Cutting, Binging, Drinking: A Case Study

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Cutting, Binging, Drinking: A Case Study

By Jennifer Guttman PsyD 01/28/16

An experienced psychologist helps a troubled young woman become "the captain of her own ship."

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Problematic substance use rarely occurs in a vacuum. Much more frequently, clinicians are faced with a variety of presenting problems, both intrapsychic and behavioral, and are required to carefully balance safety concerns while at the same time working on deep underlying conflicts and unhealthy responses to life’s many challenges. In the past, it was common for clinicians, when confronted by substance misuse in a client, to refer the client for substance abuse counseling, but today many experienced clinicians realize the wisdom in continuing to work with clients who present with complex clinical presentations in which substance use is but one of a variety of significant clinical issues. Here, Dr. Jennifer Guttman skillfully balances several pressing problems in helping a young woman achieve a more autonomous and stable sense of self…Richard Juman, PsyD

What happens when a child isn’t taught the skills he or she needs to cope with the stress encountered in life? What if he or she doesn’t learn to express emotions verbally? What happens to a child who grows up in a family where everything is supposed to appear perfect to the outside world?

Despite having good intentions, in today’s world, parents make too many decisions for their children. When they do this, they backhandedly make two mistakes. First, they undermine their child’s ability to trust in his or her own decision-making skills, and second, they fail to allow their child to learn adaptive coping mechanisms for when the pain of not succeeding is experienced.

I met Chloe about two years ago. On the outside, she was a beautiful, intelligent, 16-year-old, living a seemingly perfect life. Behind closed doors; however, the need to live up to her parents' high hopes for her had caused her to become depressed, cut herself, and start a conflicted relationship with food.

What she did not reveal at the time was that she had also been struggling with alcohol since she was 12. The drinking started with the consent of her parents on a family trip to Europe, and she was noticeably drinking quite a bit. Her behavior was the source of family jokes, but was not curtailed by the adults. From 12 onward, she continued to drink at family gatherings and hid secret indulgences in alcohol from family members.

A senior at a private high school, Chloe was going through the motions preparing to go to college; however, in my professional opinion, she was by no means emotionally ready. Her parents were overjoyed by her acceptance to one of the top 10 universities in the nation, and disregarded my urging to defer her admittance, permitting her matriculation.

Over the course of a mere six months of therapy before leaving for college, Chloe had begun a torrid love affair with a girl with whom she shared a passion for modern dance. The relationship was co-dependent and controlling for both parties; and depleted Chloe’s already scarce emotional resources. As college was looming, therapy was mainly focused on strategies to eliminate her cutting behaviors, as well as develop the coping mechanisms needed to separate from her girlfriend.

Despite a remarkable ability to maintain high academic scores, a testament to her intellect, the first semester at college marked an intensification of emotional issues and maladaptive behaviors. This was exemplified by transferring her co-dependent needs onto a boy at school, binging and purging, and alcohol and marijuana abuse. 

Chloe reported increasing self-hatred as her risk-taking behaviors continued, yet her healthy side did not surrender. Despite repeated fleeting thoughts to cut herself since entering college, she never followed through with the behavior.

Toward the end of the first semester, Chloe and her boyfriend spent a week in his bedroom smoking marijuana. At the end of the week, he hospitalized himself, fearing his own substance dependence problems; however, Chloe did not. After his hospitalization, he went back to his previous substance use.

Instead of following his lead, Chloe returned home toward the close of the first semester, with one final exam to complete. With little resistance she agreed that going back to school was not “psycho-emotionally” safe, and of course her parents complied.

At this point in her life, she acknowledged that she had an eating disorder and that her mental health issues were interfering with her functioning; however, she still did not believe she had a substance abuse problem. Regardless, she complied with my request to attend 12-step meetings, and I recommended that she and her parents attend Al-Anon, given the serious substance abuse on both her mother’s and father’s sides of the family. She also agreed to meet with a dietician and participate in therapy twice a week.

