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28 Days - A Case Study of Addictions Treatment
"28 Days" - A Case Study on Addictions Treatment
Natasha C. Gillyard
Wake Forest University
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28 Days - A Case Study of Addictions Treatment
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Addictions are prevalent in our society. From substance such as drugs and alcohol to
process addictions like sex, gambling, and eating disorders, it is likely that someone in your work
or friend circle has struggled with an addiction. Addictions counseling takes knowledge and
patience from counselors. In this case study final paper, I have chosen to apply the knowledge
from this addictions course to "28 Days" starring Sandra Bullock. In this paper I will be focusing
on the Gwen Cummings, the main character played by Sandra Bullock. She is a city newspaper
columnist that struggles with substance abuse, specifically alcohol.
Gwen is a middle age female living and working in the big city. At the start of the movie
we see her drinking heavily with her boyfriend and friends. The next day she rushes to her older
sister's wedding drunk, where she is a bridesmaid, and ruins the reception by dancing recklessly
and falling into the wedding cake. She insists that she can replace the cake, and takes the
wedding limousine in order to go to a bakery. She ends up crashing into a house, and going to
court. Her sentence is going to jail or going to a treatment facility. Her treatment is involuntary.
Gwen's substance abuse issues began when she was a young child. We can see that Gwen's
mother was an alcoholic from her childhood flashbacks. Her mother often drank when Gwen
and her older sister, Lily, were around, and she was often found passed out on the floor of their
home drunk. Gwen's father was not shown, so his role is unknown. There were several things
that made Gwen vulnerable to substances. Her mother's substance habits, feelings of loneliness,
and sociocultural factors (i.e. age, school, and societal messages) are all contributing factors that
made it easy for Gwen to fall prey to alcohol and the cyclical effects. Alcohol is a sedative.
According to Miller, Forcehimes, Zweben (2011), "sedative drugs have as their general effect a
suppression of the central nervous system. Sedative increase the activity of a certain class of
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inhibiting neurotransmitters called GABA. In reference to the above resource, sedatives have
been commonly identified as downers and shutdowners. Low doses can decrease anxiety while
giving a euphoric effect. However, there are also adverse effects. Alcohol can interfere with
memory capabilities, induce blackouts, and can be dangerous when combined with activities (i.e.
driving or operating machinery). The long-term effects of alcohol include dependency, lethal
overdose, hypertension, and congestive heart disease.
I will use the psychological model of addiction. As stated in Dr. Clark’s handout (2015),
it is one of five different lenses to view and treat addiction. This model of addiction is focuses
on the psychological stressors that drive the addiction. It sees substances as mechanism to cope
with internal and external psychological stress. Therefore the addiction is not the main problem;
the psychological stress is. It also perpetuates that there is an “addictive” personality. I believe
that this model would be effective in working with Gwen because it hones in on the
psychological stress that she is going through (i.e. guilt and loneliness). By applying this model
with Gwen I would target the reasons why she drinks, and co-create a treatment plan that would
help her to process those reasons and stressors. Then I would empower and support her while
she tried new behaviors and coping mechanism to utilize when encountering her stressors. By
addressing Gwen's underlying causes to her addiction, I hope to decrease the likelihood of
relapse. This is one of the advantages of the psychological model of addiction. I also hope that
Gwen would embrace a hope of recovery by utilizing this approach to address her psychological
stress and learning new coping skills to counter her addiction.
If I was meeting Gwen for the first time, I would complete an assessment. I would
choose the CAGE assessment. I believe it would answer several of my questions about her
substance use, such as frequency of substance use, defensiveness or denial about use, guilt, and
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other people's concerns about their drinking. I would also want to gather information about
when she started drinking, her drinking habits over time, and important life events. According to
the APA (2013), Gwen meets the criteria for alcohol use disorder. She meets four out of the
eleven criteria. As referenced in the DSM V, she continually desires to use alcohol. Going out
to drink with her boyfriend and friends is a regular social activity that she enjoys, and she does
not want to stop. Drinking has lead to her inability to fulfill her work obligations. She continues
to drink despite the fact that it interferes with her interpersonal relationships, specifically with
her sister. When Gwen and Lily interact there is always tension. Lily wants to include Gwen in
important life events, such as her wedding, but also feels frustrated with her when Gwen shows
up drunk. Gwen also drinks and drives, as seen in the movie with she drives the wedding
limousine. There is not enough information from the movie to suggest that she meets more
criteria. I would classify Gwen's severity as moderate, since four symptoms are present.
In considering co-occurring disorders during Gwen's assessment, one would consider
anxiety, depression, and PTSD. According to the American Psychiatric Association (2013), one
must meet five or more symptoms and the symptoms must be present for a 2-week time period,
showing a change in how the individual normally functions to meet the majord depressive
disorder criteria. In regards to major depressive disorder, Gwen meets one criteria. She
expressed feeling of worthlessness and guilt in regards to the effects of her alcohol use on other
people, namely Lily. Therefore, major depressive disorder and the other related depressiverelated disorders can be ruled out. It is possible that Gwen could have a co-occurring anxiety
disorder. Generalized Anxiety Disorder includes symptoms such as overwhelming anxiety and
worry, difficulty managing worry, feeling on edge, irritability, and sleep disturbance (American
Psychiatric Association, 2013). Gwen meets these symptom criteria when she is not taking
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substances. A co-occurring disorder would influence her treatment, and clinical understanding
of her behavior and cognitive decisions. Anxiety and worry takes energy. When those two
factors are present it is more difficult to make decisions and complete tasks efficiently. In
addition, having one's energy sucked by anxiety and worry contributes to fatigue and perpetuates
an unhealthy cycle oscillating between anxiety and fatigue. In regards to differential diagnosis,
one can rule out anxiety-associated disorders. Substance/medication-induced anxiety disorder
requires that a substance by or medication is etiologically connected with the anxiety one
experiences. Social anxiety disorder requires an anxiety focused on futuristic social interactions
that one must participate in or being evaluated by others. Lastly, obsessive-compulsive disorder
requires obsessive thoughts that are often unwanted and intrusive. Posttraumatic Stress Disorder
characteristically requires experiencing a traumatic event, having persistent intrusive memories
related to a traumatic event, avoidance of stimuli that remind one of the traumatic event, and a
change in reactivity due to the traumatic event (American Psychiatric Association, 2013). It is
unclear whether a traumatic event has occurred for Gwen, such as finding her mother dead from
an alcohol overdose or being raped while drunk. Therefore she does not meet the criteria for
posttraumatic stress disorder at this time.
