PS526 Unit 10 Integrated Case Study Example

The Retired Principal, the Lorazepam and the Daughter on the Phone: A PS526 Unit 10 Integrated Case Study With an Ethics Analysis

[Student Name]

Purdue University Global

PS526: Advanced Addictions Counseling

Unit 10 Integrated Case Study

[Instructor Name]

[Date]

The client, her family, the treatment center and every detail of the case are composite and illustrative; the sources cited are real.

Identifying Information

Margaret is 71, widowed for three years and a retired elementary school principal in Spearfish. For twenty years she has taken lorazepam, prescribed by her family doctor for anxiety and sleep, now at 2 milligrams each night. Since her husband died, she has added a bottle of wine most evenings. In October she fell in her kitchen, fractured her wrist and was found the next morning by a neighbor. The hospital found alcohol and lorazepam in her blood and recommended residential treatment. Her daughter, Karen, a lawyer in Denver, drove up, arranged the admission and has called the center every day since.

History

Margaret drank lightly for most of her life, a glass of wine at dinner. After her husband's death she began drinking alone in the evenings, first two glasses and then a bottle. She describes the lorazepam as "just my sleeping pill" and was surprised to learn it could interact with alcohol. She has missed two book club meetings because of hangovers, stopped driving at night after a near miss and has tried twice to stop drinking, lasting a few days each time with shakiness and poor sleep. A memory screen at admission showed mild problems, which may reflect alcohol, the benzodiazepine or both.

Diagnoses

Six items on the manual's list fit Margaret's evenings (American Psychiatric Association, 2022): the bottle she meant to stop at two glasses, the two attempts to quit that lasted days, book club and night driving given up, drinking after the fall, needing more for the same calm and the shakes when she stopped. Six criteria indicate a severe disorder.

Her lorazepam use is more complicated. Tolerance and withdrawal do not count toward a sedative use disorder when a drug is taken as prescribed, and Margaret has taken her prescribed dose. The more accurate description is physiological dependence on a prescribed benzodiazepine, combined with a dangerous interaction with alcohol. Lader (2011) reviews evidence that long-term benzodiazepine use carries risks of tolerance, dependence, cognitive problems and falls, especially in older adults, and that withdrawal after long use must be gradual.

Formulation

Biologically, Margaret's age, the interaction between alcohol and lorazepam, her fall and her memory screen make medical management the first concern. Psychologically, the drinking began with grief and loneliness, and the lorazepam has long been her way of managing anxiety. Socially, she lives alone, her daughter is far away and her social world shrank after her husband's death and her retirement.

Treatment Plan

The first priority is medical. The center's physician will manage alcohol withdrawal and, in consultation with her family doctor, plan a slow lorazepam taper over several months, as Lader recommends for long-term users. The taper will continue after discharge.

The second is cognitive behavioral therapy for drinking and anxiety. Magill and Ray (2009) found CBT produced small but significant effects across 53 trials, and its skills fit Margaret's situation. A functional analysis showed that her drinking starts at 5:00 p.m., when she used to make dinner for her husband. Treatment will target that hour, with a new evening routine, cognitive work on the thought "There's no point cooking for one" and skills for managing anxiety without relying on medication.

The third is grief. Margaret has not talked about her husband's death with anyone since the funeral. Grief counseling will begin in residential care and continue after.

The fourth is social reconnection: rejoining the book club, volunteering at the elementary school library, which she has been invited to do, and attending a women's recovery group that meets in the afternoon.

Margaret's plan begins with a taper and ends with the school library, because her recovery depends on getting both her medicine and her days right.

Ethics Analysis

Three ethical issues arise.

The first is confidentiality with Karen. Margaret is a competent adult. Her records are protected by federal confidentiality rules, and the NAADAC code requires her consent before staff share information (NAADAC, 2021). Karen's daily calls, however loving, cannot be answered with clinical details unless Margaret agrees. In week one, Margaret signed a limited consent allowing staff to tell Karen about her general progress and discharge plans, but not about her grief work or memory screen, which she wanted to share herself.

The second is capacity and autonomy. Karen has suggested that her mother move to Denver and that she take over her finances. The memory screen raises a question about capacity, but mild findings at admission, during withdrawal, do not establish incapacity. The code's emphasis on client autonomy means that decisions about where Margaret lives belong to her unless a proper evaluation finds otherwise. We arranged a repeat screen after four weeks of abstinence.

The third is the prescribing history. Twenty years of benzodiazepine prescribing raises questions about the family doctor's practice, but the counselor's role is to work collaboratively with the prescriber, with Margaret's consent, rather than to criticize. The physician will coordinate the taper directly with the family doctor.

Discharge and Aftercare

Margaret's discharge raises its own questions. Returning to an empty house in Spearfish, at the hour her drinking used to start, is the highest-risk moment in the plan. Before she leaves, she and I will write out her first two weeks of evenings, hour by hour, including the library volunteer shifts, a standing Thursday supper with a friend from book club and phone calls with Karen at a set time, so that the calls become support rather than surveillance. Her outpatient counselor will see her weekly, and the physician will check her taper every two weeks. If Margaret drinks, the plan is the same one any resident gets: tell her counselor that day, without shame, and come in. Older adults in recovery often hide lapses out of embarrassment, and Margaret has said she would rather "die than disappoint Karen," which is exactly why a lapse plan that does not route through Karen matters.

Goals

Within two weeks, withdrawal is complete and the taper plan is written. Within four weeks, Margaret completes a functional analysis and a new evening routine, and her memory screen is repeated. Within three months after discharge, she reports no drinking, continues the taper as planned and attends book club and her recovery group.

Conclusion

Margaret's case integrates a severe alcohol use disorder, physiological dependence on a prescribed benzodiazepine, grief and an anxious daughter. The DSM-5-TR and Lader's review shape the diagnosis and the slow taper, Magill and Ray's meta-analysis supports CBT aimed at her 5:00 p.m. hour and the NAADAC code guides the ethics of confidentiality, autonomy and collaboration with her prescriber.

References

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

Lader, M. (2011). Benzodiazepines revisited: Will we ever learn? Addiction, 106(12), 2086-2109. https://doi.org/10.1111/j.1360-0443.2011.03563.x

Magill, M., & Ray, L. A. (2009). Cognitive-behavioral treatment with adult alcohol and illicit drug users: A meta-analysis of randomized controlled trials. Journal of Studies on Alcohol and Drugs, 70(4), 516-527. https://doi.org/10.15288/jsad.2009.70.516

NAADAC. (2021). NAADAC code of ethics. NAADAC, the Association for Addiction Professionals. https://www.naadac.org/code-of-ethics