and I was always depressed about things. Now I am confident in life, I speak my opinion, and I am productive. I cry tears of joy, not tears of sadness,” she says. Lorrie is now eight years drug free. And her boyfriend? His treatment at the VA was also effective, and they are now married. “I now feel joy at little things, like spending time with my husband or my niece, or I look around and see that I have my own apartment, my own car, even my own pots and pans. Sounds silly, but I never thought that would be possible. I feel so happy and so blessed, thanks to the wonderful research team at NIDA.”

• Liquor store. Authored by : Fletcher6. Located at : https://commons.wikimedia.org/wiki/File:The_Bunghole_Liquor_Store.jpg . License : CC BY-SA: Attribution-ShareAlike
• Benny Story. Provided by : Living Sober. Located at : https://livingsober.org.nz/sober-story-benny/ . License : CC BY: Attribution
• One patientu2019s story: NIDA clinical trials bring a new life to a woman struggling with opioid addiction. Provided by : NIH. Located at : https://www.drugabuse.gov/drug-topics/treatment/one-patients-story-nida-clinical-trials-bring-new-life-to-woman-struggling-opioid-addiction . License : Public Domain: No Known Copyright

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Teen Cocaine Addiction Case Study: Chloe's Story

This case study of drug addiction can affect anyone – it doesn’t discriminate on the basis of age, gender or background. At Serenity Addiction Centres, our drug detox clinic is open to everyone, and our friendly and welcoming approach is changing the way rehab clinics are helping clients recover from addiction.

We’ve asked former Serenity client, Chloe, to share her experience of drug rehab with Serenity Addiction Centre’s assistance.

Chloe’s Addiction

If you met Chloe today, you would never know about her past. This born and bred London girl is 20 years old, and a flourishing law student with a bright future in the City.

A few years ago though, it seemed as if this straight A student was about to throw away her life, thanks to a  class A drug addiction .

Chloe had a great childhood. By her own admission, school was a breeze for her, with strong academic achievement and social skills making her as successful on the playground as she was in the classroom.

Age 7, Chloe started at a boarding school, and loved having friends around her all the time. With no parents about, Chloe and her friends found themselves invited to house parties. As soon as I could convince people they we 18, they moved on to London’s nightclubs.

It was here where Chloe first came across drugs, and it was a slippery slope to cocaine addiction. She explains: “At 15, I was taking poppers, graduated to MDMA at 16, and then I tried cocaine at our year 13 parties. I got separated from my friends, and found them taking cocaine in a back room. I didn’t want to be left out, so I tried it.” 

Chloe scored straight As in her A levels, and accepted a place at Kings College London to study law. She was introduced to new people, and it seemed that cocaine was available at every place they went. Parties, clubs, and even her new friends were all good sources of a line of cocaine. As a self confessed wild child by this point, Chloe didn’t want to miss out.

The demands of a law degree were high, but so was Chloe’s desire for more cocaine.

Going out almost every night to snort coke, she started to wonder if she was becoming an addict. She spent every penny of the generous allowance from her parents. Chloe spent every penny available on credit cards, and even took on a £2000 bank loan to support her habit.

Chloe estimated that at one point, her addiction had saddled her with more than £13,000 of debt.

Coming out of Addiction Denial

Chloe’s light bulb moment finally came when her best friend, who she shared a flat with, sat her down and asked why they were drifting apart.

Chloe realised that cocaine had become more important to her than her friends, family, and studies. It had to stop. Chloe found the details for Serenity Addiction Centres, and called the same day to ask for help with her addiction.

One thing Chloe particularly appreciated about Serenity Addiction Centres was the flexible approach of the counsellors . They got to know Chloe, listening to her worries, and working out a non-residential rehab plan for her. This allowed her to continue with her studies.

Chloe’s treatment was organised at a clinic not far from her university, allowing her to keep her studies on track, and keeping her life as normal as possible.

Chloe says: “Talking about how I was using cocaine, along with contributing problems from earlier in my life, were a massive help. I didn’t want to be known just as a party girl”.

“If I’d not found Serenity Addiction Centres, there would probably have been a long wait for NHS treatment. Serenity Addiction Centres got the right treatment. Everything was organised with privacy and discretion. I only shared what was happening with my flatmate.”

This level of discretion was really helpful, and the rapid results of her treatment meant that after just three months Chloe felt able to tell her parents what had been happening. 

Life after rehab

It’s amazing that Chloe has now had nearly a year where not taken cocaine, and faced her debts by working part time to repay what she owes. Even better, thanks to Serenity’s fast intervention. Chloe is on course for a 2:1 in her law degree.

If you’re ready to detox? Serenity Addiction Centre’s addiction support team are here to help you find the rehab programme which works for you. Serenity can help you beat your addiction. Gaining control over drugs, allowing you to move on and take back control of your life.

This Drug Addiction Case Study is here so others may identify. Contact us today , and begin your detox journey with Serenity Addiction Centres.

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Jo-Hanna Ivers 1* and Kevin Ducray 2

In October 2012, 83 front-line Irish service providers working in the addiction treatment field received accreditation as trained practitioners in the delivery of a number of evidence-based positive reinforcement approaches that address substance use: 52 received accreditation in the Community Reinforcement Approach (CRA), 19 in the Adolescent Community Reinforcement Approach (ACRA) and 12 in Community Reinforcement and Family Training (CRAFT). This case study presents the treatment of a 17-year-old white male engaging in high-risk substance use. He presented for treatment as part of a court order. Treatment of the substance use involved 20 treatment sessions and was conducted per Adolescent Community Reinforcement Approach (A-CRA). This was a pilot of A-CRA a promising treatment approach adapted from the United States that had never been tried in an Irish context. A post-treatment assessment at 12-week follow-up revealed significant improvements. At both assessment and following treatment, clinician severity ratings on the Maudsley Addiction Profile (MAP) and the Alcohol Smoking and Substance Involvement Screening Test (ASSIST) found decreased score for substance use was the most clinically relevant and suggests that he had made significant changes. Also his MAP scores for parental conflict and drug dealing suggest that he had made significant changes in the relevant domains of personal and social functioning as well as in diminished engagement in criminal behaviour. Results from this case study were quite promising and suggested that A-CRA was culturally sensitive and applicable in an Irish context.

1. Theoretical and Research Basis for Treatment

Substance use disorders (SUDs) are distinct conditions characterized by recurrent maladaptive use of psychoactive substances associated with significant distress. These disorders are highly common with lifetime rates of substance use or dependence estimated at over 30% for alcohol and over 10% for other substances [1 , 2] . Changing substance use patterns and evolving psychosocial and pharmacologic treatments modalities have necessitated the need to substantiate both the efficacy and cost effectiveness of these interventions.

Evidence for the clinical application of cognitive behavioural therapy (CBT) for substance use disorders has grown significantly [3 - 8] . Moreover, CBT for substance use disorders has demonstrated efficacy both as a monotherapy and as part of combination treatment [7] . CBT is a time-limited, problem-focused, intervention that seeks to reduce emotional distress through the modification of maladaptive beliefs, assumptions, attitudes, and behaviours [9] . The underlying assumption of CBT is that learning processes play an imperative function in the development and maintenance of substance misuse. These same learning processes can be used to help patients modify and reduce their drug use [3] .

