Assignment 7.

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Assignment 7.3: Final Case Study of Kym Buchman from “Rachel Getting Married”

Michelle White

Wake Forest University

Conceptualization of the Client

Kym Buchman is a 28-year-old, single, Caucasian female. She is the middle child in her

family, with an older sister and a younger brother who passed away about ten years ago. Her

parents were married during her childhood, but divorced a short time after her brother’s death.

Kym’s father Paul has remained single, but her mother Abby has a new partner. Kym’s older

sister, Rachel, recently got married to a man named Sidney and is expecting a child. The

relationships between Kym and her family members tend to be tense. Kym has struggled with

substance use, beginning with OxyContin and progressing into heroin, since the age of 16. When

Kym was 18, she and her younger brother Ethan were in a car accident. Kym had been

intoxicated and accidentally drove into a lake. Ethan drowned. Rachel, and Abby hold Kym

responsible for Ethan’s death and have not forgiven her. Kym also believes she is responsible for

Ethan’s death and that she doesn’t deserve forgiveness. Ethan’s death and Kym’s other self-

destructive behaviors have caused a deep rift between sisters and mother and daughter. Paul, on

the other hand, takes a gentler approach toward Kym and shows intense concern over her well-

being and wereabouts.

Kym currently resides in an in-patient substance abuse rehabilitation center. She has been

a part of the in-patient program for the past nine months, but she has been a client of this

particular center for approximately two years. Kym voluntarily entered treatment and she also

voluntarily admitted herself to the in-patient program after a relapse she experienced ten months

ago. Prior to her participation in the in-patient program, Kym had been participating in an

intensive out-patient program that met three times a week for three hours at a time.

Kym has requested individual counseling sessions in addition to her group counseling

sessions after returning to rehab from a three-day visit home for her sister’s wedding. She cites
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that while she was able to make some positive progress in a Narcotics Anonymous meeting and

in her relationship with her sister, that her cravings for heroin and OxyContin have intensified

recently. Despite nine months of sobriety, Kym is experiencing urges to use the substances and

some anxiety.

Kym’s substance use issues can be best be understood through the psychological and

sociocultural models of addiction. The psychological model of addiction focuses on the assertion

that psychologically problems are the primary condition and addiction is the secondary

condition. This model operates on the beliefs that addiction is driven by psychological stress and

that addiction is used as a coping mechanism. Kym’s substance use began in the 11th grade, when

she was 16. At the time, Kym was experiencing depressive symptoms as a result of bullying at

school and the pressure she felt from her parents and teachers to get good grades and get into a

good college. After sharing how hopeless and stressed she was feeling with one of her friends,

the friend offered her an OxyContin to try – telling Kym it would relieve the pain and help her

feel better.

However, Kym’s substance use issues can also be partially understood through a

sociocultural model as well. The sociocultural model asserts that familial, peer, and cultural

influences play a large and primary role in substance use. In this model, an individual should be

viewed in relation to their environment. In the US, there is a very prominent alcohol culture

where it is acceptable and common for almost all social events to involve alcohol use. Kym grew

up witnessing get-togethers, family parties, and sporting events where almost all adults drank.

Kym also grew up in Connecticut, a traditionally blue state which holds more progressive views

toward certain things. For instance, it was quite common for Kym to catch her mother and her
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mother’s friends smoking the occasional blunt on the back porch. Furthermore, the friend group

that accepted Kym during high school also experimented with a number of drugs.

Screening and Assessments

When Kym first entered treatment, she met the criteria for F11.20 Opioid Use Disorder,

severe. This was evidenced by meeting several criteria, per the Diagnostic and Statistical Manual

of Mental Health Disorders, fourth edition. First, Kym used the substance in larger amounts and

over a longer period than was intended. She originally only planned to take OxyContin a few

times to help deal with bullying incidents and college preparation stress, but used more

frequently and eventually progressed to heroin use. Kym demonstrated unsuccessful efforts to

cut down or control substance use, but would use again when the withdrawal symptoms became

overwhelming or she was once again faced with stress. Overtime, a great deal of Kym’s time was

spent obtaining, using, or recovering from its effects. When her friend who had originally

