Eliciting and Amplifying Strengths DRY

These questions from Solution-Focused Therapy and Motivational Interviewing could be used to find out more about Augusten's strengths and resources and how these could be used to tackle his substance abuse.


1. How were you able to have such a successful career, despite dropping out of school so young and only having a GED? What qualities did you draw upon to reach your level of employment? How did you convince your employer that you were able to do this kind of work? How have you been able to be a success?
2. How were you able to survive the kind of childhood you had and rise above it?
3. The pain of this problem can affect many areas of your life. What aspects of your life are still intact despite the problem, such as relationships, hobbies, interests, employment, academics?
4. When have you been able to give up drinking or drugs, or cut down your use? How were you able to do that?
5. How have you been able to attract the friendships you have? What about you would they say you have going for you? How are you able to rely on them for support?
6. Motivational interviewing- What do you get out of drinking/What do you like about it? What are the not so good things?
7. What will your life look like when you are past this? What will you be doing/What will you be saying?/How will other people react to you?


1. How were you able to have such a successful career, despite dropping out of school so young and only having a GED? What qualities did you draw upon to reach your level of employment? How did you convince your employer that you were able to do this kind of work? How have you been able to be a success?
2. How were you able to survive the kind of childhood you had and rise above it?
3. The pain of this problem can affect many areas of your life. What aspects of your life are still intact despite the problem, such as relationships, hobbies, interests, employment, academics?
4. When have you been able to give up drinking or drugs, or cut down your use? How were you able to do that?
5. How have you been able to attract the friendships you have? What about you would they say you have going for you? How are you able to rely on them for support?
6. Motivational interviewing- What do you get out of drinking/What do you like about it? What are the not so good things?
7. What will your life look like when you are past this? What will you be doing/What will you be saying?/How will other people react to you?

BIOPSYCHOSOCIAL RISK AND RESILIENCE ASSESSMENT FOR DRY

Onset of the Disorder
Biological
RISK
• Family history of substance abuse (father)
• Family history of mental disorder (mother)
• Male
PROTECTIVE
Good Physical health

Psychological
PROTECTIVE
Lack of co-occurring disorder

Social
RISK
Physical abuse from father
Ongoing sexual abuse starting at 13
Maternal abandonment
Gay

PROTECTIVE
Was able to obtain his GED and have a high paying job

Course of the Disorder

Biological
PROTECTIVE
Good physical health

Social
RISK
Lack of family support
Gay

PROTECTIVE
Boss and co-worker are supportive of intervention
Has close relationships with friends
Continues to hold a well-paying job
Access to specialized treatment for people who are gay

Rationale for DSM Diagnosis for DRY

Axis 1: 303.90 Alcohol Dependence with physiological dependence

Augusten has displayed a maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by the following symptoms, occurring in the last year:
1. tolerance: a need for markedly increased amounts of the substance to achieve intoxication or desired effect (one liter a day of whiskey).
2. withdrawal (he is given Librium while detoxing to avoid physical shock)
3. the substance is often taken in larger amounts or over a longer period than was intended time (begins with intention to drink until midnight but keeps going until bottle is finished)
4. there is a persistent desire or unsuccessful efforts to cut down or control substance use (even when he has to attend to work responsibilities, Augusten is unable to stop his use)
5. a great deal of time is spent in activities to obtain the substance, use the substance, or recover from its effects (drinks every night and is unable to meet work responsibilities due to lack of sleep and hangovers)
6. important social, occupational or recreational activities are given up or reduced because of substance use (occupational problems due to use, threatened with job loss)
7. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (drinks even though he is allergic to alcohol and has to consume large amounts of Benadryl to prevent a reaction from alcohol)
• With physiological dependence is specified due to the evidence of tolerance and withdrawal

Axis II: V71.09 No Diagnosis
No evidence, at least in DRY, of a personality disorder, although this could be assessed further.

Axis III: Allergy to alcohol

Axis IV: Problems with Primary support: Poor relationship with parents who seemed to have abandoned him as a child; mother now suffers from a stroke

Problems with the social environment: enabling drinking friends, living alone, friend with terminal illness

Occupational problems: is threatened with job loss if he does not participate in treatment

Axis 5: 50

Augusten shows a serious impairment in social and occupational functioning, which indicates a GAF of 50. This would be lower if he did not continue to have a job that provides adequate income.