Behavioral formulation and relapse prevention would be effective counseling approaches
in Gwen's treatment. According to Lewis (2015), behavioral formulation include positive
reinforcement, negative reinforcement, and punishment. Gwen has received positive
reinforcement for drinking such as pleasant feelings, friendships, a relationship. It would be
difficult to enforce a negative reinforcement since Gwen is an adult, but one can see that
punishment is working. Due to her drinking and driving incident, she has mandatory addictions
treatment. A token economy could be effective, so Gwen would see the positives of drinking
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less. One would anticipate clearer decision making, actively participating in the workplace, and
taking part in activities and hobbies that bring joy. In addition to behavioral formulation, relapse
prevention would be an effective approach in working with Gwen. Relapse prevention is helpful
in that it does not define relapse as a general event, but it takes into account the management of
relapses (Clark, 2015). By looking at relapse in depth, in the sense of a spectrum, it is possible
to be more specific with treatment and therefore have more positive outcomes. In relapse
prevention there are terms such as slip, lapse, and full-blown relapse. An example of a slip in
Gwen's case would be if she was out or at home, and she had a sip of alcohol and stopped herself.
Her stopping herself would be due to a coping skill that was used in the moment. An example of
a lapse would be Gwen drinking a full alcoholic drink, and deciding to stop there because it was
a bad idea. Again, coping skills would have been used in the moment to prevent further drinking.
A full-blown relapse would be Gwen binge drinking. Each event can be discussed with Gwen
and important information can be gleaned. An awareness of triggering places and events and
thoughts about drinking and herself are key factors in learning the circumstances in which Gwen
drinks. In her case she usually drinks with her friends at night a few times a week, so learning
what surrounds that pattern could increase self-efficacy. It would be very important to reframe
Gwen's slips, lapses, and relapses as an experience to learn from, not a failure. Intentional
objectivity decreases defensiveness, guilt, and shame while increasing the therapeutic bond.
This leads to more positive therapy outcomes. Internal objectivity allows the client a chance to
look at all of the decisions leading up to a slip, lapse, or full-blown relapse and pinpoint how a
set of coping skills could challenge address the actual issue at hand. For example, Gwen's
boyfriend could take her out on a date. He picks a nice, romantic restaurant, and he orders a beer
with his entrée. Gwen can think, "One glass of wine would be fine, since it's with dinner", and
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this can lead to her ordering a drink. This chain of events can reveal several triggers, such as
seeing her boyfriend drink and being in a restaurant that serves alcohol, and cognitions, such as
"One glass of wine would be fine". Both pieces of information are valuable as Gwen learns to
challenge her previous thoughts and behaviors. The Marlett model of relapse would come into
play at this point. An example of an effective coping response to the high-risk situation is
challenging the thought "One glass of wine would be fine" with another thought like "I know I
can't have just one glass of wine, so that would be a bad idea and I want to maintain my
abstinence".
The goals to include in Gwen's treatment include: abstinence from alcohol, to change
cognitions about alcohol use, decrease anxiety, and empower the client to build a support
network around abstinence. Progress for Gwen looks like a detox treatment followed by
maintained abstinence, effective use of coping skills for her cognitions related to alcohol use,
effective use of coping skills to manage her anxiety without substances, and interacting with her
support network in order to receive accountability as well as encouragement on her journey.
These big picture goals serve as the platform for the changes she will undertake during therapy,
and provide her with the necessary direction to do so. It addresses internal changes as well as
external changes, which is necessary in working with clients working on substance abuse issues.
Gwen's treatment plan would include several recommendations. A residential level of
care for detoxification (ASAM level three), with medical staff on site would be the first step
(Clark, 2015). After medical clearance was achieved, the other recommendations could be
started. Treatment at the residential center would last a month, and include individual therapy
twice a week, group therapy five times a week, and weekly family sessions if her family could
make it. After a month of level three treatment, I would recommend ASAM level 1 outpatient
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treatment (Clark, 2015). This would include weekly individual therapy and a local 12-step
Alcoholics Anonymous group for one year. Upon discharge from individual treatment, I would
recommend regular attendance to a local 12-step Alcoholics Anonymous group and scheduling
an individual counseling appointment as needed.
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References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders:
DSM-5 (5th ed.)
Clark, P. (n.d.). Levels of Care [PDF document]. Retrieved from
http://lmscontent.embanet.com/WF/MAC/CNS765/Documents/LevelsofCare_ADA.pdf
Clark, P. (n.d.). Relapse Prevention [PDF document]. Retrieved from
http://lmscontent.embanet.com/WF/MAC/CNS765/Documents/RelapsePrevention_ADA.pdf
Lewis, T. (n.d.). Behavioral and Cognitive Formulations [PDF document]. Retrieved from
http://lmscontent.embanet.com/WF/MAC/CNS765/Documents/BehCog_ADA.pdf
Miller, W. R., Forcehimes, A., & Zweben, A. (2011). Treating addiction: A guide for
professionals. New York: Guilford Press.