Drug misuse is viewed by CBT practitioners as learned behaviours acquired through experience [10] . If an individual uses alcohol or a substance to elicit (positively or negatively reinforced) desired states (e.g. euphorigenic, soothing, calming, tension reducing) on a recurrent basis, it may become the preferred way of achieving those effects, particularly in the absence of alternative ways of attaining those desired results. A primary task of treatment for problem substance users is to (1) identify the specific needs that alcohol and substances are being used to meet and (2) develop and reinforce skills that provide alternative ways of meeting those needs [10 , 11] .

CRA is a broad-spectrum cognitive behavioural programme for treating substance use and related problems by identifying the specific needs that alcohol and or other substances are satisfying or meeting. The goal is then to develop and reinforce skills that provide alternative ways of meeting those needs. Consistent with traditional CBT, CRA through exploration, allows the patient to identify negative thoughts, behaviours and beliefs that maintain addiction. By getting the patient to identify, positive non-drug using behaviours, interests, and activities, CRA attempts to provide alternatives to drug use. As therapy progresses the objective is to prevent relapse, increase wellness, and develop skills to promote and sustain well-being. The ultimate aim of CRA, as with CBT is to assist the patient to master a specific set of skills necessary to achieve their goals. Treatment is not complete until those skills are mastered and a reasonable degree of progress has been made toward attaining identified therapy goals. CRA sessions are highly collaborative, requiring the patient to engage in ‘between session tasks’ or homework designed reinforce learning, improve coping skills and enhance self efficacy in relevant domains.

The use of the Community Reinforcement Approach is empirically supported with inpatients [12 , 13] , outpatients [14 - 16] and homeless populations (Smith et al., 1998). In addition, three recent metaanalytic reviews cited CRA as one of the most cost-effective treatment programmes currently available [17 , 18] .

A-CRA is a evidenced based behavioural intervention that is an adapted version of the adult CRA programme [19] . Garner et al [19] modified several of the CRA procedures and accompanying treatment resources to make them more developmentally appropriate for adolescents. The main distinguishing aspect of A-CRA is that it involves caregivers—namely parents or guardians who are ultimately responsible for the adolescent and with whom the adolescent is living.

A-CRA has been tested and found effective in the context of outpatient continuing care following residential treatment [20 - 22] and without the caregiver components as an intervention for drug using, homeless adolescents [23] . More recently, Garner et al [19] collected data from 399 adolescents who participated in one of four randomly controlled trials of the A-CRA intervention, the purpose of which was to examine the extent to which exposure to A-CRA procedures mediated the relationship between treatment retention and outcomes. The authors found adolescents who were exposed to 12 or more A-CRA procedures were significantly more likely to be in recovery at follow-up.

Combining A-CRA with relapse prevention strategies receives strong support as an evidence based, best practice model and is widely employed in addiction treatment programmes. Providing a CBT-ACRA therapeutic approach is imperative as it develops alternative ways of meeting needs and thus altering dependence.

2. Case Introduction

Alan is a 17 year-old male currently living in County Dublin. Alan presented to the agency involuntarily and as a requisite of his Juvenile Liaison Officer who was seeing him on foot of prior drugs arrest for ‘possession with intent to supply’; a more serious charge than a simple ‘drugs possession’ charge. As Alan had no previous charges he was placed on probation for one year. This was Alan’s first contact with the treatment services. A diagnostic assessment was completed upon entry to treatment and included completion of a battery of instruments comprising the Maudsley Addiction Profile (MAP), The World Health Organization Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and the Beck Youth Inventory (BYI) (see appendices for full description of outcome measures) (Table 1).

3. Diagnostic Criteria

The apparent symptoms of substance dependency were: (1) Loss of Control - Alan had made several attempts at controlling the amounts of cannabis he consumed, but those times when he was able to abstain from cannabis use were when he substituted alcohol and/or other drugs. (2) Family History of Alcohol/Drug Usage - Alan’s eldest sister who is now 23 years old is in recovery from opiate abuse. She was a chronic heroin user during her early adult years [17 - 21] . During this period, which corresponds to Alan’s early adolescent years [12 - 15] she lived in the family home (3) Changes in Tolerance - Alan began per day. At presentation he was smoking six to eight cannabis joints daily through the week, and eight to twelve joints daily on weekends.

4. Psychosocial, Medical and Family History

At time of intake Alan was living with both of his parents and a sister, two years his senior, in the family home. Alan was the youngest and the only boy in his family. He had two other older sisters, 5 and 7 years his senior. He was enrolled in his 5th year of secondary school but at the time of assessment was expelled from all classes. Alan had superior sporting abilities. He played for the junior team of a first division football team and had the prospect of a professional career in football. He reported a family history positive for substance use disorders. An older sister was in recovery for opiate dependence. Apart from his substance use Alan reported no significant psychological difficulties or medical problems. His motives for substance use were cited as boredom, curiosity, peer pressure, and pleasure seeking. His triggers for use were relationship difficulties at home, boredom and peer pressure. Pre-morbid personality traits included thrill seeking and impulsivity (Table 2).

5. Case Conceptualisation

A CBT case formulation is based on the cognitive model, which hypothesizes that "a person’s feelings and emotions are influenced by their perception of events" . It is not the actual event that determines how the person feels, but rather how they construe the event (Beck, 1995 p14). Moreover, cognitive theory posits that the “child learns to construe reality through his or her early experiences with the environment, especially with significant others” and that “sometimes these early experiences lead children to accept attitudes and beliefs that will later prove maladaptive” [24] . A CBT formulation (or case conceptualisation) is one of the key underpinnings of Cognitive Behavioural Therapy (CBT). It is the ‘blueprint’ which aids the therapist to understand and explain the patient’s’ problems.

Formulation driven CBT enables the therapist to develop an individualised understanding of the patient and can help to predict the difficulties that a patient may encounter during therapy. In Alan’s case, exploring his existing negative automatic thoughts about regarding school and his academic competences highlighted the difficulties he could experience with CBT homework completion. Whilst Alan was good at between session therapy assignments, an exploration of what is meant by ‘homework’ in a CBT context was crucial.

A collaborative CBT formulation was done diagrammatically together with Alan (Figure 1). This formulation aimed to describe his presenting problems and using CBT theory, to explore explanatory inferences about the initiating and maintaining factors of his drug use which could practically inform meaningful interventions.

Simmons and Griffiths et al. make the insightful observation that particular group differences need to be specifically considered and suggest that the therapist should be cognizant of the role of both society and culture when developing a formulation. They firstly suggest that the impact played by gender, sexuality and socio-cultural roles in the genesis of a psychological disorder, namely the contribution that being a member of a group may have on predisposing and precipitating factors, be carefully considered. An example they offer is the role of poverty on the development of psychological problems, such as the link evidenced between socio economic group and onset of schizophrenia. This was clearly evident in the case of Alan, who being a member of a deprived socioeconomic group, growing up and living in an area with a high level of economic deprivation, perceived that his choices for success were limited. His thinking, as an adolescent boy, was dichotomous in that he saw himself as having only two fixed and limited choices (a) being good at sport he either pursue a career as a professional sportsman or alternatively (b) he engage in crime and work his way up through the ranks as a ‘career criminal’. Simmons & Griffiths secondly suggest that being a member of a particular group can heavily influence a person’s understanding of the causality of their psychological disorder. A third consideration when developing a formulation is the degree to which being a member of a particular group may influence the acceptance or rejection of a member experiencing a psychological illness. Again this is pertinent in Alan’s case as he was part of a sub-group, a gang engaged in crime. For this cohort, crime and drug use were synonymous. Using drugs was viewed as a rite of passage for Alan.

