____________________________________ Substance Use Disorders: Assessment and Treatment, 2nd Edition
Client : I started about 5 years ago. That’s when I joined the invest- ment firm, I’m with now. A lot of people used cocaine and I thought I would try it. At first, I would only snort a line or two at a party or someplace like that. I liked the way it made me feel. I mean, I’ve always been pretty competitive and maybe a little aggressive and it made me feel great, like I could do anything. There weren’t any bad effects—well, maybe just a little jittery feeling. That went on for about 2 years. Therapist : Then what happened? Client : I finally got a couple of big accounts and I started to make real money. My job has a lot of pressure to perform, and I work with mostly men, so I have to be twice as good to get noticed. The cocaine helped, so I started to snort a line or two during the day at work, in the women’s restroom. No big deal; I didn’t even use it every day back then. Therapist : And then what happened? Client : About a year and a half ago, I made full partner. I mean, it was a real accomplishment: corner office, private bathroom, and a cut of the profits. After that, I started to use pretty much every day. I mean, I felt entitled and the responsibility of the job is really big, and I have to direct investment strategies for a lot of brokers. For the most part I’ve exceeded expectations. Therapist : Let me make sure I understand what you have told me. You started using cocaine about 5 years ago but only occasionally at parties. But once you began making more money, about 3 years ago, your use of cocaine increased to several times a week. Then after you became a partner, your use of cocaine increased again, and now you use cocaine several times a day, every day. Did I hear you correctly? Client : Well, yes, I guess so. But I can stop whenever I want. Therapist : Could you help me understand why you think that? Client : For the last several months, I’ve been thinking that I should use less than I do, so about three times I’ve stopped using cocaine. Therapist : Can you tell me more about that? Client : I just don’t use for a few days, usually about 4 days. The only problem I have is that I feel tired and don’t sleep very well. I keep having the most horrible dreams. I called up my family physician and told him I was having trouble sleeping, so he gave me some Ambien. I take it most nights. Therapist : After about 4 days without the cocaine, what happens? Client : I just feel I’ve proved what I need to prove and go back to using again. Therapist : Over the past year, when you have been taking cocaine daily, do you find yourself thinking about using the cocaine very much? Client : I have to admit that when I’m driving to work, I think about that vial of cocaine in my desk drawer. I try to put off taking any as long as I can, but I usually talk myself into taking some within an hour after I arrive. Sometimes I tell myself that I’m only going to do a line or two in the morning and maybe another line in the afternoon, but I find that I do a couple lines every hour through the day. During the times I’ve not used cocaine, I really didn’t think about it very
much, but when I start to use again, there it is, I’m thinking about using—pretty much like I had never stopped. Therapist : I wonder, have you noticed any changes in your moods over the past year and a half since you have been using cocaine daily? Client : Well, I have been a bit edgy, maybe a little abrupt with people at work. I think that feeling like that may have made the arguments with my husband worse. But I think we would have argued anyway. The thing I feel worst about is that I’m short with the children. I have two: a boy 9 years old and a little girl 7 years old. I used to enjoy playing games with them and helping with schoolwork. My job is really demanding, so I work late many nights. I’ve tried to spend as much time as I can with the kids, but I just lose my temper with them so easily. Sometimes I think they avoid me. And my son has started to have some problems getting into fights at school. I guess that has to do with all the fighting George and I do at home. Therapist : Let me make sure I understand everything you’ve told me. Over the past 5 years, you have used progressively more and more cocaine, going from occasional use at a party to using 8 or 10 times every day. You have tried to stop using cocaine on several occasions but can only manage to stay cocaine free for about 4 days. When you stop using, you have some withdrawal symptoms: fatigue and frightening dreams. You have medicated the bad dreams by taking Ambien. You think about using cocaine a good deal and have tried to limit your daily use but with little or no success. You said that since you have been using cocaine daily your moods have changed; you feel edgy and irritable a lot of the time. This has led to you being abrupt and short with people at work. You also seem to have some sense that these changes in your mood have contributed to your marital problems and are causing you to have some fairly painful problems with your
children. Did I miss anything? Client : No, that’s about it.
Therapist : I want you to know how much I admire your willingness to talk so frankly about your life and your use of cocaine. I know it isn’t easy, and I want to thank you for being so honest with me about some very personal problems. I wonder, after our discussion, does anything occur to you in terms of your use of cocaine or any other part of your life? Client : Well, whether I’m addicted or not to cocaine, it’s a problem and I need to figure out how to do something about it. Therapist : I’m glad to hear you say that. Tell me, using a scale of 1 to 10, with 1 being no problem at all and 10 being as bad as it can possibly be, how serious a problem would you say your cocaine use is? Client : Probably about a 6. Therapist : Great. Recognizing that you are 60% of the way to the problem as being as bad as it could be is an important realization. Can you tell me why you didn’t say a 3 or 4? Or an 8 or 9? Client : Because of what’s happening with my family. At work, I’m a star, but at home I’m flunking out with my marriage and my children. Oh, what the hell, things aren’t so great at work, either. I can’t concentrate and motivate people like I used to. Something has to change. It would be a 9 or 10 if I lost my job along with my family.
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