Introduction
The case involves a 34-year-old female client named Amelia. She presents to the session because her mother believes Amelia has a drinking issue. Amelia works as an administrative officer, is divorced, and has a seven-year-old son living with her. She self-referred to counseling and, during the session, does not appear to be under the effect of any substances. This paper aims to apply the AUDIT to the client and assess the risks of relapse and factors contributing to the maintenance of her alcohol use. Finally, a motivational interviewing plan will be developed to address the client’s alcohol use in future sessions.
Application of the AUDIT
The AUDIT is a self-reported questionnaire containing ten items that assess the extent of the person’s alcohol use. The client in the case scored 3 in question 1 because she reported that she drank on weekends and sometimes could have a glass of alcohol during the week if she had a “really tough day.” Amelia scored 1 in question 2 since she said that, on average, she had 3-4 drinks a day when drinking. Her score in question 3 is 2 because she drinks more than six drinks a day “most Friday nights.” Question 4 assesses an individual’s control over his or her drinking. Amelia reports having no issues controlling her drinking because she drinks only on weekends when her child is not around her. She also does not want to stop drinking once she has started because she believes she deserves to relax. Based on the client’s self-reported information, the score for this question is 0.
Amelia scored 2 in question 5 because she failed to accomplish what was generally expected of her “every few weeks.” The client scored 0 in questions 6 and 9 because she did not need a drink in the morning, and neither she nor others were injured because of her drinking. Amelia scored 1 in question 7 because she began to feel guilty sometimes over the last several months because of conflicts with her mother, who disapproved of Amelia’s drinking. Question 8 results in a score of 1 because Amelia rarely cannot remember what happened the night before. Finally, she scored 4 in question 10 because, during the last year, she received concerns about her drinking from her mother and her office manager.
The total AUDIT score of the client is 14. According to the guidelines, if individuals score 8-14, their alcohol use can be characterized as “hazardous or harmful” (AUDIT decision tree, n.d.). It means that Amelia’s alcohol consumption may lead to health risks and the development of alcohol dependency. She has already experienced some adverse effects, such as hangovers and not remembering the previous night. Therefore, the client needs feedback and brief intervention to prevent her harmful alcohol use from developing into alcohol dependency.
Risks Associated with the Client’s Alcohol Use
The client is subject to several risks that may lead to renewed hazardous alcohol use after the intervention. The first risk factor is a lack of effective coping strategies. According to Sureshkumar et al. (2017), individuals’ coping behaviors such as avoidance have a strong association with the probability of relapse. Coping skills include the person’s ability to deal with high-risk situations and manage stress (Lewis et al., 2018). Currently, Amelia uses alcohol as a coping strategy for managing stressful situations and relaxing. This approach is unproductive since it encourages the client to consume alcohol every weekend, which may eventually lead to addiction. If the client does not learn to cope with stress, fatigue, and boredom in more effective ways, she will continue using alcohol for this purpose, which will lead to relapse.
Another risk pertaining to this client is stressful life events. According to Sureshkumar et al. (2017), undesirable life events that occurred in the last year increase individuals’ risks of relapse, especially in those who lack proper coping skills. Currently, the client feels stressed because it is difficult for her to accept that her former husband has begun a new relationship. As a result, she has started consuming more alcohol, and this situation can influence the success of her treatment if it is not addressed. In addition, the client sometimes experiences stress at work, which may also lead her to relapse.
One more important risk is the client’s social network. Sliedrecht et al. (2019) report that the support from heavy-drinking peers is one of the crucial factors of a relapse, and, in such circumstances, having children serves as a protective factor for women. Having a son indeed prevents Amelia from consuming as much alcohol as her friends do. However, her drinking occurs mainly in the company of her childless friends. It implies that meeting with them, especially on weekends, is a high-risk situation for the client, which may lead to a relapse.
