Alcohol abuse and dependence is one of the most common problems handled by psychiatrists across the globe. While several factors are attributed to the development of addiction, sexual orientation may compound the problem. Researchers have found that compared with the general population, LGBT (Lesbian, Gay, Bisexual, and Transgender) people have a higher propensity towards alcohol and drug use and have higher rates of substance abuse. Also, they are more likely to continue heavy drinking into later life (Center for Substance Abuse Treatment, 2001.).
Substance abuse is further complicated by heterosexism which contributes to homophobia, shame, and a negative self-concept. The LGBT people turn to alcohol and other drugs to deal with negative feelings. Moreover, they have difficulties accessing treatment facilities due to homophobia and discrimination from the health care providers who may be unaware or insensitive to the issues of the LGBT community. Also, substance abuse treatment programs are not equipped to meet the needs of this population (Center for Substance Abuse Treatment, 2001). In consideration of the above factors, and the fact that John Doe has a Bi-Polar I disorder, it is not strange that he has an alcohol abuse problem and is at an increased risk of relapsing if not treated and monitored well.
Clinical Model
John Doe’s case is complex due to the various factors accompanying his alcohol addiction. Therefore, I would use motivational interviewing to counsel him. Motivational interviewing enables the care provider to help the patient to find the power and strength they need to change their unhealthy behavior by setting achievable goals (Center for Substance Abuse Treatment, 1999). The primary goal of motivational interviewing is to help the patient envision positive outcomes. The benefits of using this technique include triggering a change in high-risk lifestyle behaviors, increasing the willingness to get help and fight through addiction, and increasing participation rates throughout the treatment period. It also lowers the chance of future relapses occurring, allows individuals to find encouragement during treatment, and helps them to establish self-actualization goals (Center for Substance Abuse Treatment, 1999). The above advantages make motivational interviewing the best method to handle John’s situation.
While using the technique, I would still encourage the patient to continue attending his Alcoholic Anonymous meetings and be adherent to medications for the bipolar comorbidity. Once a discrepancy is achieved, the process of recovery should be swift and effective.
Targeted Behavior, Thoughts and Issues
John is experiencing profound feelings of loneliness and believes that he will never find a life partner following the break-up with his significant other. This is something I would address carefully to change his stance. The counselor needs to be empathetic regarding John’s feelings and compliment him for expressing his feelings. They should encourage the client and point out that it is normal to feel like he is after a break-up, and that he will find a significant other ready to support him. I would motivate the patient to dwell on the fulfilment of a loving partner and marriage rather than concentrate on the lost love.
John Doe believes he can frequent the bar and avoid drinking. This is a risky behavior that increases the chances of relapsing since the environment there is conducive for one to take alcohol. He is also likely to give in to the pressure of his friends who would want him to continue drinking. The counselor should handle this issue keenly to avoid antagonizing the patient. Motivational interviewing advocates for avoiding arguments with the patient while flowing with the resistance (Center for Substance Abuse Treatment, 1999). I would, therefore, listen to John’s view regarding going to the bar and his rationale regarding avoiding drinking while there. I would then encourage him to reflect on his current situation, the risks associated with the bar visits, and the expected outcome. I also would offer incentives for every week spent without going to the bars. Studies have shown that incentive-based interventions are highly effective in increasing treatment retention and promoting abstinence from drugs (National Institute on Drug Abuse, 2000.).
The problem of nonadherence to medication for bipolar disorder should also be corrected efficiently. According to Bates, Whitehead, and Kim (2010), medication nonadherence is associated with a poor prognosis among patients with bipolar disorder. The patients are at a greater risk of suicide, experience a shorter duration between episodes, and are more likely to relapse (Bates et al., 2010). John is, therefore, predisposed to all the negative outcomes of nonadherence. I would enlighten him on the dangers of drug nonadherence and the likelihood of the disease worsening if the behavior continues. Also, I would remind him that our aim should be to recover fully from both alcoholism and bipolar disorder. Adherence is paramount for a full recovery.
The patient prides himself on his sales record as a sales representative. This would serve as a good reference for motivating behavior change. Reference to his job would stimulate positive thinking and prospects of doing better should he maintain an alcohol-free life and take his drugs as prescribed. I would encourage him to maintain his good work and put the same effort in ensuring that he puts alcohol abuse behind him.
Therapeutic Issues
Transference
Transference is an unconscious movement of conflictual desire and/or belief across space and time from one person in the past to another in the present (Schaeffer, 2016). John has previously felt judged by therapists who he felt were uncomfortable with his sexual orientation. He is, therefore, likely to transfer the same feelings to the current therapist. However, the problem can be avoided by reassuring the patient that you are comfortable with him being gay and ensuring that the patient does not feel judged.
The therapist should keep prejudices subjected to gay people out of their conversations. The language used should not be condescending towards homosexuals and the accompanying actions should reflect the therapist’s words. It would also necessitate the care provider to be keen to identify early indicators of transference, especially the negative ones. The therapist can also discuss the negative feelings with the patient hoping that the patient develops insight and finds ways to manage the painful and less desired emotions (Ladson and Welton, 2007).
Countertransference
Countertransference refers to the projection of the therapist’s feelings towards the patient. This may destroy the therapeutic relationship, often with damaging results for the patient. The feelings arise primarily due to the therapist’s compassion (desire to alleviate other’s suffering) towards the client. Meditation - self-regulation practices that focus on training attention and awareness to bring mental processes under greater voluntary control and thereby foster general mental well-being and development and/or specific capacities such as calm, clarity, and concentration – can be used to manage countertransference (Fatter and Hayes, 2013).
In John’s case, I would expect the therapists to develop countertransference as they empathize with his situation. He lost his significant other, has felt judged for his being gay, suffers from bipolar, and is struggling to quit alcohol. These are problems that the therapist can develop compassion towards and develop vulnerability to countertransference. The therapist should, therefore, be on the look-out from the beginning.
References
Fatter, D. M., & Hayes, J. A. (2013). What facilitates countertransference management? The
roles of therapist meditation, mindfulness, and self-differentiation. Psychotherapy Research, 23(5), 502-513.
National Institute on Drug Abuse. (2000). Principles of drug addiction treatment: A research-
based guide. National Institute on Drug Abuse, National Institutes of Health.
Schaeffer, J. A. (2016). Double Edged Swords: Improving Therapy Through Interpretation.
Center for Substance Abuse Treatment. (1999). Enhancing motivation for change in substance
abuse treatment.
Center for Substance Abuse Treatment (US). (2001). A provider's introduction to substance
abuse treatment for lesbian, gay, bisexual, and transgender individuals. US Dept. of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.
Bates, J. A., Whitehead, R., Bolge, S. C., & Kim, E. (2010). Correlates of medication adherence
among patients with bipolar disorder: results of the bipolar evaluation of satisfaction and tolerability (BEST) study: a nationwide cross-sectional survey. Primary care companion to the Journal of clinical psychiatry, 12(5).
Ladson, D., & Welton, R. (2007). Recognizing and managing erotic and eroticized
transferences. Psychiatry (Edgmont), 4(4), 47.