MULTI-AXIAL DIAGNOSIS FOR DRY

Axis 1: 303.90 Alcohol Dependence with physiological dependence

Axis II: V71.09 No Diagnosis

Axis III: Allergy to alcohol

Axis IV:
Problems with Primary support: Poor relationship with parents who seemed to have abandoned him as a child; mother now suffers from a stroke
Problems with the social environment: enabling drinking friends, living alone, friend with terminal illness
Occupational problems: is threatened with job loss if he does not participate in treatment

Axis 5: 50

Grateful acknowledgement to the contributions of Will Hayden, Erika Paz, and Dallas Williams.

DRY by Augusten Burroughs: Case Study

DRY is Augusten Burroughs’ second memoir and the sequel to RUNNING WITH SCISSORS. Augusten’s parents divorced early in his life. His father was a professor, who abused Augusten physically when he was drunk. Augusten described an incident at nine years old in which he had to jump out of the car his father was driving because his father threatened to crash the car and kill his son. On another occasion, his father burned Augusten on the bridge of his nose with a cigarette.

When he was 12, his mother sent Augusten to live with her psychiatrist. The adopted 33-year old son and former patient of the psychiatrist raped Augusten at 13, and he was sexually abused for the next three years by this man. By the time Augusten left the psychiatrist’s house at age 17, he had little formal education, having dropped out of school after sixth grade. He instead obtained his GED. Despite this lack in education, Augusten was able to work his way up, by his mid-twenties, to a high-paying job in the advertising industry earning $200,000 as a Manhatten copywriter.

Augusten had his first drink at age 12 when he drank a bottle of red wine. Between the ages of 13 to 17, he smoked marijuana and drank alcohol once a week. At age 18, he drank nightly, always to intoxication (five drinks or more). Between ages 19 to 20, he was drinking 10 drinks per night. He also used cocaine once every six months. At age 21 to 30, he was drinking a liter of Dewar’s a night and using cocaine once a month.

When the book opens, Augusten describes being unable to limit his drinking. “I would plan to drink only until 11 or 12, but it would never actually happen. The few times that I didn't drink for a night, or alcohol wouldn't have the desired effect of numbing, I'd be overwhelmed with emotions, usually grief, and it was just really upsetting. It freaked me out because I felt like a wreck inside, like my structure was rotting and alcohol was sort of the glue holding me together. In a lot of ways, I felt like it was the only thing allowing me to function. In fact, it was the opposite. I was able to function despite it.” Augusten drinks even though he actually has an allergy to alcohol, necessitating his taking several Benadryl tablets before imbibing.

Augusten’s apartment is filled with hundreds of empty Dewar’s bottles because he is embarrassed to be seen (or heard – the clanking bottles) disposing of them. Because of the bottles, he never invites anybody to his apartment. Augusten’s support network comprises his best friend Pighead, an investment banker dying of AIDS; his drinking buddy Jim, a coffin salesman; and Greer, his tightly-wound colleague. His mother had a stroke 10 years prior, which left her paralyzed on one side and wheelchair-bound. Augusten doesn’t visit, although e-mails daily. Although he feels pressure from her to take care of her, he believes, after her giving him away to be abused, she does not deserve more than this.

His alcoholism begins to interfere with his performance at work. He starts missing meetings, shows up late, and smells like alcohol. Eventually, his co-workers stage an intervention. His boss and his partner at work, Greer, propose that he go to rehab or risk getting fired. He agrees to go to a gay rehab clinic in Minnesota, the Proud Institute, for 30 days. There, he is given Librium while he is detoxing to prevent him from physical shock from the alcohol withdrawal.

After 30 days at Proud, Burroughs returns to New York and takes his recovery seriously, throwing himself into his work with renewed vigor, and attending Alcoholics Anonymous meetings and outpatient therapy. He is clean for awhile, but Pighead's illness and a relationship with a man Augusten meets at A.A. who is addicted to crack cocaine cause him to relapse. He not only drinks but now starts using crack cocaine and puts himself at risk by going to a “crack house” one night. Despite hallucinating spiders, he retains his employment, although it takes him two years to return to A.A., where he recovers once more.

