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440 – Addiction Case Study
Using the PACER Method
Counselor Toolbox Podcast Episode 440
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director,
Podcast Host: Counselor Toolbox and Case Management Toolbox

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– Review a case study using the transdiagnostic, transtheoretical PACER approach

– As they say on Law and Order…
– The following story is fictional and does not depict any actual person or event.”
– John is 37 years old and presents for marijuana use as a requirement of his probation. He has a wife and 2 kids, 4 and 9.
– Sleep
– On an average night how much sleep do you get- 6 hours
– On an average night how many times do you wake up- __not often
– After an average night’s sleep how do you feel- Tired ___ Okay __x_ Energetic ____
– When you wake up feeling refreshed, how much sleep do you get- 8+
– Sleep hygiene self assessment.
– Nutrition
– Using a free app like SparkPeople, track your nutrition for a week.
– Which nutrients do you get less than 75% the full RDA- D, Calcium, potassium
– Which nutrients do you get less than 25% of the RDA- None
– When was the last time you had a full panel blood test to examine your kidney and liver function, thyroid and vitamin D levels- ___- months
– Describe your eating habits: I eat a lot of fast food and meat
– Do you eat due to stress or for comfort when you are upset- yes
– Do you drink at least 64 ounces of noncaffeinated, nonalcoholic beverages each day- No
– How much caffeine do you have on an average day- (100-150 mg/8oz of regular coffee; 35-50 mg/8oz of soda) 300 mg

– Nutrition
– How much nicotine do you have on an average day- (1 mg/1 cigarette; 6-24mg/vaping cartridges, 100mg/cigarillo) __200mg___
– Are you currently over or under fat- (Note: People can have a lot of muscle and not be unhealthy) _yes I need to lose about 30#____
– Have you recently had any problems with excessive thirst or hunger- __no
– Do you have problems with hypoglycemia (your blood sugar dropping)- _no
– Has your doctor tested your blood sugar lately (fasting blood test)- __no
– Do you mainly gain weight around your belly- __yes__
– Referral to PCP for physical to include nutritional evaluation, hormone evaluation and possible addition of multivitamin to address nutritional deficiencies.
– Pain
– Do you have any chronic pain- __no__
– If so what causes it-________________ How long have you had it- ____
– What makes it worse- ___________
– What makes it better- _____________________
– How has it impacted your mood/relationships/energy/sleep/self-esteem-

– Exercise/sedentariness
– Do you exercise- ____no______ If yes, how often and for how long- _________
– How is your energy, mood and appetite after you exercise- ___N/A________________
– Do you sleep better on days you exercise- __N/A___ Does muscle soreness make it harder to sleep- __N/A___

– Energy
– Which best describes your average energy level Low___ I can get through the day_x__ Great! ___
– Have you had your thyroid levels tested lately- __N__ If so were they in normal range- __-__
– Using a pulse ox monitor: What is your resting heart rate- __75_ What is your O2 saturation- __98___
– Do you have high blood pressure- _Y__ (medicated) Heart conditions- _N____ if so, what

– Libido/Sex hormones
– How is your sex drive- Low __ Good _x__ Incredible__
– Has there been any change in your sex drive- __Y___ If so when and what caused it- ____-__
– If you are over 45 have you had your sex hormone levels tested in the past year- ___N___
– How often do you engage in sexual activity- ___1-2x / week

– Do you tend to feel on edge and startle easily- ___N___
– Do you have a history of trauma- ____N___
– Do you have any autoimmune issues/inflammatory conditions like psoriasis, rheumatoid arthritis, Chron’s disease, lupus etc.- ___N_
– Have you ever had a concussion or other traumatic brain injury- ___N_____
– How often do you have headaches- ____Y__ What triggers them- _stress_
– What helps them go away- ______neck massage or ice/heat___
– Do you ever see spots or floaties when you get a headache- Y__
– Do you get migraines- ___N_____
– How often do you drink alcohol- _daily_ What do you drink- Beer/wine _X_
– How many drinks do you have in an average week- __2-3/wk
– Do you gamble or play the lottery- __Lottery___ How much money do you spend on it each week- ___$20____

