PS511 Unit 10 Comprehensive Case Study Example

Pull Tabs, Brandy and a Borrowed $11,000: A PS511 Unit 10 Comprehensive Case Study of Co-Occurring Gambling and Alcohol Use Disorders

[Student Name]

Purdue University Global

PS511: Chemical and Psychological Dependency Counseling

Unit 10 Comprehensive Case Study

[Instructor Name]

[Date]

The client, his family, the clinic and every detail of the case are composite and illustrative; the sources cited are real.

Identifying Information

Ray is 52, married for twenty-six years, with two adult children, and has worked as an electrician at a taconite pellet plant for twenty-two years. He was first seen briefly in Unit 4. In March his wife found papers for a $6,000 personal loan she had not known about and learned he had also borrowed $5,000 from his brother. She gave him a choice between treatment and a separation. He came to intake the following Monday.

History of the Problem

Ray began playing pull tabs, the paper tickets sold in many Minnesota bars, about eight years ago at a bar near the plant where crews stop after shift. For years he spent twenty or thirty dollars a week. After his father died in 2023 and overtime at the plant was cut, he began stopping at the bar most nights and spending $100 to $300 a visit. He plays to "get even" after losing, hides receipts, has lied to his wife about his pay and has tried twice to quit, lasting a week. He feels restless and irritable on nights he does not go.

Drinking travels with the gambling. Ray drinks four to six brandy and Cokes on each visit to the bar and has driven home after drinking many times. He began keeping a bottle in the garage last year. He has no withdrawal symptoms but needs more to feel relaxed and has missed two Saturday shifts because of hangovers.

Mental Status and Screening

At intake Ray was alert, oriented, ashamed and tearful when describing his wife's discovery. He reported low mood for six months, poor sleep and feeling like "a failure." He denied thoughts of suicide, though he said, "Sometimes I think the life insurance would solve it." That statement was explored directly; he denied intent or a plan, agreed to a safety plan and agreed that his wife could hold the firearms in the house for now. A depression screen showed moderate symptoms.

Diagnoses

The manual treats gambling disorder as an addiction in its own right (American Psychiatric Association, 2022). Potenza et al. (2019) describe its core features: needing to gamble with more money for the same excitement, restlessness when cutting back, failed attempts to stop, preoccupation, gambling when distressed, chasing losses, lying to hide gambling, risking important relationships or work and relying on others for money. Ray shows eight of the nine: increasing amounts, restlessness, repeated failed efforts, gambling when upset after his father's death, chasing losses, lying, jeopardizing his marriage and relying on his brother's loan. Preoccupation is less clear. Eight criteria place his gambling disorder in the severe range.

For alcohol, Hasin et al. (2013) describe the eleven criteria and the severity levels. Ray's drinking shows five: more brandy than he means to have, driving home after it, two Saturday shifts lost to hangovers, a need for more to relax and carrying on despite fights with his wife. Five criteria indicate a moderate alcohol use disorder.

The depressive symptoms need further assessment once drinking has stopped, since heavy drinking and gambling losses can both produce low mood.

Ray's gambling and drinking happen in the same bar on the same nights, so a plan that treats one without the other leaves the bar door open.

Biopsychosocial Formulation

Engel (1977) argued that illness should be understood through biological, psychological and social factors together. Biologically, alcohol lowers Ray's inhibitions at the moment he decides whether to buy more tabs, and the excitement of a near win on a pull tab is its own powerful reward. Potenza and colleagues note that gambling disorder involves reward and control systems similar to those in substance use disorders. Psychologically, Ray turned to gambling after his father's death and the loss of overtime, using it to escape grief and money worries, and chasing losses kept him going. Socially, the bar near the plant is where his crew gathers, so stopping means losing his after-shift social circle, and pull tabs are sold everywhere he goes.

Treatment Plan

Problem 1, gambling: Ray will attend weekly individual cognitive behavioral therapy focused on gambling thoughts, such as the belief that a losing streak means a win is due, and on chasing. Financial controls are a core part of treatment: his wife will manage the household accounts for at least six months, Ray will carry no more than $20 in cash, and he will cancel the credit card he used for cash advances. He will be referred to a Gamblers Anonymous meeting in Virginia and to a free financial counseling service. Measure: no gambling days, confirmed by his wife and the account statements, for four consecutive weeks within two months.

Problem 2, alcohol: Ray will set a goal of abstinence for at least three months, since moderation in the bar where he gambles would keep both problems going. His doctor will be asked to consider naltrexone, which is used for alcohol use disorder. Measure: no drinking days in the weekly log, with his wife's confirmation, for four weeks within six weeks.

Problem 3, mood: Depression will be reassessed after four weeks without alcohol and treated with therapy or referral for medication if symptoms remain. Ray and I will go back over his safety plan at each meeting through April.

Problem 4, relationships and routine: Two couples sessions will address trust and the debt. Ray will ask two crewmates to join him for coffee at the diner instead of the bar after shift, and he will return to the bowling league he quit in 2023. Measure: three or more non-bar social contacts each week within one month.

Relapse Prevention and Aftercare

Witkiewitz and Marlatt (2004) describe relapse as the product of high-risk situations meeting a person's coping skills, confidence, craving and expectations. For Ray, the highest-risk situations are payday, the drive past the bar after shift and stressful days at the plant. His plan includes a different route home, direct deposit to the joint account his wife manages and a phone call to his sponsor on payday. If he lapses, he will tell his wife and counselor the same day, which is meant to keep a single lapse from turning into the hopeless conclusion Witkiewitz and Marlatt call the abstinence violation effect.

After twelve weeks of individual therapy, sessions will drop to every two weeks for three months and then monthly, with Gamblers Anonymous continuing.

Conclusion

Ray meets criteria for a severe gambling disorder and a moderate alcohol use disorder that share the same setting, the same nights and the same escape from grief and money stress. Engel's model, Potenza and colleagues' account of gambling disorder and Hasin and colleagues' criteria support treating both together, with financial controls, abstinence from alcohol, attention to mood and a relapse plan built on Witkiewitz and Marlatt's model around paydays and the drive home.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196(4286), 129-136. https://doi.org/10.1126/science.847460

Hasin, D. S., O'Brien, C. P., Auriacombe, M., Borges, G., Bucholz, K., Budney, A., Compton, W. M., Crowley, T., Ling, W., Petry, N. M., Schuckit, M., & Grant, B. F. (2013). DSM-5 criteria for substance use disorders: Recommendations and rationale. American Journal of Psychiatry, 170(8), 834-851. https://doi.org/10.1176/appi.ajp.2013.12060782

Potenza, M. N., Balodis, I. M., Derevensky, J., Grant, J. E., Petry, N. M., Verdejo-Garcia, A., & Yip, S. W. (2019). Gambling disorder. Nature Reviews Disease Primers, 5, Article 51. https://doi.org/10.1038/s41572-019-0099-7

Witkiewitz, K., & Marlatt, G. A. (2004). Relapse prevention for alcohol and drug problems: That was Zen, this is Tao. American Psychologist, 59(4), 224-235. https://doi.org/10.1037/0003-066X.59.4.224