Drug use, according to CBT models, are socially learned behaviours initiated, maintained and altered through the dynamic interaction of triggers, cues, reinforcers, cognitions and environmental factors. The application of a such a formulation, sensitive to Simmons and Griffiths (2009) aforementioned observations, proved useful in affording insights into the contextual and maintaining factors of Alan’s drug use which was heavily influenced by the availability of drugs ,his peer group (with whom he spent long periods of time) and their petty drug dealing and criminality. Similarly, engaging with his football team mates during the lead up to an important match significantly reduced his drug use and at certain times of the year even lead to abstinence. Sharing this formulation allowed him to note how his drug use patterns were driven, as per the CBT paradigm, by modifiable external, transient, and specific factors (e.g. cues, reinforcements, social networks and related expectations and social pressures).

Employing the A-CRA model allowed for this tailored fit as A-CRA specifically encourages the patient to identify their own need and desire for change. Alan identified the specific needs that were met by using substances and he developed and reinforced skills that provided him with alternative ways of meeting those needs. This model worked extremely well for Alan as he had identified and had ready access to a pro- social ‘alternative group’ or community. As he had had access to an alternative positive peer group and another activity (sport) which he was ‘really good at’, he simply needed to see the evidence of how his context could radically affect his substance use; more specifically how his beliefs, thinking and actions in certain circumstances produced very different drug use consequences and outcomes.

6. Course of Treatment and Assessment of Progress

One focus of CBT treatment is on teaching and practising specific helpful behaviours, whilst trying to limit cognitive demands on clients. Repetition is central to the learning process in order to develop proficiency and to ensure that newly acquired behaviours will be available when needed. Therefore, behavioural using rehearsal will emphasize varied, realistic case examples to enhance generalization to real life settings. During practice periods and exercises, patients are asked to identify signals that indicate high-risk situations, demonstrating their understanding of when to use newly acquired coping skills. CBT is designed to remedy possible deficits in coping skills by better managing those identified antecedents to substance use. Individuals who rely primarily on substances to cope have little choice but to resort to substance use when the need to cope arises. Understanding, anticipating and avoiding high risk drug use scenarios or the “early warning signals” of imminent drug use is a key CBT clinical activity.

A major goal of a CBT/A-CRA therapeutic approach is to provide a range of basic alternative skills to cope with situations that might otherwise lead to substance use. As ‘skill deficits’ are viewed as fundamental to the drug use trajectory or relapse process, an emphasis is placed on the development and practice of coping skills. A-CRA was manualised in 2001 as part of the Cannabis Youth Treatment Series (CYT) and was tested in that study [21] and more recently with homeless youth [23] . It was also adapted for use in a manual for Assertive Continuing Care following residential treatment [20] .

There are twelve standard and three optional procedures proposed in the A-CRA model. The delivery of the intervention is flexible and based on individual adolescent needs, though the manual provides some general guidelines regarding the general order of procedures. Optional procedures are ‘Dealing with Failure to Attend’, ‘Job-Seeking Skills’, and ‘Anger Management’. Standard procedures are included in table 3 below. For a more detailed description of sessions and procedures please see appendices.

Smith and Myers describe the theoretical underpinnings of CRA as a comprehensive behavioural program for treating substance-abuse problems. It is based on the belief that environmental contingencies can play a powerful role in encouraging or discouraging drinking or drug use. Consequently, it utilizes social, recreational, familial, and vocational reinforcers to assist consumers in the recovery process. Its goal is to essentially make a sober lifestyle more rewarding than the use of substances. Interestingly the authors note: ‘Oddly enough, however, while virtually every review of alcohol and drug treatment outcome research lists CRA among approaches with the strongest scientific evidence of efficacy, very few clinicians who treat consumers with addictions are familiar with it’. ‘The overall philosophy is to promote community based rewarding of non drug-using behaviour so that the patient makes healthy lifestyle changes’ p.3 [25] .

A-CRA procedures use ‘operant techniques and skills training activities’ to educate patients and present alternative ways of dealing with challenges without substances. Traditionally, CRA is provided in an individual, context-specific approach that focuses on the interaction between individuals and those in their environments. A-CRA therapists teach adolescents when and where to use the techniques, given the reality of each individual’s social environment. This tailored approach is facilitated by conducting a ‘functional analysis’ of the adolescent’s behaviour at the beginning of therapy so they can better understand and interrupt the links in the behavioural chain typically leading to episodes of drug use. A-CRA therapists then teach individuals how to improve communication and other skills, build on their reinforcers for abstinence and use existing community resources that will support positive change and constructive support systems.

A-CRA emphasises lapse and relapse prevention. Relapseprevention cognitive behavioural therapy (RP-CBT) is derived from a cognitive model of drug misuse. The emphasis is on identifying and modifying irrational thoughts, managing negative mood and intervening after a lapse to prevent a full-blown relapse [26] . The emphasis is on development of skills to (a) recognize High Risk Situations (HRS) or states where clients are most vulnerable to drug use, (b) avoidance of HRS, and (C) to use a variety of cognitive and behavioural strategies to cope effectively with these situations. RPCBT differs from typical CBT in that the accent is on training people who misuse drugs to develop skills to identify and anticipate situations or states where they are most vulnerable to drug use and to use a range of cognitive and behavioural strategies to cope effectively with these situations [26] .

7. Access and Barriers to Care

Alan engaged with the service for eight months. During this time he received twenty sessions, three of which were assessment focused, the remaining seventeen sessions were A-CRA focused; two of the seventeen involved his mother, the remaining fifteen were individual. As Alan was referred by the probation services, he was initially somewhat ambivalent about drug use focussed interventions. His early motivation for engagement was primarily to avoid the possibility of a custodial sentence.

8. Treatment

My sessions with Alan were guided by the principles of A-CRA [27] which focuses on coping skills training and relapse prevention approaches to the treatment of addictive disorders. Prior to engaging with Alan, I had completed the training course and commenced the A-CRA accreditation process, both under the stewardship of Dr Bob Meyers, whose training and publication offers detailed guidelines on skills training and relapse prevention with young people in a similar context [27] .

During the early part of each session I focused on getting a clear understanding of Alan’s current concerns, his general level of functioning, his substance abuse and pattern of craving during the past week. His experiences with therapy homework, the primary focus being on what insight he gained by completing such exercises was also explored. I spent considerable time engaged in a detailed review of Alan’s experience with the implementation of homework tasks during which the following themes were reviewed:

-Gauging whether drug use cessation was easier or harder than he anticipated? -Which, if any, of the coping strategies worked best? -Which strategies did not work as well as expected. Did he develop any new strategies? -Conveying the importance of skills practice, emphasising how we both gained greater insights into how cognitions influenced his behaviour. After developing a clear sense of Alan’s general functioning, current concerns and progress with homework implementation, I initiated the session topic for that week. I linked the relevance of the session topic to Alan’s current cannabis-related concerns and introduced the topic by using concrete examples from Alan’s recent experience. While reviewing the material, I repeatedly ensured that Alan understood the topic by asking for concrete examples, while also eliciting Alan’s views on how he might use these particular skills in the future.