– For each of the following feelings, identify how often you feel it each week, what triggers it and what makes it better.
– I feel happy 0-3 days a week __3__ 4 or 5 days a week __ More than 5 days a week __
– What 5 things help you feel happy- ___my kids, my wife, friends_
– I feel sad or depressed 0-3 days a week __0__ 4 or 5 days a week ____ More than 5 days a week ____
– What triggers it- NA
– What helps you feel better- NA
– I feel stressed or overwhelmed 0-3 days a week __X__ 4 or 5 days a week ____ More than 5 days a week _____
– What triggers it- ___Work, my kid struggling in school and being [oppositional] about doing his homework, probation, getting used to being “out”
– What helps you feel better- __Watching TV and smoking
– I feel anxious or worried 0-3 days a week _0_ 4-5 days a week _ >5 days a week ____
– What triggers it- __
– What helps you feel better- ______
– I feel angry, resentful 0-3 days a week __0_ 4 or 5 days a week __ >5 days a week
– What triggers it-
– What helps you feel better-
– I feel guilty 0-3 days a week _1_ 4 or 5 days a week __ >5 days a week
– What triggers it- ___I feel guilty that I was in jail for the past year and wasn’t able to be there for my kid.
– What helps you feel better- ___-_____

– In the past year, I have experienced the following losses which caused me to feel grief: None
– What stressors are currently present- __Trying to not violate probation, adjusting to being back with the family, son’s behavior
– What makes son’s behavior better- When I spend time with him
– What does he like to do- Play basketball at the park
– What is different when you are happy- I can smoke as much as I want and people leave me alone
– How long does it take for you to calm down after you get upset- _20-30min.
– What helps you calm down- __smoking, distracting myself___

– How is your attention/concentration- ___awful___
– Have you ever been diagnosed with ADHD- _N____
– Has there been a change in your ability to concentrate lately- _N__ How long- ___6 months___
– If so, what is causing it- __lack of sleep- Stress- I don’t know.
– Does it seem to be taking longer to process information- _Y_
– How is your memory- __Good______ Have you been more forgetful than usual- ___N_____
– If so, when did your forgetfulness start- NA What is causing it-
– When you think about yourself, your life, the world, other people, do you tend to feel angry, suspicious or hopeless- ___Y___
– If yes, have you always felt this way or did something happen to change your feelings- __Started watching the news and spending time around people__

– Negative self-talk
– Do you frequently judge or criticize yourself- _N_______
– Do you hold yourself to a higher standard than you hold other people- ____N______
– Do you think you are lovable/likeable only if you are perfect (or almost perfect)- ___N_______
– Where did you learn your negative self talk- __N/A

– Pay attention to your thoughts for a week. Place a check by the thinking errors which are most common for you and contribute to your unhappiness.
– All or none thinking Find Exceptions
– Assuming/Jumping to conclusions without all the facts Get the facts
– Focusing on a small aspect instead of the bigger picture Consider alternate explanations
– Expecting life to be fair
– Taking things too personally Consider alternate explanations
– Taking something bad and blowing it out of proportion (catastrophizing)
– Focusing on the negative and ignoring the positive
– Expecting people to be able to read your mind Evaluate how you communicated what you wanted and practice assertive communication
– Assuming you know what others are thinking. Evaluate your evidence and get the facts.

Educate about cognitive distortions and interventions. Provide worksheets to address CDs.

Cognitive: Hardiness
– Time management
– How effective are you at managing your time- ___Good __
– Do you often take on too much and feel overwhelmed or rushed- No
– Are you a perfectionist- __N___ If yes, how does that impact your mood, sleep and relationships-
– Do you procrastinate- __Y__ If yes, how does that impact your mood, sleep and relationships- __I tend to get irritable when I have something to do that I am procrastinating then irritable when I feel rushed.
Develop a schedule that includes the “must dos” delegates and simplifies when possible.

