Case Study from Field Experience: Therapeutic Approaches to Addiction Recovery

This case study documents my clinical practice with a client at Serenity Recovery Centers in Memphis, Tennessee, throughout my practicum for HSV 594: Field Practicum II. This report aims to illustrate the integration of counseling theories, ethics, and skills into real practice through direct and indirect services provided to a client with substance use and co-occurring disorders: Case Study from Field Experience: Therapeutic Approaches to Addiction Recovery.

The following is a comprehensive overview of the client’s background information, presenting issues, assessment, diagnosis, treatment plan, and counseling skills used. Theoretical concepts and evidence-based practice back the discussion.

Background Information

Patient Identification

The client, under the pseudonym Derrick, is a 38-year-old African American male in the intensive outpatient program at Serenity Recovery Centers. He now lives in a transitional sober-living home that is near the treatment center. His demographics and age are important due to the higher frequencies of chronic health complications in African American men with a history of substance use disorder. Correct identification and demographic information helped the interdisciplinary team communicate effectively and align with communal health and social resources.

Social History

Derrick has been out of touch with his immediate family, his ex-wife, and two children for more than five years, and this has added to the loneliness situation and emotions. He now lives in a transitional sober-living home with three other men in early recovery and struggles with the same housing issues other transitional sober-living tenants are facing.

His work record is characterized by unstable employment, and this has been mainly in physically demanding jobs, including warehouse work and construction jobs, where he has often lost employment due to his absenteeism and substance use. Currently, he is engaging in an employment training program at Serenity Recovery Centers to restore his employability and life skills.

The lifestyle history of Derrick depicts maladaptive behaviors and self-care neglect as a continuous pattern. He had been involved in excessive consumption of cocaine and alcohol over more than 12 years, with a periodical intake of marijuana, and the addiction in question had badly affected his physical and mental well-being. He has also reported poor eating habits, having little contact with physical exercise, and he avoids any routine medical appointment.

He denies using tobacco. The only substantial source of emotional support available to him is therapy, peers, and counselors. He has felt terribly isolated and emotionally vacant as he was divorced from his wife and separated from his children three years ago.

Past Medical History

The medical history of Derrick includes a history of untreated hypertension and recently diagnosed Hepatitis C, suspected of being acquired through exposure to used drug paraphernalia when actively using the substance. He has never had any surgical intervention, and he denies any known allergies to drugs or foods. Derrick has been placed on lisinopril 10 mg orally once daily to help him control his blood pressure levels, and he has been adherent to this regimen since admission.

His history of immunizations is not complete, with the exception of the COVID-19 immunization, through which he was immunized during his entry into the recovery program. The tendency to regularly attend the emergency department with the issue of substance intoxication and complications represents a broader picture of systemic and individual health consequences of the chronic, untreated addiction over time.

Family History

Derrick’s family history shows important patterns that could have contributed to his present substance abuse and mental problems. His father struggled with alcohol addiction and passed away at 52 due to liver cirrhosis, which was directly associated with the years of alcohol intake. His mother is alive. She experiences depression and hypertension, which she controls with minimal help.

Derrick is an only child and claims little interaction with extended relatives. Even though no official diagnoses of mental disorders in the family have been revealed, Derrick feels that substance use and mental illness have been underreported in the family. Such intergenerational patterns of addiction with emotional detachment and a lack of mental health awareness point to the need to adopt a family systems perspective when approaching the behavioral and emotional issues Derrick is struggling with.

Mental Health History

Derrick was diagnosed with major depressive disorder about five years ago, but he has not received regular and organized mental health care treatment since the diagnosis. His history of depression has manifested itself as symptoms of insomnia, pervasive feelings of guilt, hopelessness, anhedonia, and passive suicidal thoughts and ideas. Besides these symptoms, Derrick also shows emotional numbing, irritability, and hypervigilance, which are characteristic of unresolved trauma.

He justifies most of his substance abuse as being a desperate measure to shut off invasive memories and prevent emotional discomfort due to childhood neglect and loss. Though he has never had suicide thoughts, he admits that the use of substances has been a sort of gradual suicide and a way to seal off emotionally about life.

Since his admission to the treatment, Derrick has recorded significant improvement in his functional skills. He is currently able to conduct activities of daily living independently, such as personal hygiene, preparing his meals, and completing his daily therapeutic schedule. His long-term recovery objectives are well defined and comprise staying clean and sober, regaining relationships with his two children, and obtaining reliable work with the help of the vocational support services.

Moreover, Derrick has expressed an interest in comprehending the psychological and environmental causes of his addiction and learn to regulate his emotions better. Self-awareness combined with openness to feedback and intrinsic motivation were recognized as strengths of therapy at an early stage and were effectively applied during the counseling process.

Presenting Problem

At the first visit, Derrick reported chronic and troublesome symptoms, such as severe cravings for crack cocaine, chronic emotional deadness, and uncontrolled anger outbursts. He expressed serious concern over his relapse history, particularly during unstructured post-treatment times.