Relevant Maintaining Factors: Biological Factors
In this client, the key maintaining biological factor might be craving resulting from cue reactivity. It means that the individual craves alcohol whenever she sees cues related to alcohol consumption, for example, images of alcoholic beverages. This response occurs because alcohol affects the parts of the nervous system responsible for emotion, stress, and reward regulation (Guinle & Sinha, 2020). The changes occurring due to alcohol use result in cravings for alcohol and a shift from controlled to compulsive drinking (Guinle & Sinha, 2020). This factor is likely to be present in the client because she reports that she does not want to stop drinking after she starts. She sometimes “lose[s] track” when someone buys her a drink, or she consumes alcohol in the company of friends. As a result of this craving, her alcohol use maintains.
Psychological Factors
The client’s maintenance of her alcohol use is also influenced by several psychological factors. The first such factor is alcohol expectancies, which refer to people’s beliefs about how alcohol consumption will influence them (Cooke &d Crawford, 2021). Individuals may have negative alcohol expectancies, believing that, for example, alcohol will lead to increased distress levels, or positive ones, assuming that alcohol will increase their self-confidence or reduce stress. It has been found that alcohol expectancies may predict people’s use of alcohol (Cooke &d Crawford, 2021). The client in the given case has positive alcohol expectancies since she consumes alcohol to relax and reduce stress. Therefore, this factor may contribute to the maintenance of her alcohol use.
Another psychological factor involved in the presented case is drinking motives. According to Cooke and Crawford (2021), there are two dimensions of drinking motives: positive/negative and internal/external. Positive motives reflect an approach goal, while negative refer to an avoidance goal. Further, external motives mean drinking to comply with other people, while internal imply consuming alcohol for personal reasons. A combination of positive and internal motives is the most strongly associated with maintained alcohol use (Cooke & Crawford, 2021). In the given case, the client has positive external drinking motives. This is because she mostly drinks to relax and have fun with her peers. In addition, she drinks mostly when she is with her friends. Consequently, to a certain extent, her drinking motives contribute to the maintenance of her alcohol use because she consumes alcohol to accomplish her inner goals.
One more psychological factor pertaining to the case is drinking refusal self-efficacy. It refers to individuals’ confidence in their ability to refuse drinks (Cooke & Crawford, 2021). This factor may predict weekly drinking and the quantity of consumed alcohol (Cooke & Crawford, 2021). The client in the case seems to have poor drinking refusal self-efficacy because she can lose track of how much she drinks. As a result, the amount of consumed alcohol can exceed six drinks per sitting.
Social and Cultural Factors
Social and cultural factors play a significant role in the maintenance of the client’s alcohol use. One of the main influences in the given case is descriptive norms that reflect how other people in the individual’s environment behave (de Visser, 2021). The client’s social circle consists of people of her age or younger who do not have children and spend their time consuming large amounts of alcohol. As a result, the client perceives drinking behavior as normal and appropriate, which encourages her to maintain her alcohol use. She thinks that alcohol consumption is the right approach to relaxation and stress relief and believes that she deserves to indulge in this activity after a working week. In addition, the American culture to which the client belongs can also contribute to her alcohol use maintenance. This is one of the cultures where alcohol is integrated into many everyday social activities, for example, university life and the establishment of social connections (de Visser, 2021). Therefore, this cultural context may encourage the client to maintain her alcohol consumption.
Key Client Discrepancies
In order to change the client’s drinking behavior, motivational interviewing (MI) may be applied. One of the primary goals of MI is to help individuals notice discrepancies between their goals, values, or their views of themselves and their current behaviors (Lewis et al., 2018). In the given case, the client sees herself as a responsible person and a good mother. She also wants her mother to be proud of her, and she states that she has already achieved it: her mother is proud that her daughter has a good job and takes care of her son. Yet, the client also shared that she felt ashamed when she realized how much she disappointed her mother by her drinking behavior.
Thus, the key discrepancy in the case is that the client views herself as a good mother and daughter and a responsible employee. However, her current behavior threatens each part of her identity. Her drinking prevents her from being a good mother because she can fail to pick her son from school because of a hangover. The client’s image of a good daughter is damaged by her conflicts with her mother because of the client’s drinking. Finally, her alcohol consumption impairs her reputation as a worker because she has already received concerns from her office manager about her drinking. The client has to be encouraged to notice all these discrepancies during MI and become motivated to change her behavior.
