Lupine Publishers | Scholarly Journal Of Psychology And Behavioral Sciences
Abstract
This paper is a counseling case report of
15 sessions on a client who has been diagnosed with smoking cigarette from
Kelem Worq Preparatory School. CO6 was an 18 -year-old grade 12th social stream
student in Keleme Worq Preparatory School. CO6 was the second of the four
children in his family. Assessment tools included a detailed interview and
behavioral records. CO6 has been smoking cigarette since grade eight. At the
time of counseling CO6 smoked five per day. CO6 drunk 4-6 glasses of beer
occasionally, has done this for several years. Other than these drugs no other
drug use reported. Many factors identified during the assessment were
considered critical in accounting for the cause and persistence of CO6’s
cigarette smoking [1,2]. Cognitive behavioral counseling was the theoretical
framework that informed the case formulation. The counselor used self-reports
of the client as outcome measures. SQ3R study method, the five Ds and cognitive
behavioral therapy technique were applied to solve the client’s major problems
of academic, smoking and alcohol drinking problems, respectively. Progress was
evident by improved class attendance, more sustained focus on her academic
studies, and continued improvement in sleep. The client has minimized his
cigarette smoking and stopped his alcohol drinking.
Introduction
This paper is a counseling case report on
a client who has been diagnosed with smoking cigarette from Kelem Worq
Preparatory School. The assessment part has included the necessary identifying
information with appropriate changes to shield the client’s real identity [3].
As part of the treatment plan the presenting problems will be identified and
matched to the criteria set forth in the Diagnostic and Statistical Manual of
Mental Disorders, 4th edition text revision (DSM-IV-TR) multi-axial diagnosis(
its new version is also available, DSM-V).
Nicotine or Tobacco Use
Disorders
Tobacco Use Disorder according to
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), diagnosis
assigned to individuals who are dependent on the drug nicotine due to use of
tobacco products. Tobacco contains the psychoactive drug nicotine, which is a
central nervous system stimulant. The immediate effects of nicotine
administration are tachycardia, hypertension, increased respiration,
hyperglycemia, enhanced memory storage, improved concentration, and appetite
suppression. Nicotine can be taken through several routes, including inhalation
(smoking cigarettes, cigars, or pipes), chewing tobacco and snuff [4-8]. Nicotine
produces dependence and withdrawal symptoms upon cessation of use, the onset of
which occurs about one hour after the last dose. Withdrawal symptoms include
irritability, annoyance, anxiety, and cravings for nicotine. Substance abuse
disorders have high comorbidity with tobacco use disorder. People in early
recovery from other drugs or alcohol tend to smoke heavily or chew tobacco.
Features of tobacco products that enhance their addictive potential include the
rewarding properties of nicotine, the behavioral reinforcement of the hand- to
-to mouth habit, lack of social support to cease smoking, the ease of access of
tobacco products, and the cultural acceptance of tobacco products. Another
factor which enhances nicotine’s addictive qualities is bioengineering by
tobacco companies, which add ammonia to nicotine to facilitate absorption and
bioavailability (Figure 1). The Diagnostic and Statistical Manual of Mental
Disorders indicates that risk factors for Tobacco Use Disorder include
low-income levels, low level of Education, and diagnosis of the following
disorders: conduct disorder, depressive disorder, anxiety disorders,
personality disorders, psychotic disorders, and other substance use disorders.
There is also a genetic component to Tobacco Use Disorder (American Psychiatric
Association, 2013).
Case Description
CO6, code name of the client, was an
18-year-old grade 12th social stream student in Keleme Worq Preparatory School.
He was the second child among the four children. His father was 55 years old
and lives outside Addis Ababa due to his workplace, but he visits his family in
every weekend day. C06 had smooth communication with his father. His mother was
housewife and learned up to grade 12. C06’s mother was a smart for him, and she
communicates friendly. His oldest sister in the family was 22 years old, and
she was indulgent, reluctant to take great care of others. The rest younger
sister and brother are 14 and 8 years old, respectively, and both of them have
good communications with him. C06 described his parents’ parenting style as
democratic. C06’s birth and childhood time were normal. He grew up in a close
and loving family and recalls a happy childhood, and uneventful adolescence. As
he reported that his parents were supportive and sensitive to his needs and
encouraged his to be independent and responsible.
CO6 describes himself as a “good boy” who excelled socially and involved in
many extracurricular activities. But he described himself as not good boy in
academic performance as he was socially. He had a healthy self-esteem growing
up and never engaged in risky behaviors or got into trouble other than smoking
cigarette and drinking alcohol. CO6’s peer relationships during childhood and
adolescence were good and he remains close with several high school friends and
he was remembered by his jocks. CO6 had also developed good peer relationships
with neighborhood children and enjoyed with them sometimes. CO6 dated during
elementary school and had a few casual relationships while he was high school
students. Still he has not serious romantic relationship with anyone. CO6
struggled to get out of bed in the morning, sometimes missing his morning
classes. He stays up until 8:00 or 10:00 pm for eating and watching TV but he
did not have much involvement during super time. And he had good self-esteem
towards himself and had not suicidal ideation and never attempted suicide.
