Faith Johnson CNS 765: Assignment 7.

CNS 765Final Case Study: 28 Days

In the film 28 Days, the main character is a young Caucasian female named Gwen who is

an alcoholic and substance user. She uses Vicodin that has not been prescribed to her in times

where she feels overwhelmed and anxious. Gwen lives in the city with her boyfriend, Jasper,

who is also an alcoholic. Gwen’s mother was also an alcoholic who passed away when Gwen

was a child due to an overdose. Gwen was raised by her aunt and her sister is the only family she

has, although that relationship is severely damaged due to Gwen’s drinking. wen has struggled

with alcohol for 15 years and begins drinking the moment she wakes up and gets out of bed. The

night before her sister’s wedding, she was out partying with her boyfriend, who both became

vastly intoxicated. Her actions the night before caused her to run 45 minutes late to her sister’s

wedding, in which she was a bridesmaid. During the wedding reception, Gwen and her boyfriend

had become intoxicated to the point where their dancing caused Gwen to fall into her sister’s

wedding cake, indefinitely damaging their relationship further. Her embarrassment of the

situation and her sister’s comment, “you make it impossible to love you,” (Topping & Thomas,

2000) caused Gwen to spiral and make poor decisions. As a consequence, Gwen’s driving under

the influence resulted in reckless driving and ultimately the destruction of property as she

crashed into a home. Due to her actions, Gwen was mandated by the court to complete 28 days at

a rehab center or go to prison.

To conceptualize Gwen’s case, the Sociocultural Model will be used. Since the

Sociocultural Model places an emphasis on influences outside of the self (i.e. familial and peer)

and being that Gwen’s mother had a history of substance use along with Gwen being in a

relationship where alcohol and having a good time are viewed as necessities, this model would

help bring insight into how Gwen’s past and those she is surrounded by influences and impacts
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her using. Gwen is observed feeling unlovable and unaccepted for her current lifestyle, which

has resulted in her and her sister having little to no understanding of each other. Gwen does not

see an alternative perspective to living and relies heavily on substances. At one point, Gwen

states, “there are addicts here who need cigarettes like they need air” (Topping & Thomas,

2000). Instead of pointing fingers at Gwen and encouraging her current behaviors, Gwen is

seeking help without expressing her need of help, which is where the utilization of a systematic

approach would be beneficial for her recovery. To begin helping Gwen in her recovery, it is

important to establish a foundation that aids in providing acceptance, guidance, and

acknowledgement of current and past behaviors.

Gwen presents with severe alcohol use disorder tendencies as evidence by: alcohol was

taken in larger amounts or over a longer period of time than intended, a great deal of time is

spent in activities necessary to obtain alcohol (clubs), craving or a strong desire or urge to use

alcohol, continued use despite having persistent or recurrent social or interpersonal problems

caused or exacerbated by the effects of alcohol, recurrent alcohol use in situations in which it is

physically hazardous, a need for markedly increased amounts of alcohol to achieve intoxication

or desired effect, and alcohol is taken to relieve or avoid withdrawal symptoms (American

Psychiatric Association, 2013). Gwen is observed as being rebellious with little to no desire to

change. During her first week at rehab, her boyfriend comes to visit her, sneaks her into his car,

and they leave the rehab facility, though Gwen knew there were consequences for leaving.

Together, they leave, get drunk, have sex, and then Gwen returns to the rehab facility. In

response to her actions, Gwen’s counselor refers her to jail at which time Gwen states, “I don’t

belong in jail, I don’t even belong here. I’m not like those people out there. I can control myself,

if that’s what I wanted I could. I can” (Topping & Thomas, 2000).

Faith Johnson CNS 765: Assignment 7.3

Gwen also meets the criteria for mild opioid use disorder as evidence by: craving or

strong desire or urge to use opioids, continued opioid use despite having persistent or recurrent

social or interpersonal problems caused by or exacerbated by the effects of opioids, and recurrent

opioid use in situations in which it is physically hazardous (American Psychiatric Association,

2013). Upon Gwen’s arrival at the rehab facility, the bottle of Vicodin she had carried with her

was taken from her. At which time, Gwen proceeds to make a phone call to her boyfriend

requesting that he sneak more in during his visit. To keep the Vicodin hidden, she placed the

bottle at the bottom of a tissue box. In one instance, following her sneaking out of rehab, she had

become so anxious that she frantically searched for the bottle in which she tried to take a pill but

instead ended up throwing the whole bottle out the window. Later, she decides to climb out of

her bedroom window in an attempt to retrieve the pills where she falls and becomes injured. It

was this moment that she realizes that something is wrong with her and states, “human beings

should be able to breathe, I can’t breathe. I don’t want to die” (Topping & Thomas, 2000).

Throughout this time, she experiences flashbacks of her past and partying.