Motivational Interviewing Plan
MI includes four processes that should be followed in a MI plan. The first step is engaging, which involves establishing a therapeutic relationship with the client, agreeing on treatment goals, and collaborating on reaching these goals (Fifield et al., 2019). During this step, the counselor should use such techniques as open-ended questions, reflections, affirmations, and summaries to assess the client’s understanding of the problem, show empathy, and improve the client’s self-efficacy. For example, the counselor may make an affirmation about this client, saying that she is good at taking care of her son, and reflect and summarize her feelings and beliefs about her life circumstances.
The second step is focusing, which includes outlining the direction in which the client and the counselor are moving. During this stage, the counselor should encourage the client to set a goal for her behavior change (Fifield et al., 2019). The client’s purpose in the given case will be to reduce the amount of consumed alcohol. In order to facilitate the goal-setting, the counselor may encourage the patient to list the pros and cons of making and not making this behavior change (Fifield et al., 2019). At this stage, the client will be able to notice her key discrepancies by identifying that drinking less will help her be a better mother, daughter, and employee.
The third step of MI is evoking, which involves dealing with ambivalence. Ambivalence is a natural human condition since it is difficult for people to make major changes to their lifestyles (Lewis et al., 2018). Dealing with ambivalence involves using change talk, which changes the focus from the problem to the client’s intrinsic wants and needs for change (Fifield et al., 2019). This client’s ambivalence may be linked to her belief that her alcohol consumption is not problematic. Thus, the counselor can guide the conversation to lead the client to her own decision to decrease alcohol use.
The final step of MI is planning, which involves developing specific actions to achieve the client’s target. It is crucial that the counselor does not impose his or her solutions on the client but allows the client to develop her own solutions according to the SMART framework (Fifield et al., 2019). In the given client’s case, the client may be encouraged to develop a goal to reduce her alcohol consumption to no more than two drinks over a month, without increasing the number of days in which she uses alcohol. The client will also need to be taught basic adaptive coping skills to prevent relapse during stressful life events.
Conclusion
The client in the case engages in hazardous drinking, which puts her at risk of developing alcohol dependency. Her risks of relapse include a lack of coping skills, stressful life events, and a social network of heavy-drinking individuals. The client’s key discrepancy is that she wants to be a good mother, daughter, and employee, but her binge drinking interferes with these goals. MI is intended to help the client notice these discrepancies and develop solutions to reduce her alcohol use.
References
AUDIT decision tree. (n.d.). AUDIT.
Cooke, R., & Crawford, J. (2021). Psychological predictors of alcohol consumption. In R. Cooke et al. (Eds.), The Palgrave handbook of psychological perspectives on alcohol consumption (pp. 77-104). Palgrave Macmillan.
de Visser, R. O. (2021). The social contexts of alcohol use. In R. Cooke et al. (Eds.), The Palgrave handbook of psychological perspectives on alcohol consumption (pp. 135-157). Palgrave Macmillan.
Fifield, P., Suzuki, J., Minski, S., & Carty, J. (2019). Motivational interviewing and lifestyle change. In J. M. Rippe (Ed.), Lifestyle medicine (3rd ed., pp. 207-217). CRC Press.
Guinle, M., & Sinha, R. (2020). The role of stress, trauma, and negative affect in alcohol misuse and alcohol use disorder in women. Alcohol Research: Current Reviews, 40(2), 05.
Lewis, J. A., Dana, R. Q., & Blevins, G. A. (2018). Substance abuse counseling (6th ed.). Cengage Learning.
Sliedrecht, W., de Waart, R., Witkiewitz, K., & Roozen, H. G. (2019). Alcohol use disorder relapse factors: A systematic review. Psychiatry Research, 278, 97-115.
Sureshkumar, K., Kailash, S., Dalal, P. K., Reddy, M. M., & Sinha, P. K. (2017). Psychosocial factors associated with relapse in patients with alcohol dependence. Indian Journal of Psychological Medicine, 39(3), 312-315.
Appendix
Table 1. The Alcohol Use Disorders Identification Test: Self-Report Version.