Until this professional contact CO6 had not seen by any other professionals for
a serious physical or mental problem.
Clinical Assessment
I would like to inform you that I have
had 15 sessions in person with this client. The clinical assessment included a
clinical interview and behavioral observation. CO6 has been smoking cigarette
since grade eight. At the time of counseling the client smoked five per day. He
started smoking again after awaking the first cigarette smoked was within the
first 30 minutes. CO6 drunk 4-6 glasses of beer occasionally, has done this for
several years. He didn’t see alcohol drinking as a problem. CO6 always smokes
while drinking alcohol and CO6 used coffee sometimes. Other than these drugs no
other drug use reported. When CO6 became depressed he wants to smoke. In
addition to his depression, head ace, watching his friends while they smoked or
handed cigarette, drinking alcohols and sometimes his low performance in
academic were the most triggering factors for his desire to smoke.
CO6 had no past successes with behavior change: Quit smoking twice when he was
grade nine for 2 months but relapsed. He, at the time of counseling, wanted to
quit smoking to prevent the medical and social consequences of smoking. Even if
CO6 was ready to quit at this time, CO6 was worried about his ability to
succeed in his quitting. His limited time for self-care, peer pressures, his
low selfconfidences to quitting, absences of social supports from his schools
and families and his alcohol consumptions were his potential barriers to
quitting. However, his strong motivation, strong health reasons, one previous
quit attempt with some duration (2 months), his high self–esteem towards
himself and, friends who want to quit with him were the assets of the client.
Diagnostic Formulation
Based on the assessment findings in the
initial interviews, the following diagnosis was formulated.
Axis I: Substance abuse (cigarette smoking and alcohol drinking).
Axis II: No
Axis III: No
Axis IV: Problems related to the social environment (inadequate social
support), and Educational Problems (academic problems and inadequate school
environment)
Axis V: Moderate functioning
Case Conceptualization
Several factors identified during the
assessment were considered critical in accounting for the etiology and
persistence of CO6’s cigarette smoking. Cognitive behavioral model was the
theoretical framework that informed the case formulation. The emphasis placed
on developing a case formulation leads to treatment goal-setting and planning.
CO6 was an eighteen-year-old boy who came from a medium class family. His chief
complaint when he met the counselor was that he smoked cigarette accompanied by
symptoms such as withdrawal and tolerance symptoms. CO6 said that he can’t
concentrate in attending classes every day, which was why CO6 said he left
school to smoke cigarette after break time. As the clinical interview revealed
that the client had not exposed his smoking for his parents. CO6’s most serious
problem was his cigarette smoking. From a behavioral perspective, these impulse
control difficulties may have developed because of faulty learning experiences,
including pressures from his close friends in school and neighboring, his
modeling of his significant others’ behavior and lack of guidance from parents.
For CO6’s problem behaviors, precipitating factors included alcohol drinking,
holding of cigarette by his friends and watching of theses friends while
smoking , going to toilet with friends at break time and his thought of ‘’I am
poor in education”. Client’s perpetuating factors included his poor quit
attempts, no support at school, withdrawal symptoms associated with cigarette
smoking and his low self-confidence in succeeding in quitting cigarette
smoking.
CO6’S strengths include his sociable behaviors with school and neighboring
friends. CO6 has a strong desire to quit smoking as CO6 believed that health
and social consequences of cigarette smoking was inevitable. The counselor
selected cognitive behavioral therapy for this client to solve his problems of
cigarette smoking and its associated symptoms. It has been shown that
cognitive-behavioral therapy, combined with a smoking cessation medication
(such as the nicotine patch, nicotine gum, for example), is quite effective for
smokers who are motivated to quit. Cognitive-behavioral counseling is an
evidenced-based psychological treatment that focuses on identifying and
changing maladaptive thoughts, emotions, and behaviors that trigger, worsen,
and/or maintain a range of problems (such as depression, anxiety, addiction,
etc.). Because changing your smoking-related behaviors-and restructuring your
thoughts related to smoking urges- is essential to quitting,
cognitivebehavioral counseling can effectively be applied to smoking cessation.
An intensive cognitive-behavioral therapy program is typically composed of
three phases: preparation, quitting, and maintenance (or relapse prevention).
Treatment Plan and Course
of Treatment
Based on the case formulation, CO6 and
the counselor collaborated in the development of the following prioritized list
of problems and treatment goals. The order and relative importance placed on
these goals was largely determined by the client, although there was input from
the counselor in directing treatment efforts to goals that would have the most
impact on CO6’s cigarette smoking and its associated symptoms, and had the
greatest likelihood of success. The treatment plan followed the problem format,
a format that presents the target problems with its major goal and objectives
and intervention methods in structured form.