Derrick admitted that he tended to use substances to dull his feelings and evade painful memories. As he went through intake, he said that being sober will make him “feel raw,” a potent use of words to describe the vulnerability he feels so far in trying to manage unresolved trauma without the protection of substance use.

Derrick reported having intrusive childhood memories and a persistent apprehension of being abandoned since he was always afraid of being neglected and was likely to have experienced unresolved attachment traumas. He was reluctant at first during the initial phases of counseling. However, he began to respond well by opening up some of his past traumatic issues, which included a long history of being emotionally neglected and often witnessing instances of domestic violence at home.

These negative childhood events were precursors to his subsequent problems. His prevailing anxiety and depression have also been exacerbated by the period of social isolation and years of unemployment, something that he admitted to understanding as major relapse triggers.

Assessment

A thorough assessment based on DSM-5 criteria, American Society of Addiction Medicine (ASAM) placement dimensions, and trauma-informed screening measures was performed, which allowed evaluating Derrick on the levels of psychological, emotional, and environmental functioning. The outcomes showed a high score in emotional dysregulation, high substance dependence, as well as high social instability. His change readiness was categorized under the preparation stage, where he exhibited a high level of internal drive but poor coping skills.

These results justified his enrollment in an intensive outpatient program, where an approach that combines trauma-informed treatment, one-on-one counseling, and psychiatric assessment could help support co-occurring mental health and substance use concerns.

Diagnosis

The clinical presentation of Derrick fits with a number of DSM-5-TR diagnoses, such as Cocaine Use Disorder (F14.20), Severe, Alcohol Use Disorder (F10.20), Severe, Major Depressive Disorder (F32.1), Moderate, and Disruption of Family by Separation or Divorce (Z63.5) (American Psychiatric Association, 2022). The diagnoses were developed with the help of structured clinical interviews, reliable self-report instruments, and stable behavioral reports during the intake and initial visits.

The continuous abuse of cocaine and alcohol, even when Derrick was severely impaired and had major depressive mood as noted by anhedonia, insomnia, and hopelessness, makes him a candidate for dual diagnosis. Family alienation is another factor affecting emotional strength and healing, pointing out the need to provide a comprehensive, trauma-informed treatment addressing not only substance abuse but also affect management.

Treatment Plan

The primary objectives of the treatment plan for Derrick include the attainment of sustained substance abstinence, the regulation of emotions, and overall daily functioning. The core interventions consist of a weekly individual-based cognitive behavioral therapy to help him change his distorted thinking, trauma-informed counseling to work through past adverse childhood experiences, and group therapy sessions to provide the patient with peer support.

Also, he was referred for a psychiatric examination to discuss the possibility of antidepressant drugs. A relapse prevention strategy was developed, recognizing emotional and situational triggers, coping mechanisms, areas of high risk, and a contact person to call in case of emergency to ensure stability and minimize the risk of relapse.

Secondary objectives of Derrick’s treatment involved restoring family relationships and improving readiness to work to promote lasting recovery. To gain self-awareness and adaptability, he was engaged in psychoeducational courses in the fields of addiction neuroscience, the psychological consequences of trauma, and mindfulness-based stress reduction interventions (Sarkhel et al., 2020).

Derrick was advised to keep a daily mood diary, add some light exercise to his routine, and begin to participate in a local sober support community. To enable him to be accountable and aligned with the therapy, multidisciplinary treatment team meetings, frequent therapist check-ins, and self-assessments were conducted on a weekly basis.

Application of Human Service and Counseling Theory to Practice

Person-Centered Therapy

The development of trust and psychological safety during the therapeutic relationship with Derrick was based on a person-centered approach. Giving empathy, genuineness, or congruence, and unconditional positive regard, the counselor helped Derrick develop a nonjudgmental and accepting atmosphere that enabled him to feel listened to and respected (Yao & Kabir, 2023).

This relationship position allowed him to reduce emotional defenses and start opening up vulnerable elements of his experience. Most notably, it restored a feeling of self-determination, enabling Derrick to possess a sense of ownership of the entire recovery experience.

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) was applied to help Derrick realize and change his negative thought patterns, including his feelings that he was unlovable, which has been a contributing factor to his depressive symptoms and substance dependence. He also participated in cognitive tasks such as keeping a record of his automatic thoughts and scrutinizing their legitimacy, actions that allowed him to substitute his unhealthy thoughts with more positive and realistic ones.

CBT also assisted him in realizing the way his thoughts shifted his emotions and behaviors (Chand et al., 2023). Moreover, this method provided him with tangible skills to manage cravings, distress emotions, and impulsive tendencies better.

Motivational Interviewing

Motivational interviewing (MI) strategies were used to enhance Derrick’s intrinsic desire to change and motivate him to commit to the recovery process. This client-centered focus was aimed at overcoming the feelings of ambivalence by encouraging Derrick to consider the positive and negative outcomes of spending his remaining years intoxicated as opposed to being sober (Emery & Wimmer, 2023).