– Do you feel safe most of the time- _____y___ If no, where do you not feel safe and why-
– What helps you feel safe- __My dogs. My neighborhood.__
– Are you able to have peace and quiet when you want it and when you sleep- ___No_____ If no, what can you do to reduce unwanted noise- Headphones
– During the day are you able to access natural light, or at least a really bright working area- ___Yes_
– When you sleep, are you able to make your room totally dark or block out the light- _Y_
– Do you eliminate blue light from television and electronic devices at least 2 hours before bed- ___N__
– What smells are you regularly exposed to-
– Noxious/unpleasant/irritating _asphalt and roofing tar__
– Triggering (reminds you of something unpleasant) __musty smells (old buildings) remind me of jail
– Happy/relaxing/energizing __barbecue, home cooking
– Are you able to keep your environments at a temperature you find comfortable- __No, trying to keep utility bills down___
– Do you feel you are capable, lovable and deserving- _y____ If not, why not- ___
– Do you have healthy relationships or regularly fear abandonment- ____Healthy overall______
– Can you effectively identify and communicate feelings and thoughts and get your needs met- ___y_____
– Do you have a social support system that can provide practical assistance and emotional support- __practical assistance, yes…emotional support not as much___

Addiction Specific Questions
– Acute Intoxication and/or withdrawal: Can be managed in outpatient
– Biomedical complications impacting recovery: None
– Emotional, behavioral and cognitive conditions: Stress and anxiety that is self-medicated with cannabis and nicotine
– Readiness to change: Action due to wanting to stay out of prison
– Relapse/continued use potential: High
– Recovery Environment: Significant other smokes pot, friends smoke pot. Won’t smoke in front of kids
Addiction Specific Questions
– Relapse Prevention
– When you are not using what is different
– Kids are around
– I am at work
– I am in jail
– How do you deal with stress and cravings in those situations-
Addiction Specific Questions
– Emotional: Relief to be off probation
– Obstacle: Anxiety/stress
– Mental: Belief that I can stay clean until I get off papers. I will probably be able to concentrate a little more
– Obstacle: Knowledge of ways to defeat drug tests
– Physical: More energy/less fatigue
– More anxiety
– Social: Be able to be there for my kids.
– Obstacle: Friends use
– Environmental: May be able to move into a better place once I’m off probation
– Obstacle: Lots of drugs in the neighborhood
Initial Tx Plan goals
– Referral to PCP for hormone evaluation and nutritional assessment
– Tagamet lowers T. which can increase cortisol and anxiety. Cannabis increases T which lowers cortisol and anxiety.
– Vitamin D deficiency can lead to or worsen anxiety and hypertension
– Calcium deficiency inhibits production of serotonin
– Potassium helps regulate serotonin
– Remove all cannabis from the house
– Begin helping Sam with his homework each night and taking him to play basketball after dinner if he does his homework
– Learn about cognitive distortions and start addressing one each week.
– Learn distress tolerance skills to teach your son
– Make a list of things to do when you are feeling stressed besides smoke

Initial Tx Plan goals
– Specific Worries for Discussion (Beginning Week 1)
– Getting through probation without violating
– One day at a time
– View it as a challenge
– Psychological flexibility
– Getting my son’s behavior under control
– Positive reinforcement
– Potential LD assessment
– Not smoking pot even though my wife is smoking
– Finding other “rewards” for not using
– Talking with her about not using at the house
– Dealing with having to stay at this crappy job for the next 18 months
– Mindful focus
– Positive review and forecasting

– PCP assessed hormone levels and determined levels to be on the extreme low end of the normal range. No intervention
– Has lost 12# since starting to play basketball with his son in the evenings, reduced blood pressure medication.
– Arguing less with his wife since his son is behaving better, although she is still smoking, just not at the house.
– Has not used, but is still not intrinsically motivated to quit.

– Substances are often used to self medicate
– Helping him identify previous coping strategies and learn new distress tolerance skills (to teach his son) is helping with his stress at home and at work
– Engaging in activity with his son leaves less time to use
– Marijuana alters not only brain chemicals, but also hormones.
– Marijuana can stay in the body for a long time since THC is stored in the fat.