Godley & Meyers [21] propose a homework exercise to accompany each session. An advantage of using these homework sheets is that they also summarise key points about each topic and therefore serve as a useful reminder to the patient of the material discussed each week. Meyers, et al. (2011) suggests that rather than being bound by the suggested exercises in the manualised approach, they may be used as a starting point for discussing the best way to implement the required skill and to develop individualised variations for new assignments [27] . The final part of each session focused on Alan’s plan for the week ahead and any anticipated high-risk situations. I endeavoured to model the idea that patients can literally ‘plan themselves out of using’ cannabis or other drugs. For each anticipated high-risk situation, we identified appropriate and viable coping skills. Better understanding, anticipating and planning for high-risk situations was difficult in the beginning of treatment as Alan was not particularly used to planning or thinking through his activities. For a patient like Alan, whose home life is often chaotic, this helped promote a growing sense of self efficacy. Similarly, as Alan had been heavily involved with drug use for a long time, he discovered through this process that he had few meaningful activities to fill his time or serve as alternatives to drug use. This provided me with an opportunity to discuss strategies to rebuild an activity schedule and a social network.

During our sessions, several skill topics were covered. I carefully selected skills to match Alan’s needs. I selected coping skills that he has used in the past and introduced one or two more that were consistent with his cognitive style. Alan’s cognitive score indicated a cognitive approach reflecting poor problem solving or planning. Sessions focused on generic skills including interpersonal skills, goal setting, coping with criticism or anger, problem solving and planning. The goal was to teach Alan how to build on his pro- social reinforcers, how to use existing community resources supportive of positive change and how to develop a positive support system.

The sequence in which these topics were presented was based on (a) patient needs and (b) clinician judgment (a full description of individual sessions may be found in appendices).

A-CRA procedures use ‘operant techniques and skills training activities’ to educate patients and present alternative ways of dealing with challenges without substances. Traditionally, CRA is provided in an individual, context-specific approach that focuses on the interaction between individuals and those in their environments. A-CRA therapists teach adolescents when and where to use the techniques, given the reality of each individual’s social environment.

9. Assessment of Treatment Outcome

A baseline diagnostic assessment of outcomes was completed upon treatment entry. This assessment consisted of a battery of psychological instruments including (see appendices for full a description of assessment measures):

-The Maudsley Addiction Profile (MAP). -The Beck Youth Inventories. -The World Health Organization Alcohol, Smoking and Substance Involvement Screening Test (ASSIST).

In addition to the above, objective feedback on Alan’s clinical and drug use status through urine toxicology screens was an important part of his drug treatment. Urine specimens were collected before each session and available for the following session. The use of toxicology reports throughout treatment are considered a valuable clinical tool. This part of the session presents a good opportunity to review the results of the most recent urine toxicology screen and promote meaningful therapeutic activities in the context of the patient’s treatment goals [28] .

In reporting on substance use since the last session, patients are likely to reveal a great deal about their general level of functioning and the types of issues and problems of most current concern. This allows the clinician to gauge if the patient has made progress in reducing drug use, his current level of motivation, whether there is a reasonable level of support available in efforts to remain abstinent and what is currently bothering him. Functional analyses are opportunistically used throughout treatment as needed. For example, if cannabis use occurs, patients are encouraged to analyse antecedent events so as to determine how to avoid using in similar situations in the future. The purpose is to help the patient understand the trajectory and modifiable contextual factors associated with drug use, challenge unhelpful positive drug use expectancies, identify possible skills deficiencies as well as seeking functionally equivalent non- drug using behaviours so as to reduce the probability of future drug use. The approach I used is based on the work of [28] .

The Functional Analysis was used to identify a number of factors occurring within a relatively brief time frame that influenced the occurrence of problem behaviours. It was used as an initial screening tool as part of a comprehensive functional assessment or analysis of problem behaviour. The results of the functional analysis then served as a basis for conducting direct observations in a number of different contexts to attest to likely behavioural functions, clarify ambiguous functions, and identify other relevant factors that are maintaining the behaviour.

The Happiness Scale rates the adolescent’s feelings about several critical areas of life. It helps therapists and adolescents identify areas of life that adolescents feel happy about and alternatively areas in which they have problems or challenges. Most importantly it identifies potential treatment goals subjectively meaningful to the patient, facilitates positive behaviour change in a range of life domains as well as help clients track their progress during treatment.

Alan’s BYI score (Table 4) indicates that at the time of assessment he was within the average scoring range on ‘self-concept’, and moderately elevated in the areas of ‘depression’, ‘anxiety’, and ‘disruptive behaviour’. His score for ‘anger’ suggested that his anger fell within the extremely elevated range. When this was discussed with Alan he agreed that this was quite accurate. Anger, and in particular controlling his anger, was subjectively identified as a treatment goal.

10. Follow-up

Given that follow-up occurred by telephone it was not feasible to administer the full battery of tests. With Alan’s treatment goals in mind it was decided to administer the MAP and ASSIST. Table 5 below illustrates Alan’s score at baseline and follow-up for the MAP and ASSIST. For summary purposes I have taken areas for concern at baseline for both instruments.

Alan’s score for cannabis was the most clinically relevant as it placed him in the 'high risk’ domain while his alcohol score indicated that he had engaged in binge drinking (6+ drinks) at T1. However, at T2 Alan’s score suggests that he had made considerable reductions in the use of both substances. Also his MAP scores for parental conflict and drug dealing suggest that he had also made major positive changes in the relevant domains of personal and social functioning as well as ceasing criminal behaviour.

At 3 months post-discharge I contacted Alan by phone. He had maintained and continued to further his progress. His drug use was at a minimal level (1 or 2 shared joints per month). He was no longer engaged in crime and his probationary period with the judicial system had passed. He had received a caution for his earlier drugs charge. At the time of follow-up he was enjoying participating in a Sports Coaching course and was excelling with his study assignments. Relationships had improved considerably with his mother and sister and he had re-engaged with a previous, positive, peer group linked to his involvement with the GAA . Overall he felt he was doing extremely well.

11. Complicating Factors with A-CRA Model

There are many challenges that may arise in the treatment of substance use disorders that can serve as barriers to successful treatment. These include acute or chronic cognitive deficits, health problems, social stressors and a lack of social resources [7] . Among individuals presenting with substance use there are often other significant life challenges including early school leaving, family conflicts, legal issues, poor or deviant social networks, etc. A particular challenge with Alan’s case was the social and environmental milieu which he shared with his drug using peers. For Alan, who initially had few skills and resources, engaging in treatment meant not only being asked to change his overall way of life but also to renounce some of those components in which he enjoyed a sense of belonging, particularly as he had invested significantly in these friendships. A sense of ‘belonging to the substance use culture’ can increase ambivalence for change [7] . Alan’s mother strongly disapproved of his drug using peer group and failed to acknowledge Alan’s perceived loss. This resulted in mother- son conflict. The use of the caregiver session allowed an exploration of perceived ‘losses’ relative to the ‘gains’ associated with Alan’s abstinence. It was moreover seen to be critical to establish alternatives for achieving a sense of belonging, including both his social connection and his social effectiveness. Alan’s sports ability allowed for this to be fostered. He is a talented sportsman which often meant his acceptance within a team or group is a given.

Despite the positive effects of A-CRA it is not without its shortcomings. The approach is at times quite American- oriented, particularly around identifying local resources and its focus on culturally specific outlets in promoting social engagement as alternatives to substance use. While this is supported in the literature, it may not necessarily be transferable to certain Irish adolescent contexts or subcultures.