Collaboration of therapeutic dialogue was achieved via using open-ended questions, affirmations, reflective listening, and summarizing. This approach motivated Derrick to explain his reasons for being sober, especially the need to have a relationship with his children again. With special attention to personal choice and autonomy, MI decreased defensiveness and redefined resistance as an important self-learning opportunity and a chance to grow.

Trauma-Informed Care

All therapeutic contact with Derrick was guided by a trauma-informed approach so that his lived experience was engaged sensitively, respectfully, and with clinical awareness. Through the identification of behavioral cues and verbal disclosures of past trauma, physical and emotional safety were prioritized in the therapeutic milieu (Grossman et al., 2021).

Grounding skills, affect regulation, and psychoeducation about trauma responses were introduced before more deeply traumatic content was explored to build coping capacity. This model also guided interdisciplinary communication, as all treatment team members coordinated their approach with the aim of increasing consistency, preventing re-traumatization, and fostering Derrick’s overall psychological stability.

Group Therapy

Based on the therapeutic factors of group counseling, Derrick has significantly experienced universality, catharsis, and interpersonal learning. Understanding that he is not the only one facing problems brought on a sense of reassurance, as it helped to reduce the feelings of shame and isolation. The group experience offered relief from emotional distress and self-disclosure, and he felt more at ease transgressing past traumas (Malhotra et al., 2024).

With these methods of active listening and engagement, Derrick received new insight and coping mechanisms. His role changed, as he ceased observing passively and started a contributive role, indicating increased confidence, emotional resilience, and social connections.

Conclusion

This case study highlights how the theory of counseling has been applied and incorporated into practice. The establishment of the therapeutic alliance with Derrick assisted him to become insightful, develop skills, and achieve sobriety through person-centered therapy, CBT, and MI, as well as through trauma-informed care practices. The nature of treatment went beyond the individual to embrace social and structural support.

Accordingly, this field experience at Serenity Recovery Centers has underpinned my knowledge of the transforming impact of counseling in the management of co-occurring disorders and refined my capability of ethically serving diverse groups of people.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (DSM-5-TR). American Psychiatric Association. https://www.psychiatry.org/psychiatrists/practice/dsm

Chand, S. P., Kuckel, D. P., & Huecker, M. R. (2023, May 23). Cognitive behavior therapy. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK470241/

Emery, R. L., & Wimmer, M. (2023, February 9). Motivational interviewing. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK589705/

Grossman, S., Cooper, Z., Buxton, H., Hendrickson, S., Lewis-O’Connor, A., Stevens, J., Wong, L.-Y., & Bonne, S. (2021). Trauma-informed care: Recognizing and resisting re-traumatization in health care. Trauma Surgery & Acute Care Open, 6(1), 1–5. https://doi.org/10.1136/tsaco-2021-000815

Malhotra, A., Mars, J. A., & Baker, J. (2024, October 29). Group therapy. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK549812/

Sarkhel, S., Singh, O., & Arora, M. (2020). Clinical practice guidelines for psychoeducation in psychiatric disorders general principles of psychoeducation. Indian Journal of Psychiatry, 62(8). https://doi.org/10.4103/psychiatry.indianjpsychiatry_780_19

Yao, L., & Kabir, R. (2023, February 9). Person-centered therapy (Rogerian therapy). StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK589708/

ORDER A PLAGIARISM-FREE PAPER HERE

We’ll write everything from scratch

---

Case Study
The Case Study written assignment should be submitted sometime after 90 hours but before the 180 hours are complete. It must be received prior to the final evaluation reports and certificate of completion. The Case Study is worth 15% toward your final grade. Each student is required to submit a 5-10 page (double-spaced) APA style paper on a case that he/she is working on at the field placement.

The study must be on one of the following topics: a case study on a client, a special project, special training, or a significant experience. Guidelines for completing this presentation are provided below. When submitting your paper, it must be clear which topic you have chosen so the appropriate rubric for grading can be used.

Please include this topic title on your cover page. If you would like to request an alternate topic, you must obtain my approval so please contact me directly either via email to discuss.

APA style formatting should include proper title page with running head, correctly margined with page numbers, and if quotations are used properly sourced with a reference page.

The case study should include an introduction that informs the reader of the content and purpose of your paper and include a strong conclusion that summarizes the key elements of your paper. In your case study, it is important to disguise and change any personal identifying information about your client and to give a pseudo-name. No one should be able to recognize your client by your descriptions.

In fact, it is acceptable to change some of the background information a little to further disguise the client. The case study is not a psychosocial history of your client. Only include enough information to give a context to your case study. The focus is on the application of human service/counseling theory to professional practice.

Throughout your paper make connections to counseling/human services theory and support your statements with references. I am looking for you to explain the “why” behind any counseling or human services approaches and treatment plan. If your case study is a project, also make those connections to human service and management theory with references.

Students need to demonstrate the ability to make strong connections to theory (with scholarly references). The connection from theory to professional practice are key aspects of all written papers for the practicum, including the case study. At least three scholarly references need to be included in the case study.

Please see the Writing Rubric Writing Rubric – to learn how you will be graded.