I don’t require that my clients with problematic substance use attend 12-step meetings because I believe that attendance should be a choice. However, I have been much more effective in helping clients achieve sobriety with stamina when therapy and support groups occur interdependently. In my experience, doing one without the other is less effective and relapse is more likely. 

Chloe found AA more helpful than Al-Anon. She chose to attend regular meetings, despite still not believing she had a substance abuse problem, and found a sponsor her age with whom she connected. Of her own accord, she decided to completely stop drinking for three months. She made less progress with the dietician and binging/purging continued to be an ongoing problem.

Therapy was focused on assisting in the development of a core-self and an ability to make healthier life choices. The following therapeutic steps were taken to fulfill these goals.

Becoming Acquainted With Her Authentic Self

Chloe had been on a path to study chemistry since that’s what she felt would please her parents. Her real passion; however, was writing, in particular poetry. She was terrified of becoming a writer for fear of failure. Initially, desensitization was used to get her back to writing poetry, such as journaling, followed by submissions to poetry competitions and eventually taking creative writing classes at one of the highest ranking colleges in the United States. Feeling like she could write again helped build her self-esteem and sense of self-worth.

Chloe also had a love for music that she had stopped pursuing. I encouraged her to seek out and attend concerts of all types both on her own and with peers, to reacquaint herself with the true happiness that music brought her. It became an important exercise to find healthy activities that made her happy without chemical interference.

Stopping Co-dependent Relationships

Over the course of her life, Chloe had moved from one co-dependent relationship to another. First, she had co-dependent relationships with her parents, always seeking to please them at the expense of her own desires. From there, she moved on to co-dependent relationships with friends, where she became the problem-solver, thus indispensible and unlikely to be abandoned. Next, she attempted to solve her girlfriend’s mental health issues by controlling her behavior. Again, she demonstrated her desperation to be loved and in doing so, she held on to relationships in very unhealthy ways.

Finally, in her relationship with her boyfriend, after she left school, she desperately tried to guide him into sobriety while also trying to make sure he completed his schoolwork so that he would graduate on time. She became anxious and depressed whenever she felt she was not in a position to be able to control the outcome of his actions. The state of her mood became dependent on both his emotions and his behavior.

Chloe had to make her own choice as to whether this relationship continued to be healthy for her. A lot of our time in therapy was spent talking about whether she could tolerate a hiatus in her relationship. The benefit of a hiatus would be two-fold: it would give her the opportunity to practice being alone for the first time, as well as prove that she could cope without controlling his behavior. Armed with a clearer perspective, she could return to the relationship to decide if it was healthy for her or not. 

She did, in fact, decide to initiate a three-month hiatus, despite it being an extremely painful decision for her. She is now five weeks into the separation and has shown significant growth both internally and with social relationships. No one can predict what choice she will make when the three months are up, but based on the strides she has made in just these five weeks, it is clear that the journey will be more important than the final decision.

Learning Emotional Language:

Chloe grew up in a family of non-communicators. She lacked the language to describe her feelings and had a complete inability to manage or negotiate conversations that became emotionally draining.

As a result, she would initially use substances to suppress her emotions. Once she became substance-free, she transferred this need to “numb” herself to food. Food also became a substitute for expressing her emotions and, as a result, she engaged in emotional-eating behaviors. Whenever Chloe experienced an emotion she could not identify, she would be triggered to binge. Frequently, this binging would lead to a compulsion to purge.

The emotional language Chloe possessed to describe her feelings was limited to “weird” and “anxious.” First, we put a moratorium on these “go to” words and phrases; and then we generated a lengthy list of emotional words Chloe put into the notes folder of her phone. Whenever she had the urge to binge, she was to assume that she was experiencing an emotion, review the list and either journal about her mood or talk out her feelings with whomever she was engaged.

We also strategized ways in which she could assertively, but mindfully, end conversations that were becoming emotionally heated for her. The goal was for her to feel she could better “captain” conversations as opposed to always being a “passenger” at the mercy of waves of emotions.

As Chloe improved her ability to express her emotions and assertively manage conversations, her binging behavior began to decrease. Concurrently, there was a rise in her self-esteem and core strength.

