A multidisciplinary approach to addiction can provide better long-term outcomes for those in treatment
Carl was in his late 40s at the time of referral to the residential programme. He was referred from a local out-patient addiction service which he had been attending for alcohol and drug misuse. Carl engaged well in the therapeutic programme from the first day and responded particularly well to group therapy.
Carl was born the fourth of a large family; both of his parents were deceased. He portrayed a very difficult relationship with his mother and described his father as an alcoholic. Carl did not remember receiving any warmth/comfort from his parents and noted that crying was strongly discouraged. Carl has five children, two living with him and three living with their mother. He was engaged in legal proceedings to gain custody of his children. Carl reported that his children suffered from some trauma and neglect throughout their childhood due to their parents’ addiction to alcohol and other substances. Carl described himself as intelligent and was moved up a class in school several times as a child. He suffered from physical and sexual abuse during his school years. He described acting aggressively with his peers. When in treatment, Carl was facing charges for physical assault. His ex-wife, who he described as a drug-user, is the mother of his children. Carl expressed deep hurt in relation to the break-up of his marriage. He described himself as a ‘loner’ and noted that he now has few close friendships. He described a strong interest in animals, music, literature and film. He has a history of stomach abscess, septicaemia, pneumonia and hepatitis C.
An in-depth clinical interview was conducted and Carl was socialised to the TMCAT. Findings from the assessment were grouped into two areas – drug/alcohol misuse and emotion regulation.
Carl reported a history of abusing alcohol, recreational and prescription drugs which began at nine years of age. He reported that he had been using heroin intermittently for 30 years. Carl had attempted to abstain from substance/alcohol use and has attended five other addiction services in the past, but he continually relapsed. He had successfully completed a detoxification programme 10 days prior to attending the service. He described high levels of motivation to abstain from drugs and alcohol permanently in order to support and care for his children.
Carl described difficulties expressing and identifying emotions, particularly sadness. He described strong feelings of guilt in relation to his treatment of his children in the past which he found difficult to process. Carl described difficulties managing his anger and admitted to physically assaulting another man in the past. He described severe difficulty sleeping which he related to extremely unhelpful thoughts which were impacting his mood and ability to relax. Carl described symptoms of irritable bowel syndrome (IBS) which he related to family stress and his difficulty expressing emotions.
The Toranfield model of care for addiction (TMCAT) was undertaken which involved developing a dynamic individualised care plan (DICP) to address Carl’s specific needs. CBT was undertaken to address some of Carl’s difficulties. CBT has a large evidence base for treating mental health difficulties and is key in the effective treatment of substance and alcohol addiction. Carl also engaged in client-centred counselling and psychotherapy. It has been identified that there are complex interactions between addictive behaviours, the provision of counselling and treatment outcomes. However, in spite of this complex process, research suggests that counselling is effective in reducing alcohol and other substance use when compared with a control group. In addition, a growing body of literature highlights the importance of counsellor characteristics on outcomes for clients. Carl and his family engaged in a family-based intervention. Recent studies suggest that family and network approach either match or improve client outcomes in comparison to individual interventions. Carl also had regular access to the neuromuscular therapist/traditional Chinese practitioner. Principles of Chinese medicine are effective in treating individuals with addiction difficulties. According to Ashton, Nodiyal, Green, Moore and Heather (2009), clients treated for alcohol addiction with acupuncture showed a significant decrease in alcohol consumption and distress.
Based on the findings from the initial assessment, the following formulation of different factors was developed for understanding Carl’s difficulties.
Predisposed: Carl was exposed to parent-child attachment problems in early life. He may have suffered from neglectful parenting with a large family, a father with alcohol addiction, social disadvantage, and a mother who was struggling to meet the family’s basic needs for survival. He suffered from physical abuse within the school environment and described a tendency for risk-taking and sensation-seeking.
Precipitating: Carl grew up in an environment where alcohol and drugs were readily available. He endured several changes of class during his school years which resulted in a loss of peer friendships. He was exposed to physical and sexual abuse and learned to resolve difficulties in peer relationships through aggression. He did not learn to regulate his emotions as a young child; hence he was likely to have used drugs and alcohol to regulate negative mood states.