Problem-1: low academic performance
a) As evidenced by: low results grade to grade.
b) As evidenced by: poor class attendance.
c) As evidenced by: lack of study skills.
d) As evidenced by: absent from schools.
e) As evidenced by: late in the morning to go to school.
Goal-1: to improve academic performance
Objectives and Interventions.
Objective-1: teaching study skills
Interventions: The SQ3R study method was employed to target
co6’s poor study skills and to improve his academic performance.
Objective
-2: Increase class attendances
Interventions: To improve class attendance, a behavioral
contingency was developed to ensure CO6’s woke up by 7:00 am so he could attend
all his scheduled classes for that day. In addition, CO6 would shower, eat a
light breakfast, and walk to school. If he completed this schedule 3/5 days,
CO6 would reward himself by going pool houses for the weekend or to the movies
with classmate.
Objective
-3: work on sleep difficulty
Intervention: Poor class attendance and an inability to study
were major contributors to poor academic performance. It was decided to target
CO6’s sleep difficulties that were a major cause of missing classes and daily
fatigue that made it difficult to study. Maladaptive sleep-related behaviors
were identified, and corrective homework assigned. The client and the counselor
set up a sleep log and agreed to keep the sleep log, maintain regular sleep
hours, eliminate daytime naps, to make sure the bedroom has oxygen, and
restrict bedroom activities to sleep.
Problem
2: Cigarette Smoking
a) As evidenced by: smoked for five years.
b) As evidenced by: nicotine dependence withdrawal.
c) As evidenced by: fugue out of school for smoking.
d) As evidenced by: slum physical appearances.
Goal-2: Cigarette Smoking Cessation
Objectives and Interventions.
Objective
1: To confront with the urge to smoke
Intervention
To achieve this objective the client and
counselor applied the five Ds
a) Delay, even for a short while.
b) Drink water.
c) Deep breathing.
d) Do something different and,
e) Discuss the craving with another person.
Objective
2: Teaching different behavioral tips
to quit smoking cigarette
Intervention
tips
a) Write out a list of reasons to quit
and display it prominently e.g. on wall.
b) Get rid of all tobacco products, ashtrays, lighters, matches, etc. from all
areas which you inhabit.
c) Clean all clothes in order to remove cigarette smell.
d) Enlist the support of non-smoking friends, relatives, and workmates.
e) Change the environmental cues, e.g. the telephone often causes a reflex
action to smoke, move the telephone to another place to change the cue.
f) Keep hands busy e.g. knitting, gardening, drawing, origami.
g) Sit in non-smoking areas.
h) Positive self-talk.
i) Try to avoid stressful situations in the immediate period after stopping.
j) Set aside the money normally spent on cigarettes to buy something as a
reward do not drink alcoholic beverages because these are associated with
relapse.
k) Avoid, even temporarily, social situations normally associated with smoking.
practice saying, “No thank you, I don’t smoke.
l) Ask other smokers not to give cigarettes, offer to buy cigarettes or smoke
in the patient’s presence.
m) Think positive and remember your reasons for quitting in the first place.
n) View quitting as a day-at-a-time process rather than an immediate lifelong
commitment.
Problem
3: alcohol drinking
Goal
3: To stop drinking alcohol: The
psychologist also offered cognitive behavioral therapy techniques for his
alcohol abuse and some behavioral tips.
Progresses
The counselor used self-reports as
outcome measures. The therapist reviewed co6’s sleep log and daily activity
record to evaluate the success of these interventions at modifying sleep
behavior and class attendance. Progress was evident by improved class
attendance and a more consistent bedtime routine. CO6 reported better class
attendance; more sustained focus on her academic studies, and continued
improvement in sleep. The client has minimized his cigarette smoking and
stopped his alcohol drinking. The treatment is still under supervision.
Strengths and Weakness
Use of the core conditions of (empathy,
genuine and unconditional positive regard) as relationship building throughout
the whole counseling processes helped me to express my values, reactions, and
feelings as they became appropriate to what was happening in the therapy sessions.
It helped me to create a trusting working relationship with my client. The
process helped the counselor to understand the value of supervision. The
supervision helped the counselor to identify themes that had not been obvious
to the counselor. It helped the counselor articulate the counselor role as a
counselor. Supervision helped the counselor to identify areas where the
counselor was not challenging my client enough and to be conscious of any
manipulative signs by client and how to handle them. Supervision also helped
the counselor to identify strengths in empathizing, listening, summarizing, and
paraphrasing. Sometimes client would tend to talk very little and at such times
the counselor would tend talk more and to give advice to my client may consider
as weakness.
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