Social Skills:

Throughout her life, Chloe had difficulty engaging with peers. As a result, when she started indulging in alcohol through middle school, this became an outlet to manage her social self-consciousness.

Needless to say, the initial three-month hiatus from substances posed a serious threat to her ability to socialize. At first, she isolated herself from peers, preferring to watch Netflix alone or with her mother. When she did venture out, it was often painful and resulted in binge eating to manage her self-conscious and self-denigrating thoughts.

For a while, it felt like she was just holding out for the three-month substance moratorium to pass so she could return to alcohol and marijuana. She was continuing to refuse to acknowledge that she was using substances as a coping mechanism, to ease her social anxiety and to compensate for her concurrent social skills deficits.

Shortly before the three months were up, she went to visit her boyfriend (this is before their relationship hiatus) on the campus of the college from which she was on medical leave. Since this visit occurred during the substance moratorium, she decided to try to go with him to a party and not drink. She believed that she shouldn’t have a problem just being around alcohol. Within a short period of time watching others drink, she became angry, resentful and hysterical.

Later, she described to me a battle raging within her. She was so close to being through with the three months, so “why not drink?” On the other hand, what did it actually say about her relationship with alcohol if every time she was around it she felt like she had to have it or risk falling apart? Information from three months of AA meetings was flooding her mind, and she told me she fled the party in tears.

That night Chloe decided she needed to make sobriety a lifestyle choice.

While this was a major breakthrough, it posed a whole new set of issues. How would she tell people that she didn’t drink anymore? How would she forge friendships without using alcohol as a basis for getting to know people and for making herself comfortable in social situations?

We used gradually desensitizing steps; she first worked with peers she had a relationship with one-on-one in coffee shops or at the movies. Then, she worked her way up to forging new friendships with people through AA meetings. Next, she worked on practicing in group interactions with sober friends. From there, she practiced making new friends with peers who did drink, but with whom she could interact during the day in a sober environment with full transparency about her sobriety.

Finally this week, I’m proud to say she was able to go out in a group with new non-sober friends in a sober environment. She is aware she is far from being ready to interact in any venue where alcohol is readily available; however, the social progress she has made and her motivation to make these lifestyle changes is a testament to her core strength of character.

Stopping Errors In Her Thoughts:

Chloe engages in a lot of thinking errors, reflective of self-denigration. These include the following maladaptive thinking types.

Fortune Telling - expecting bad things to happen

Chloe was always anticipating the worst in situations. Now she is learning to look for the evidence in a situation that would indicate that anything bad is going to happen. She is recognizing that there is almost always no real evidence to back up her negative thought process.

Magnification – making small negative events very big in your mind

This caused Chloe to make assumptions about what people thought about her, her behavior or her performance. In this way she registered only negative experiences in catastrophic proportions. We worked on self-talk to balance this.

Minimization – ignoring positive events

Chloe is learning not to filter out positive comments people make about her by dismissing them. Instead, she is now forcing herself to say “thank you” when she receives a compliment. This is a much harder task for her than it may seem on the surface.

All or None Thinking – thinking in absolutes with no grey areas

Chloe has a perfectionistic belief system when it comes to her body, work performance, etc. We have been working on how she needs to accept that perfection is an unattainable ideal like a dog chasing its tail. She is learning to work at finding her best, most authentic self. In finding that, she will hopefully attain peace and satisfaction for how hard she has worked toward self-development.

Chloe is a woman with so many attributes: integrity, courage, strength of character, will, determination, intellect, beauty, resolve, sense of humor, social responsibility, creativity and generosity. Maladaptive behaviors have kept some of these strengths hidden from the world. Each day I watch as she sheds old habits and develops healthy behaviors. As she does, more of her inner light radiates. I can only begin to imagine how bright this light will eventually shine. 

Jennifer Guttman, PsyD, is a New York and Connecticut licensed clinical psychologist with practices in Westort, CT and Manhattan. Along with 20 years in private practice, she has supervised and mentored psychologists and social workers as well as lectured on the use of cognitive-behavioral strategies in various treatment settings. She is published in the area of Anger Control.

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