12. Treatment Implications of the Case

A-CRA captures a broad range of behavioural treatments including those targeting operant learning processes, motivational barriers to improvement and other more traditional elements of cognitivebehavioural interventions. Overall, this intervention has demonstrated efficacy. Despite this heterogeneity, core elements emerge based in a conceptual model of SUDs as disorders characterized by learning processes and driven by the strongly reinforcing effects of the substances of abuse. There is rich evidence in the substance use disorders literature that improvement achieved by CBT (7) and indeed A-CRA (Godley et al. and Garner et al. [22 , 20] ) generalizes to all areas of functioning, including social, work, family and marital adjustment domains. The present study’s finding that a reduction in substance-related symptoms was accompanied by improved levels of functioning, social adjustment and enhanced quality of life, provides further support for this point.

In conclusion, there is some preliminary evidence that A-CRA is a promising treatment in the rehabilitation of adolescent substance users in Ireland and culturally similar societies. Clearly, results from a case study have limited generalisability and there is need for larger controlled studies providing robust outcomes to confirm the efficacy of A-CRA in an Irish context. A more systematic study of this issue is in the interest of adolescent substance users and the health services providers faced with the challenge of providing affordable, evidencebased mental health and addiction care to young people.

13. Recommendations to Clinicians and Students

The ACRA model is a structured assemblage of a range of cognitive and behavioural activities (e.g. a rationale and overview of the paradigm, sobriety sampling, functional analyses, communication skills, problem solving skills, refusal skills, jobs counselling, anger management and relapse prevention) which are shared in varying degrees with other CBT approaches. The ACRA model has the advantage of established effectiveness. A foundation in empirical research together with its manual- supported approach results in it being an appropriate “off the shelf ” intervention, highly applicable to many adolescent substance misusers. Such a focussed approach also has the advantage of limiting therapist “drift”. Notwithstanding the accessible manual and other resources available on- line, clinicians and students are strongly encouraged to undergo accredited ACRA training and supervision.

Unfortunately such a structured model, despite its many advantages, does have limitations. This model may not meet the sum of all drug misusing adolescent service user treatment needs, nor is it applicable to all adolescent drug users, particularly highly chaotic individuals with high levels of co- morbidities or multi-morbidities as often found in this population [29 , 30] . Whilst focussing on specifically on drug use, ACRA does not directly address co-existing problem behaviours or challenges such as depression, anxiety, personality disorder, or post traumatic stress disorder (PTSD) synergistically linked to drug use. It is possible that given the high levels of dual diagnoses encountered in this population as well as the compounding effect that drug use exerts on multiple systems, clinicians and practitioners may find a strict application of the ACRA model limiting, necessitating the application of an additional range or layer of psychotherapeutic competencies? Additionally the ACRA model does not focus explicitly on other psychological activities useful in the treatment of drug misuse such as the control and management of unhelpful cognitive styles or habits; breathing or progressive relaxation skills; anger management; imagery, visualisation and mindfulness. That is, as a manual based approach comprising a number of fixed components, a major potential challenge facing clinicians and students is the tension they may experience between maintaining strict fidelity to a pure ACRA approach, versus the flexibility l approved by more formulation driven CBT approaches?

The advantages of a skilled application of a formulation driven approach which are cited and summarised in are multiple and include the collaborative nature of goal setting, the facilitation of problem prioritisation in a meaningful and useful manner; a more immediate direction and structuring of the course of treatment; the provision of a rationale for the most fitting intervention point or spotlight for the treatment; an integration of seemingly unrelated or dissimilar difficulties in a meaningful yet parsimonious fashion; an influence on the choice of procedures and “homework” exercises; theory based mechanisms to understand the dynamics of the therapeutic relationship and a sense of targeted and ‘extra-therapeutic’ issues and how they could be best explained and managed, especially in terms of precipitators or triggers, core beliefs, assumptions and automatic thoughts.

Thus given the above observations and together with the importance placed on engagement and retention, the high variability in the cognitive, emotional, social and developmental domains [4] differences in roles (e.g. teenagers who are also parents) and levels of autonomy as well as high degrees of dual diagnosis or co- morbidities found in this group [29 , 30] practitioners are encouraged to also develop competencies in allied psychological treatment models such as Motivational Interviewing [31] ; familiarity with the core principles of CBT, disorder specific and problem-specific CBT competences, the generic and meta- competences of CBT as well as an advanced knowledge and understanding of mental health problems that will provide practitioners with the confidence and capacity to implement treatment models in a more flexible yet coherent manner,. In addition to seeking supervision and mentorship students and practitioners are directed, as a starting point, to University College London’s excellent resources outlining the competencies required to provide a more comprehensive interventions [11] .

Both authors reported no conflict of interest in the content of this paper.

Author Contributions

Conceived and designed the experiments: JI. Recruitment & assessment and on going treatment t of patient JI. On going supervision of case KD. Contributed reagents/materials/analysis tools: JI, & KD. Wrote the paper: JI. Contributed to final draft paper KD.

Acknowledgments

We thank Adolescent Addiction Services, Health Service Executive.

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March 1, 2017

Case Study: When Chronic Pain Leads to a Dangerous Addiction

How did an educated, elderly engineer wind up with a heroin habit? 

By Daniel Barron

It was 4 P.M., and Andrew

* had just bought 10 bags of heroin. In his kitchen, he tugged one credit-card-sized bag from the rubber-banded bundle and laid it on the counter with sacramental reverence. Pain shot through his body as he pulled a cutting board from the cabinet. Slowly, deliberately, he tapped the bag's white contents onto the board and crushed it with the flat edge of a butter knife, forming a line of fine white powder. He snorted it in one pass and shuffled back to his armchair. It was bitter, but snorting heroin was safer than injecting, and he was desperate: his prescription pain medication was gone.

I met Andrew the next day in the emergency room, where he told me about the previous day's act of desperation. I admitted him to control his swelling legs and joint pain. He was also detoxing from opioids.

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Andrew looked older than his 69 years. His face was wrinkled with exhaustion. A frayed, tangled mop of grizzled hair fell to his shoulders. Andrew had been a satellite network engineer, first for the military, more recently for a major telecommunications company. An articulate, soft-spoken fellow, he summed up his (rather impressive) career modestly: “Well, I'd just find where a problem was and then find a way to fix it.”

Yet there was one problem he couldn't fix. “Doctor, I'm always in the most terrible pain,” he said, with closed eyes. “I had no other options. I started using heroin, bought it from my neighbor to help with the pain. I'm scared stiff.”

For two decades Andrew had suffered serial joint failures from a combination of arthritis, obesity and other factors. Each began as an achy pain and ended in a joint replacement. His right shoulder was the first to go, followed by both hips, a knee and an ankle. Pain always ensued. The new joints kept getting infected: more surgery, more pain. To make things worse, a bathtub mishap broke his right femur. That led to an operation to insert a full-length titanium rod. A perfect storm of complications had left Andrew barely able to hobble around the small apartment he shared with his adult son. (Andrew's wife had left him shortly after he broke his femur, and his son took him in.) Pain became Andrew's all-consuming nemesis, devouring most of his waking hours.

Andrew was first prescribed an opioid after one of his many surgeries. This was in the late 1990s, around the time when prescriptions for these painkillers began to take off nationally. His doctor began him on Vicodin, a commonly used opioid that combines hydrocodone with acetaminophen (Tylenol).