During her first few days at rehab, Gwen met the criteria for alcohol withdrawal as

evidenced by: insomnia, nausea or vomiting, transient visual, tactile, or auditory hallucinations

or illusions, psychomotor agitation, and anxiety (American Psychiatric Association, 2013). As

noted above, Gwen experienced flashbacks/hallucinations of her past, including partying with

her friends and seeing herself talking to herself prior to making past decisions. For instance, as

Gwen was hanging from the tree outside of her window in an attempt to retrieve the Vicodin, she

had hallucinations of seeing herself standing in the window saying, “you know you’re screwed.”

She was also seen vomiting in the bathroom during her first night at rehab and tossing all night,
Faith Johnson CNS 765: Assignment 7.3

displaying difficulties falling and staying asleep. However, following her release from rehab,

Gwen no longer meets the criteria for alcohol withdrawal.

In co-occurrence to Gwen’s alcohol use disorder – severe diagnosis, she also displays

symptoms of posttraumatic stress disorder as evidence by: directly experiencing the traumatic

events, witnessing, in person, the event as it occurred to others, learning that the traumatic events

occurred to a close family member, experiencing repeated or extreme exposure to aversive

details of the event, recurrent, involuntary, and intrusive distressing memories of the event, and

dissociative reactions in which the individual feels or acts as if the traumatic event were

recurring (DSM-V, 2013). Gwen grew up in the home with her older sister and her alcoholic

mother, her father had left when she was very young. Throughout the film, Gwen is observed

experiencing flashbacks of her childhood and the trauma associated with living with a mother

who was an alcoholic. In these instances, Gwen’s adverse childhood experiences can be

observed. As a child, she would see her mother black out and become unconscious from drinking

so much, in which cases she would get in the floor with her mother and slap her in the face to

wake her up. For Gwen, this was nearly an everyday occurrence. Unfortunately, her mother’s

drinking took her life and Gwen’s aunt was the one to share the news with Gwen and her sister.

Gwen and her sister were alone with their mother when she passed away and thought that she

had just passed out again. Following this event, Gwen and her sister were taken to live with their

aunt. For Gwen, this was the beginning of a lifelong struggling.

In considering treatment options for Gwen, and taking her past into consideration, an

intensive outpatient program for a minimum of 14 weeks following her discharge from rehab

would be the starting point for treatment. Gwen will be referred to an SAIOP group where she

will continue to learn skills and techniques to remain abstinent from alcohol. Sessions will take
Faith Johnson CNS 765: Assignment 7.3

place three times per week for three hours each session. Continuation of a group setting will be

beneficial for Gwen as she is able to build relationships with those who are going through similar

experiences. The only life Gwen knew prior to entering rehab was a life full of partying, alcohol,

and drugs. An IOP group will help build upon the establishment of life outside of alcohol and

drugs and hold her accountable for her actions. It is clear that Gwen is seeking change, but she

has expressed feelings of being alone and unworthiness. She has also expressed that she is

searching for instant change/gratification, this is another area an IOP group would be beneficial.

Likewise, her boyfriend is toxic for her and does not see anything wrong with drinking all of the

time. In fact, he stated that he does not feel that adults can be happy without drinking. For Gwen,

this is not an environment that would encourage and support abstinence. In one instance,

following her boyfriend’s proposal, Gwen states, “I don’t need any more stories, I have enough

stories. I would like a life” (Topping & Thomas, 2000). An IOP group would assist Gwen in

establishing a solid foundation in working towards maintain abstinence before working to repair

relationships damaged by her choices.

Following SAIOP group therapy, Gwen will be referred to a step-down aftercare group

where she will attend 12 sessions to continue sole focus and monitoring of her abstinence from

alcohol. This aftercare group will ensure that Gwen is stable enough to remain abstinent before

working to begin treatment of her mental health issues. Following the completion of the 12

sessions of aftercare group, Gwen will be referred to a dual-diagnosis group where she will then

be able to begin treatment for her PTSD along with continuation of her alcohol use. It is apparent

that Gwen’s PTSD correlates with her alcohol use and both should be treated simultaneously.

Not only has Gwen seen her mother pass away in front of her but she also found her roommate at

rehab lying in the bathroom floor that had overdosed on a mystery drug. This incident caused
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Gwen to have flashbacks of seeing her mother on the floor. Gwen will continue in the dual-

diagnosis group for a minimum of 14 sessions along with individual therapy on an as needed

basis.

Eventually, Gwen will begin family counseling with her sister to work towards re-

establishing their relationship. It appears that Gwen’s older sister is the only family she has,

aside from their aunt that they have little communication with. Family therapy would help Gwen

and her sister work towards understanding each other’s side of the story. Gwen is observed

feeling like she does everything wrong, messes everything up, and is hard to love. Prior to

talking to Gwen, her older sister believed that Gwen used alcohol as an excuse to lose all self-

control and to indulge. However, towards the end of the film Gwen’s sister visits her at rehab

where she apologizes and shares with Gwen that she has always felt small around her because

she knew she had a gravitating force, was always noticed and thought that Gwen knew this all

along. However, she also shared that she realized that Gwen did not realize any of this and states,

“even a pain in the ass needs someone to take care of them. I didn’t do that, and I should have”

(Topping & Thomas, 2000). From there, Gwen shares that she never asked for the help and

apologizes for making things so impossible. Family therapy would build upon this conversation

and fill in the gaps where they are otherwise lacking.