supplied the OxyContin could no longer get the drug, Kym had to find other connections with

classmates and suppliers. When she began using heroin, it would take up to a day for Kym to

recover from the use. For years, Kym experienced cravings and a strong desire to use. Her

recurrent use resulted in failure to fulfill major role obligations – getting fired from multiple jobs,

failing out of the two college courses she attempted, and being viewed as unreliable by her

family members. Kym continued use despite having persistent social or interpersonal problems

caused by the effects of her use. Kym placed significantly less value on her relationships with

her family, gave up any hobbies she had, and lost all of her non-using friends. Kym experienced

increased tolerance over time. When Kym did try to cut back or quit, she experienced

hallucinations, sweating, shaking, agitation, and nausea.

At this point in Kym’s treatment, she meets the criteria for F11.11 Opioid Use Disorder,

in Early Remission in a Controlled Environment. Kym now qualifies for this distinction because

she no longer experiences the following criteria: 1) substance is often taken in larger amounts or

over a longer period than was intended, 2) persistent desire or unsuccessful efforts to cut down or

control substance use, 3) great deal of time is obtaining, using, or recovering from its effects, 4)

recurrent use resulting in failure to fulfill major role obligations at work, school or home, 5)

continued use despite having persistent social or interpersonal problems caused by the effects of

substances, 6) important social, occupational or recreational activities are given up/reduced, 7)

increased tolerance and 8) withdrawal symptoms. Kym does still experience cravings, but one

symptom does not constitute an active usage diagnosis. However, her early remission distinction

comes with the caveat that this was achieved in a controlled environment. This diagnostic

distinction can be removed when Kym leaves the in-patient program and maintains sobriety

outside the facility.

During treatment at the facility, Kym was also screened for and diagnosed with F43.10

Post Traumatic Stress Disorder. In particular, her trauma seems to stem from the car accident

that resulted in the death of her younger brother. She met criteria for the condition by displaying

the following symptoms: 1) having repeated, disturbing memories, thoughts, or images of a

traumatic experience, 2) having repeated, disturbing dreams of a traumatic experience, 3) feeling

very upset when reminded of a traumatic experience, 4) having physical reactions when

something reminds of a traumatic experiences, 5) persistent or exaggerated negative beliefs

about self/others/world, 6) blaming oneself, 7) persistent negative emotional state, 8) loss of

interest in once enjoyable things, 9) feeling emotionally numb or being unable to have positive

emotions, 10) reckless or self-destructive behavior, and 11) difficulty concentrating. This
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diagnosis is important to consider in Kym’s substance use treatment because, based on the

psychological model of addiction, her traumatic experience is a persistent source of stress that

could trigger her to use. It is imperative that Kym not view opioids as a solution to feeling

emotionally numb and improving her negative emotional state. It is also important that Kym be

given other coping mechanisms to deal with this stress and to have the opportunity to process her

trauma in safe space where she will be supported and not left to deal with the negative emotions

alone.

Modes of Treatment

As part of the in-patient rehabilitation program, Kym is receiving group therapy as the

primary mode of treatment. The group serves as both a psychoeducational group and a traditional

processing group. Half the time is allotted for group members to check-in (reporting their mood,

length of sobriety, and healthy coping skills) and seek feedback from their peers. The other half

of the time is reserved for a topic to help the clients further their knowledge about addiction.

During these sessions, the clinician reinforces the client’s healthy coping skills and commends

them for their length of sobriety. After returning from her trip home, Kym would benefit from

having both individual therapy and family therapy added to her regiment. Individual therapy

would allow for treatment of Kym’s co-morbid PTSD. It would give her a safe environment to

explore her trauma, how it impacts her daily life, and how it impacts her recovery while giving

her skills to deal with the symptoms of PTSD. The family therapy would aid in addressing

Kym’s PTSD, but also in improving the quality of her interpersonal relationships. Much of the

tension between Kym and her family was caused by the death of her younger brother. Family

sessions would help to encourage healing and radical acceptance. It would also help with Kym’s
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recovery after she leaves the in-patient treatment program. Allowing the family to discuss past

events and current growth will strengthen the support system that Kym has.