Pain, like vision, touch or taste, is a sensory signal. The brain has an elaborate network of receptors, neurons and centers dedicated to pain. Opioids exert their effects by binding to mu-opioid receptors, which are densely concentrated in brain regions that regulate pain perception and reward. Activating mu receptors blocks pain signals in the spinal cord and the response to this signal in the brain. Mu receptors also cause the release of dopamine in reward pathways, which is why opioids cause both analgesia and euphoria.

Surgery after surgery, opioids became Andrew's vitamins, as vital to his pain control as blood pressure drugs are for hypertension. Yet in 2005 Andrew noticed he was feeling anxious about his pill supply. “You start out with a bottle of 30 pills, then there's only 20, then only 10. It's scary when you run out.”

Credit: Chris Gash

Months after his surgeries, after his scars were healed, he still struggled with deep, biting pain. It had spread throughout his body and required more pills to tame. Andrew had transitioned from what is called acute pain (pain from his surgical wounds) to chronic pain (pain in the absence of an obvious cause). He had also developed a tolerance to the opioids. On a cellular level, this means that his neurons expressed fewer mu receptors, so he needed to flood his system with higher doses to get the same effect as before. (Andrew, ever the engineer, appreciated the irony of wrangling yet another network, this time with drugs.)

Possibly, the opioids had contributed to Andrew's spreading pain. Some patients on these drugs have been known to develop increased pain sensitivity known as opioid-induced hyperalgesia.

From Prescription Meds to Street Drugs

As his tolerance for opioids grew, Andrew found that even 15 milligrams of oxycodone no longer worked for him. After he relocated to his son's apartment, he no longer had a primary care provider familiar with his history and could not refill his medications.

With nowhere to turn, Andrew mentioned his situation to his neighbor, who sold him diverted opioids—prescription medications hawked on the street. When these ran out, his neighbor sold him heroin. Andrew's dependence on heroin terrified him, and at $100 a day, it threatened to bankrupt him as well.

This trajectory is by no means unusual, according to Andrew's lead doctor, William Becker, an addiction medicine specialist and assistant professor at the Yale School of Medicine: “Chronic pain is the new initiation to heroin. We're finding that it's older and older patients, who start on the path to chronic pain, then on to opioids, then on to heroin.” Andrew's case is a “classic example,” he said. “The numbers are controversial, but as tens of millions of people taking opioids for pain age, we think 10 percent and maybe more will develop at least a mild opioid use disorder. And their pain isn't going away. We have to become more fluent in managing the co-occurrence of chronic pain and addiction.”

His words and recent warnings from U.S. surgeon general Vivek H. Murthy about the “urgent health crisis” caused by our lax approach to opioids now come to mind every time I consider writing a prescription for one of these painkillers. I also think of Andrew standing at his kitchen counter, hands trembling as he forms a line of heroin.

Relief and Release

Luckily for Andrew, Becker runs the Opioid Reassessment Clinic, which is pioneering strategies to taper patients with chronic pain from high-dose opioid use to Suboxone, a clever sublingual tablet that combines buprenorphine and naloxone. Buprenorphine activates the mu-opioid receptor. When taken under the tongue, it provides pain relief and prevents withdrawal. Naloxone is added as a safeguard to keep abusers from injecting the drug. When taken sublingually, naloxone has no effect. When injected, it blocks the mu receptor and causes acute withdrawal, a physiological inducement to use Suboxone in the prescribed manner.

At a dollar a day, Suboxone is affordable. In combination with intensive psychosocial therapy, it is a safe and highly efficacious treatment for opioid use disorders. And, as Andrew attested, it actually controls pain better than heroin. Instead of being strung out on heroin, Suboxone allowed Andrew to meaningfully interact with our medical team. He undertook a program of proved therapies for chronic pain that included physical therapy, mindfulness training and psychosocial therapy. Andrew left the hospital after nearly three weeks with a clear plan: weekly check-ins at Becker's Suboxone clinic and continued physical and psychosocial therapy tailored for pain. The last time I saw him in his hospital room, he was excited at the prospects: “The plan is to continue with Suboxone and to stay with it. And hopefully I won't have any more surgeries. It's been a rough decade, a long haul, but I'm making slow progress.”

Andrew will be managing pain and addiction for the rest of his life, but now he has a variety of tools for doing so that are safe, legal and effective.

Daniel Barron is director of the Pain Intervention and Digital Research Program, a National Institutes of Health–funded research clinic devoted to developing better tools to define chronic pain and psychiatric conditions, at Brigham and Women's Hospital and Spaulding Rehabilitation Hospital. He completed his medical training and psychiatry residency at Yale University, his graduate work at the University of Texas and his fellowship in interventional pain medicine at the University of Washington. He is author of  Reading Our Minds: The Rise of Big Data Psychiatry . Follow him on X (formerly Twitter)  @daniel__barron  or visit his website at  danielsbarron.com

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Case Reports in Addictive Disorders

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• Section One: Introduction
• Section Two: Learning and Teaching Resources to Support Integration of Mental Health and Addiction in Curricula
• Section Three: Faculty Teaching Modalities and Reflective Practice
• Section Four: Student Reflective Practice and Self-Care in Mental Health and Addiction Nursing Education
• Section Five: Foundational Concepts and Mental Health Skills in Mental Health and Addiction Nursing
• Section Six: Legislation, Ethics and Advocacy in Mental Health and Addiction Nursing Practice
• Section Seven: Clinical Placements and Simulations in Mental Health and Addiction Nursing Education
• Section Eight: Reference and Bibliography
• Section Nine: Appendices and Case Studies

Section Nine

Case studies, also in this section.

• Alignment between CASN/ CFMHN Entry-to-Practice Mental Health and Addiction Competencies and Sections in the Nurse Educator Mental Health and Addiction Resource
• Process Recording
• Criteria for Validation: Process Recording
• Criteria for Phase of Relationship: Process Recording
• Journaling Activity
• Safety and Comfort Plan Template
• Advocacy Groups for Mental Health in Canada
• Tips for Engaging Lived Experience
• Glossary of Terms
• Case Study 1
• Case Study 2
• Case Study 3
• Case Study 4
• Case Study 5
• Case Study 6
• Case Study 7
• Case Study 8
• Case Study 9

The case study is an effective teaching strategy that is used to facilitate learning, improve critical thinking, and enhance decision-making Sprang, (2010). Below are nine case studies that educators may employ when working with students on mental illness and addiction. The case studies provided cover major concepts contained in the RNAO Nurse Educator Mental Health and Addiction Resource.

While not exhaustive, the case studies were developed and informed by the expert panel. It is recommended that educators use the case studies and tweak or add questions as necessary to impart essential information to students. Also, educators are encouraged to modify them to suit the learning objective and mirror the region in which the studies are taking place. Potential modifications include:

• demographics (age, gender, ethnicity);
• illness and addiction, dual diagnosis or additional co-morbidities such as cardiovascular disease; and
• setting (clinical, community).

Suggested “Student questions” explore areas of learning, while “Educator elaborations” recommend ways to modify the case study. Discussion topics are a limited list of suggested themes.

When using these case studies, it is essential that this resource is referenced.

See Engaging Clients Who Use Substances BPG appendices for examples

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Case Studies

“jessie and her mom were able to repair their mother-daughter relationship, jessie successfully completed criminal drug court, and past hurts were addressed and allowed the family to move forward in a cohesive and loving way.” .