Protective: Carl had a good cognitive ability and was committed to addressing his difficulties. He loved riding horses. In addition, he engaged with a counsellor in the locality and had a good knowledge of theory relating to addiction.
Maintaining: Carl was physiologically dependent on some of the substances he was abusing. His father reinforced his son’s addiction by abusing alcohol. He had a poor social support network, a lack of financial resources, and few employment opportunities. Carl had high levels of stress which he related to family interactions and legal/custody issues. Carl had developed unhelpful coping strategies for the associated negative mood states which resulted in maintaining his alcohol and other substance use.
Treatment: Based on the initial assessment and formulation, Carl engaged in a therapeutic programme based on his DICP. Carl attended the psychiatrist, but no major mental health issues were identified. He engaged in CBT sessions. He had difficulty identifying emotions and tended to deal with strong emotions through avoidance and intellectualising. Carl was supported in identifying and processing strong emotions such as sadness, guilt, fear and anger. Predisposing factors and early warning signs of anger difficulties were identified and psycho-education was provided on managing unhelpful thoughts. Techniques for releasing anger were also discussed which utilised imagery, physical, and verbal expression. Assertive communication skills were covered using specific examples from Carl’s life (e.g. communicating with his children’s social worker). Sleep difficulties were also addressed and Carl was provided with information on sleep hygiene to help obtain sufficient sleep. Relapse prevention aided Carl in identifying high-risk situations and early warning signs of relapse.
Carl participated in client-centred counselling/psychotherapy during his residential programme. These sessions offered him the opportunity to explore aspects of his addiction, uncovering underlying issues which predated his substance misuse. Incidences of early sexual abuse by a same sex peer were discussed which uncovered feelings of deep shame, guilt and anger which left Carl questioning his sexuality. This issue had complicated Carl’s sexual development. He had kept these events secret, never knowing his place in relationships and at times feeling sexually out of control. Such experiences played a role in Carl’s predisposition to risk-taking and sensation-seeking. This therapy supported Carl to further explore such events in a safe and therapeutic environment.
Carl engaged in group therapy and psycho-education on a daily basis while attending TMCAT. This involved emotional processing, formulating on the aetiology of addiction, and addressing barriers to recovery. He also engaged in a mindfulness programme twice weekly.
Carl’s older children, who reside with him, attended the family programme. These meetings occurred once-weekly and involved a facilitated discussion of issues concerning all three. The children shared some distressing experiences which were as a direct result of Carl’s substance misuse. Carl responded as a parent, validating their experiences and acknowledging responsibility for neglecting them on several occasions. In this context, his children also expressed appreciation of Carl’s ongoing support for them. Family therapy sessions were highly emotive and at times challenging for Carl. All three recognised the challenges Carl is likely to face during his application for access to his other children.
The overall traditional Chinese medicine treatment principle in addressing Carl’s difficulties was to calm the Shen (mind). The goals of this treatment were to facilitate Carl to relax in the evenings and to improve his sleep pattern. This treatment aimed to promote relaxation and to release suppressed feelings of anger. Local and distal acupoints followed by massage to the limbs/shoulders were used to improve circulation and mobility which had been restricted due to pain. Points addressed frustration, aggression, depression and cravings. Finally, Carl was taught simple breathing exercises while engaging in Tai Chi/Qiqong to quieten his mind and improve oxygen intake.
Upon completion of the 28-day rehabilitation programme, Carl was determined to remain abstinent from alcohol and other substances. His cravings reduced considerably, aided by acupuncture, CBT and participation in individual/group therapy. Through engaging in relapse prevention, Carl had a clear written outline of situations which posed a high risk to relapse and strategies to deal with them. He committed to attending the aftercare programme, utilising community supports and engaging in extracurricular activities to promote self-efficacy.
Carl reported that although he continued to struggle with expressing strong emotion, he had an improved ability to process emotion by utilising emotion regulation knowledge and skills. This was further facilitated through family therapy whereby Carl began to communicate and share his thoughts and emotions more effectively with his children. Carl planned on utilising assertive communication skills in his dealings with others in the future. Through processing of emotion, traditional Chinese practice and psycho-education on sleep hygiene, Carl’s sleep improved over the course of his treatment.