The length of the treatment will be three months. At this facility, the in-patient treatment

program only lasts for a year. Kym has been in this program for approximately nine months and,

therefore, the program can only provide three additional months of treatment. However, after she

completes the program, Kym will be referred to another organization that facility she’s currently

at works closely with. This organization primarily offers group therapy, but can also

accommodate once monthly individual sessions with clients. At this new site, Kym can

participate in a 20 or 40-hour Dual Diagnosis group, a Cognitive Behavioral Therapy group, or a

Seeking Safety (PTSD) group. This organization also offers a once monthly grief support group

that Kym can utilize in addition to the group she chooses for treatment and her individual

sessions. If Kym would like to continue family therapy, either the facility or sister organization

can refer counselors in the area. Referring Kym to this other organization after the completion of

her in-patient treatment is the best approach because it’s a step down from her current intensive

treatment. It allows her to continue working on her substance use and mental health issues, but in

a non-controlled environment. Based on the amount of time she has been sober and the presence

of cravings, Kym is not yet ready to transition to a non-controlled environment and only self-

help groups instead of counseling-based groups.

Counseling Approaches and Strategies

The first counseling approach that will be utilized for Kym is Motivational Interviewing.

Motivational Interviewing is a person-centered approach that focuses on exploring ambivalence

and encouraging motivational processes within a person so they can facilitate change. It is a

collaborative process between the counselor and the client with the purpose of identifying and
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achieving goals. This is a beneficial approach for Kym because substance use and entering

recovery comes with a lot of ambivalence. Especially for substance use, there is often the desire

to quit because an individual knows it causes problems, but there is also the desire to feel the

effects of the substance. While Kym has made it past this stage and into early remission, her

cravings are still accompanied by this ambivalence. On one hand, she has these nine months of

sobriety and is continuing to make great progress in her recovery and her relationships with

others. But on the other hand, she knows that she can use and once again experience those

desired effects from either OxyContin or heroin. Motivational Interviewing would allow Kym to

work through this ambivalence and continue to set goals for her recovery. Motivational

Interviewing would encourage her change talk, give her the autonomy she feels she lacks in other

areas of her life, and draw out her own ideas and values rather than being stuck with those of the

counselor.

The second approach that will be utilized for Kym is Cognitive Behavioral Therapy.

Cognitive Behavioral Therapy or CBT is a type of therapeutic treatment (commonly associated

with psychotherapy or talk therapy) that helps individuals learn how to identify and change

destructive thought patterns that have a negative influence on their emotions and behaviors. CBT

focuses on identifying an individual’s cognitive distortions, their core beliefs, and their irrational

beliefs. This type of therapy is particularly beneficial for Kym because it will help with both her

substance use and her PTSD. Both have been perpetuated by irrational beliefs and cognitive

distortions that Kym holds about herself. For example, Kym holds the irrational core belief that

she is unworthy of love and affection because of her past self-destructive behaviors and the harm

that she has inflicted upon others. One of CBT’s techniques, guided discovery, will allow Kym
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to discover the beliefs that she holds about herself. Once she recognizes these, the technique of

cognitive restructuring can be used to change the way that Kym thinks, especially about herself.

The main relapse prevention tools that will be used alongside these methods include

coping strategies, problem solving, educating about apparently irrelevant decisions, and

recognizing cognitive distortions. Learning and implementing new coping strategies will allow

Kym to deal with stress in a healthier way that doesn’t result in substance use. Problem solving

will help Kym overcome difficult situations and rely on her new coping mechanisms without

resorting to her addiction. Educating Kym about apparently irrelevant decisions will provide her

with the skills to do a DBT-esque chain analysis and see how certain triggers and behaviors can

lead down a slippery slope. Recognizing cognitive distortions will aid in cognitive restructuring

and improving Kym’s negative mood, which reduce her stress and her urges to use.

Kym’s main treatment goal is to maintain her abstinence and stay in recovery. This looks

like not using OxyContin, heroin, or other narcotics at any point. To maintain her recovery, Kym

will utilize healthy coping skills, the lessons learned in her psychoeducational group sessions,

and her growing support system.