Meet Jessie

Age:  19 Family:  Mother & stepmother

Before MDFT:  Criminal drug court - Jessie was arrested for cocaine possession when she was pulled over by police. Being 19 and a first offender, she was offered the option of participating in criminal drug court, which she and her mother were very willing to do together. Jessie’s mother had been in drug court herself with the same judge when she was a young mother. Jessie and her mother had already been in the process of working on their mother-daughter relationship, both being aware that Jessie needed to make the transition to young adulthood. Mom struggled with appropriate parent-child boundaries and had her own difficult intimate relationship with her partner. Jessie struggled with past hurts from Mom’s addiction when she was a child and dealing with Mom’s partner, who was physically aggressive with Jessie. Jessie had very limited self-care/healthcare practices or a positive sense of how to take control of her life. MDFT Treatment Focus: 

Eliminating substance use and adopting a drug-free lifestyle for Jessie and renewing Mom’s focus on her own recovery given her daughter’s crisis

Complying with the drug court program, which required testing negative for all substances, appearing weekly for court, demonstrating progress in academics/employment, and generally managing the demands of the program.

Developing self-care practices and proactive healthcare practices, particularly in the face of an unexpected and difficult pregnancy that spiraled into a medical crisis

Evolving in the sense of who Jessie wanted to be as a young woman and developing the capacity for a healthy intimate relationship

Working out past hurts and current family relationships, particularly between Jessie and Jess, and the challenges posed by Jess’ partner; Mom ultimately left her partner in order to care for her daughter and take a stand for the type of relationship she wanted for herself

After MDFT:  Jessie and Jess were able not only to repair their mother-daughter relationship but to develop a new relationship based on mutual respect and care appropriate at Jessie’s level of development. Jessie remained clean of all substances and she successfully completed criminal drug court. Jessie developed self-care and self-love practices. Jess’ difficult relationship ended, and the past hurts between Jessie and Jess were addressed, which allowed the family to move forward in a cohesive and loving way. Read the full case summary.

Age:  17

Family:  Mother & grandparents Before MDFT:  Drug use since age 11 related to mental health problems including severe anxiety, depression, and PTSD symptoms stemming from exposure to domestic and community violence. Isaac was both using and selling drugs. He had tried several other unsuccessful treatments including a residential program. He was in constant, and often violent, conflict with his mother, had few social ties and was failing in school. He was on community probation at the time of his referral to MDFT and was at very high risk of being placed in a long-term commitment facility. Isaac was open-minded and loved his mother deeply despite their violent conflicts. However, he held strong feelings of resentment toward his father who left him and his mother to start another family. MDFT Treatment Focus: 

Improve communication between Isaac and his mother, including listening, problem-solving, and talking in a way that they could understand each other and not get defensive

Develop Isaac’s emotional regulation skills to reduce violence and confrontational dialogue, and increase understanding by being able to listen without reactivity

Help Isaac establish personally meaningful long-term goals and build self-awareness of how his continued drug use and criminality interfered with a positive life plan 

Build Isaacs’s belief in himself and hope for his future

Improve mom’s self-care practices and help her engage in therapy for her own issues

Help Isaac’s mother set developmentally appropriate expectations, function as the mother in the relationship even when not feeling her best, and begin to believe in and trust Isaac

After MDFT:  Isaac's case demonstrates how MDFT’s focus on multiple domains—the youth, parent, family, and community—work synergistically to create deep, lasting, and positive change. There was significant change within Isaac, in his mother as a person and in her parenting practices, in the relationship between mother and son, and in how they interacted with their community and accessed critical resources and support.

Read the full case summary.

Age:  18 Family:  Mother and Father (Divorced) Before MDFT:   Drug and alcohol addiction, depression, school failure. Joy had just flunked out of her first year of college and had a long history of substance use and depression including several suicide attempts. In the midst of this, Joy was also insightful and intelligent. MDFT Treatment Focus : 

Challenge Joy to examine the discrepancies between her dreams and goals and her current behavior, especially addressing how she would like her life to change and developing action plans to help Joy stop using drugs and alcohol, manage her emotions, and get her life on a healthy developmental trajectory

Help mother and father resolve their parenting differences and clarify their expectations for Joy and their parental roles

Help Joy to develop a strong sense of self, resolve cultural identity issues, and establish a positive peer network as an emerging adult

Foster better communication between Joy and her parents about matters of everyday life and to heal past and current hurts and resentments

After MDFT: The journey with Joy and her parents over the course of six months of therapy, although challenging in many ways, was a success story. Joy's therapy highlights the many themes that develop during the transition from adolescence into young adulthood and describes the MDFT therapist's role in helping youth and parents work through these issues and make the many changes necessary for successful preparation for this new life stage. It is also one of many examples of how MDFT works with parents to be a team despite conflict and separation.

Age:  17 Family:  Mother Before MDFT: School failure and truancy, drug use, general disregard for mom’s rules. James was 17 and still in the ninth grade. Mom was at the end of her rope. James was also funny, social, well-liked by peers. MDFT Treatment Focus:

Help mom develop skills to enable her to better regulate her emotions, and influence James in a more effective manner

Minimize the risk of neighborhood and negative school influences on James

Help James establish life goals and develop tangible steps for reaching them, including tools to help him reduce his drug use

Facilitate communication between James and his mother to emphasize feelings of love and concern

After MDFT:  James’ case demonstrates the importance of addressing both parental despair and hopelessness as well as parenting skills, improving the emotional relationship between mother and son, addressing neighborhood risk factors, and helping James discover his healthy and positive self. The therapist helped both James and his mother set forth and focus on concrete goals that each would work to achieve. As therapy ended, James and his mother focused on his plans to attend Job Corps. James’ mother was proud of her son, and James was able to express his appreciation for her in hanging in with him through it all and how he would continue to need her support. Read the full case summary.

Age:  17 Family:  Mother Before MDFT:  Ryan’s drug use, mom’s drug use, break-down of their relationship. Ryan’s mother, Marge, is a single parent with a history of cocaine addiction and current alcohol dependence; she feels like a failure as a mother and does not know how to help her son. Ryan is resistant to treatment and acts independently from his mother.

MDFT Treatment Focus:  

Help Ryan identify life goals, plans to achieve his goals, and learn to regulate his emotions and express them in a healthier and less destructive manner

Help Marge address her own substance misuse, establish self-care practices, utilize available supports as a single parent, and adopt new parenting skills

Facilitate communication between Ryan and Marge to help them reconnect and resolve past feelings of abandonment and neglect, and to enhance their communication and family problem-solving skills

Empower Marge to work more effectively with Ryan’s school and to organize pro-social activities for Ryan

After MDFT:  Ryan’s case demonstrates the importance of addressing the pain of the past and improving communication between youth and parents, to empower parents with the skills to cope with their own problems, and to enhance parenting practices. It is an example of how we work as allies of single parents to build support so that they can become the excellent parents they want to be and not be overwhelmed. By the end of treatment, both Marge and Ryan had stopped using alcohol and drugs. During the final session, they were able to communicate to each other the many positive changes they had both made during the course of treatment. Read the full case summary.

Due to the sensitive nature of our work, all case study names and identities have been altered for confidentiality.

What people are saying, “before treatment school was not my best friend. i didn’t like being there. i got in constant trouble. i didn’t do my work. i wasn’t even motivated to stay in school. after the treatment, i changed my attitude. it’s good not to argue with my parents all the time about my grades, and to not worry about being kicked out...the program helped my parents and me talk without screaming. we listen to each other...the mdft therapist helped me get into another school and i’m glad they helped me to get there. it is amazing and really different from both high schools i went to previously. i like it a lot.”.