To best work with Gwen, motivational interviewing will be utilized. Motivational

interviewing will allow Gwen an opportunity to gain effective listening skills while also learning

how to accept direction. It is important that Gwen make change by use of her own meaning for

change. Motivational interviewing will help Gwen to think for herself, discuss her own reasons

for change, and adapt skills to implement the change with little direction from others. It is

apparent that Gwen relies heavily on others and feels like her life has no direction. She has
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adapted a life of alcohol and sex and has no one to turn to aside from her boyfriend. Gwen needs

the support and encouragement to seek and maintain change, and motivational interviewing will

allow her to do this without strings attached. Over time, she will learn to live for and answer for

herself without the fear of being alone or like an outcast. For instance, during a session I may

would ask Gwen to create a list of reasons why she wants to change and live abstinent of alcohol.

From there, I would discuss the reason with her and then ask her to describe any pros and cons

related to each reason. I would provide her with advice to help direct her, but I would not directly

tell her what to do. Instead, Gwen would be encouraged to make connections between the

directions provided to her and the reasons for change she listed on her own.

For instance, upon being released from rehab, Gwen is having dinner with her boyfriend,

where she realizes that he is not good for her and her recovery. Instead of encouraging Gwen to

stay away from alcohol, he encourages her to re-engage with old friends who also offer her a

drink. In this moment Gwen states, “everything has to be different and that includes us. I’m

trying to change things; I’m trying to change me” (Topping & Thomas, 2000). Upon leaving the

restaurant, Gwen sees a horse and attempts a technique learned while in rehab. In this moment

she tells herself that, “I can’t control the little things and I just have to let go.” From there, Gwen

expressed an understanding that in order to change, it required her to start with herself and let go

of the things and the people that were not there to support her. Motivational interviewing will

branch off of this and continue encouraging Gwen to seek the little things in life, to go after what

is best for her and to let go of what is not. Gwen has just learned how to ask for help and

motivational interviewing will empower this new journey and confirm that asking for help is a

sign of strength that should be embodied. Along the way, she is bound to become lost and
Faith Johnson CNS 765: Assignment 7.3

confused, but motivational interviewing is a way to guide her without pushing her to make

decisions that are not of her own.

In regard to relapse prevention, the following techniques would be utilized with Gwen:

self-efficacy, coping, and acknowledgement of triggers. Self-efficacy would be used to help

Gwen build confidence in her own ability, to continue growing so that she is able to overcome

any obstacle she may be faced with. In order to overcome and remain abstinent, Gwen must learn

how to be confident in herself and no longer rely on others. Once self-efficacy has been

introduced, coping skills using cognitive behavioral therapies will be put into play. There is no

doubt that Gwen will be placed in situations where her abstinence will be tested. However, with

the use of CBT to teach Gwen coping skills, she will be more likely to overcome. Similarly, the

acknowledgment of triggers will help Gwen to adapt an understanding of what her triggers are so

that she is better able to avoid them. In return, she would have coping skills to fall back on in

place of relapsing. In session, Gwen would be asked to create a list of situations in which she

would be most prone to relapse. From there, she would be asked to create a list of coping skills

that she could utilize in place. Following the creating of these lists, we would engage in a

discussion about why the situations listed are triggers for her and the importance of utilizing

coping skills learned. After all, according to the Marlatt model of relapse, is coping skills are

ineffective, the level of self-efficacy and overall positive outcomes is greatly decreased.

With all of this in mind, treatment goals for Gwen would begin with continued abstinence

from alcohol, the development of positive and reinforcing coping skills, acknowledgement of her

past and readiness for her future, understanding of her childhood, and the re-establishment of a

relationship with her older sister. Progress will be measured by how well she does with

abstaining from alcohol, how well she adapts to change and overall eagerness to engage in
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therapy, and her acceptance level. For instance, one thing she was taught while in rehab was

before getting into a relationship, get a plant and keep it alive for a year, then a dog, and then a

relationship. If she were able to be successful at maintaining a plant and a dog, then she would

have an understanding of her readiness to present her new self to a new relationship. Gwen will

be given homework assignments each week that will help measure her progress, one of which

will be to keep a daily log of her moods and any situations where she felt might have led her into

using. She will also be encouraged to find a hobby that she can engage in at least four times per

week. Throughout treatment, Gwen will be challenged to overcome one obstacle at a time but

will be frequently reminded that she is not walking this journey on her own.
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References

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders

(5th ed.).

Topping, J. (Producer) & Thomas, B. (Director). (2000). 28 Days [motion picture]. United

States: Columbia Pictures.