— Youth in Miami

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Introduction to Social Work: An Advocacy-Based Profession

Student resources, case studies.

Case Study for Chapter 10: Substance Use and Addiction

Jennifer’s brother Emmett resorted to drugs and alcohol to drown his sorrow after their dad left their mother. The local inner city high school had its share of dealers and Emmett’s will power was nil. While weed (cannabis, marijuana, pot) was Emmett’s initial drug of choice, his substance use later led him to having a heroin addiction. Now out of the closet as a gay man, Emmett also was introduced to the club/party drugs of ecstasy and crystal meth. It breaks Jennifer’s and her mom’s heart to watch Emmett maintain his addiction despite some brief stints in drug rehab and attendance at local AA meetings. Emmett’s sponsor uses tough love—a mix of encouragement and challenge—to help Emmett stay on his path to and through recovery.

1) What local, state, and national policy and practice resources exist for social workers who work with people who abuse substances?

2) With the help of a social worker, how might family members intervene to help Emmett recover and maintain his sobriety? How might they benefit personally from social work services as well?

3) How much stigma encircles people who succumb to substance abuse or addiction?  

4) What specific challenges might need to be addressed in treatment in order for Emmett to truly achieve a high functioning level?

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Robert’s story

Robert was living with an alcohol addiction and was homeless for over 25 years. He was well known in the local community and was identified as one of the top 100 A&E attendees at the Local General Hospital.

He drank all day every day until he would pass out and this was either in the town centre or just by the roadside. In addition, Robert was also incontinent and really struggled with any meaningful communication or positive decision making due to his alcohol usage. This often resulted in local services such as police, ambulance being called in to help. He had no independent living skills and was unable to function without alcohol.

In addition, and due to his lifestyle and presenting behaviours, Robert had a hostile relationship with his family and had become estranged from them for a long period of time.

Robert needed ongoing support and it was identified at the General Hospital that if he was to carry on “living” the way he currently was, then he wouldn’t survive another winter.

On the back of this, Robert was referred to Calico who organised a multi-disciplinary support package for him, which included support with housing as part of the Making Every Adult Matter programme.

After some initial challenges, Robert soon started to make some positive changes.

The intensive, multidisciplinary support package taught him new skills to support him to live independently, sustain his tenancy and make some positive lifestyle changes which in turn would improve his health and wellbeing.

This included providing daily visits in the morning to see Robert and to support him with some basic activities on a daily/weekly basis. This included getting up and dressed; support with shopping and taking to appointments; guidance to help make positive decisions around his associates; support about his benefits and managing his money. In addition, he was given critical support via accessing local groups such as RAMP (reduction and motivational programme) and Acorn (drugs and alcohol service), as well as 1 to 1 sessions with drugs workers and counsellors to address his alcohol addiction.

After six months Robert continued to do well and was leading a more positive lifestyle where he had greatly reduced his A&E attendance. He had significantly reduced his alcohol intake with long periods of abstinence and was now able to communicate and make positive decisions around his lifestyle.

Critically he had maintained his tenancy and continued to regularly attend local groups and other support for his alcohol addiction and had reconnected with some of his family members.

By being able to access these community resources and reduce his isolation he is now engaged in meaningful activities throughout the day and has been able to address some of his critical issues. A small but significant example is that Robert is now wearing his hearing aids which means that he can now interact and communicate more effectively.

Addiction Intervention Case Study II - Tyler

Like many young drug addicts, Tyler presented himself as an average post-college, millennial attempting to navigate his way forward. Born and raised in Wisconsin, Tyler found himself at the age of 26 living in South Florida and a job waiting tables at a local restaurant. He had the benefits of a loving family back home, good-looks and a friendly disposition.  

Having once again completed detox for his addiction to heroin, Tyler contacted me about recovery coaching at the recommendation of a rehab center he once attended. Tyler had been to multiple treatment centers over the last ten years; every attempt at sobriety was followed by an even worse relapse. A cycle which is not uncommon for addicts.

I met Tyler for our first coaching session at a nearby Starbucks. We connected well, and our conversation about staying sober easily flowed back and forth. At the end of the hour, we agreed to meet again later that week at the same location. We also agreed he would attend a narcotics anonymous meeting that night.  

Later that evening I received a panicked text followed by an equally frantic telephone call from Tyler saying he had tested positive for drugs and was immediately being removed from the sober house he'd been staying at. I was surprised because nothing about our earlier meeting indicated to me he was using or going to use. He already contacted me earlier to say he went to the meeting and everything was going well.

I later discovered Tyler never went to the meeting and instead bought heroin. Having to leave the sober house on the spot, he went to his girlfriend's house for the night. I contemplated this sudden turn of events before finally falling asleep. I wondered what I had missed earlier.

The next morning I contacted Tyler's parents to tell them what had transpired the night before. Despite being an adult I thought it was important to speak with his parents directly. They were disappointed but not surprised.

I told them I thought Tyler needed to be in treatment. He had been through several rehab programs before, so his parents were skeptical about there being anything different at another rehab center.   

I suggested they consider sending him to Alina Lodge; a long-term rehab facility I had recently visited in New Jersey. Alina Lodge was started in 1957 and is one of the few places that has maintained its strict program and long lengths of stay, sometimes extending beyond twelve months. I told them that being at Alina Lodge changed the way I thought about treatment, and I no longer considered traditional models sufficient for chronic relapsers. 

After speaking with the clinical team, Tyler's parents agreed Alina Lodge would be an appropriate placement for him. 

Tyler was against going back to treatment and was determined to get sober himself in Florida. I told him this decision could affect the rest of his life, and that he needed to consider going to Alina Lodge. He had the opportunity to crush his addiction once and for all, or risk living with it forever.

I was also sure to ask “if you love your girlfriend as much as you expressed to me earlier then you would surely go back to treatment.” These concepts softened the blow of returning to rehab again. The conversation continued for a couple of hours later, over text, where Tyler finally agreed to go to Alina Lodge. 

That Friday, I picked Tyler up at his girlfriend's house and brought him to the airport, so he could fly to New Jersey. I sent his mother pictures of Tyler boarding the plane and then of the plane leaving the gate. She was relieved to know he was safely en route.

Tyler is still at the beginning of his journey, and many obstacles lie ahead for him. He occasionally expresses a desire to skip out and return to his girlfriend in Florida. We remind him of the consequences such a decision would yield, and refocus him back on recovery.

CLIENT NAME: Tyler

AGE & GENDER: 26; Male

OCCUPATION: Waiter 

DIAGNOSIS:   Drug addict  

TREATMENT: One year of residential treatment (ongoing)

CURRENT STATUS: In treatment 

GetHelpForAddiction.com

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AHRQ Seeks Examples of Impact for Development of Impact Case Studies

Has your organization used an AHRQ tool to improve patient care, make a culture change or save costs? 

The agency would like to learn more about your use of AHRQ resources to develop Impact Case Studies. Since 2004, the agency has developed more than 400 Impact Case Studies that illustrate AHRQ’s contributions to healthcare improvement. Available online and searchable via an interactive map , the Impact Case Studies help to tell the story of how AHRQ-funded research findings, data and tools have made an impact on the lives of millions of American patients. 

To help us share your impact story, send a short description of how and where AHRQ resources were used, along with your contact information, to [email protected] .

Internet Citation: AHRQ Seeks Examples of Impact for Development of Impact Case Studies. Content last reviewed May 2024. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/news/case-study-examples.html