Critique of the DSM and Biomedical Perspective

Although Prozac lifted Lauren’s depressive and obsessive-compulsive symptoms, antidepressants generally are not as effective for everyone. Indeed, they may work better for anxiety than depression. About 68% of the improvement in depressive symptoms is from the placebo effect; additionally, only a third of people remit from depression with their first course of antidepressants, and half experience a 50% reduction in symptoms. In sum, although people respond to antidepressants, the effect of medication for depression is not spectacular. A recent meta-analysis showed that only for severe depression were antidepressants worth the risk-benefit ratio.

Finally, side effects are underreported to doctors. The main side effect with which Lauren struggled was lack of sexual desire/difficulty having orgasm, a common reaction to antidepressants. This seemed to become more of a problem when Lauren entered into a monogamous relationship; she and her then boyfriend tried all sorts of alternative remedies to try to correct the side effect, but nothing appeared to help with this issue.

* * *
Acknowledgement: Warm thanks to Diane Hazzard, my student of summer 2008, for the majority of this analysis of PROZAC DIARY.

Treatment Plan

Treatment Plan

Biological
Lauren’s treatment plan is mainly biological and the book is about her experience of taking Prozac. From her account, it seems that she has regular contact with her prescribing psychiatrist.

Psychological
Based on Lauren’s past suicide attempt(s) and suicidal ideation, the practitioner must assess her current risk for suicide and continue to monitor this throughout treatment. The practitioner can make sure to assess risk using a strengths-based approach by inquiring how Lauren has dealt with and got over her thoughts of self-harm in the past.

Although we know that Lauren has been hospitalized, it isn’t clear the treatments she received. Her “anxiety about eating” remains a concern (she claims that she had anorexia nervosa when she was younger). Further assessment of her eating patterns and extent of body disturbance is warranted.

Clearly, the writing of her memoir was a way that Lauren worked through her depression and her recovery. The fact that it was published and reached such a wide audience likely helped her experience meaning from the depression.

Social
As part of her recovery from depression, which Lauren attributes to Prozac, she says that she was able to have friends when she returned to graduate school and she eventually met a romantic partner. However, at the outset of the book, it seems that a referral to a cognitive-behavioral group might have helped her cope better, teach her needed social skills, and address some possible cognitive distortions that may get in the way of her recovery (“I’ll lose my creativity if I’m depressed). One of her major risk factors for a compromised adjustment is her isolation and lack of social support and group treatment may provide her with some beginning support and skills that she can take into other relationships.

Finding Strengths

The following types of techniques from solution-focused therapy show how we can discover more strengths and resources that Lauren may have:

1) Ask about the resilient qualities that have allowed Lauren to get to this point despite the pain she endured as a child and adolescent. What qualities does Lauren see in herself that allowed her to complete her education?
2) Ask coping questions such as: “You have really been through a lot. How were you able to cope when you were living with your family?” “How did you cope if things got rough in college?”
3) Ask about previous accomplishments: “What do you consider your greatest accomplishments?” “What allowed you to (accomplish X) when you were dealing with depression at the same time?”
4) Exception finding questions: Try to find a time when things were better. “What was different then?” “Were there times you have felt better than you feel now?” “What was different then?” “Were you doing anything different then to manage your situation?”
5) Externalizing: Make a linguistic difference between the person and the disorder. “What is different about the times you have been able to control the compulsions?”
6) Help envision the future: “Lauren, what will your life look like when you are feeling better?” “What will you be doing and saying?” “What will other people be saying to you?”

Risk and Resilience

Assessing a person from a risk and resilience framework helps see both the risk and the strengths and offers a more balanced appraisal. PROZAC DIARY does not emphasize strengths and resources; it is written in language symbolic of Lauren’s depression. Indeed, Lauren states that her creative writing is inspired by her depression; therefore, it is weighted to this account. Despite this slant, Lauren presents with many protective factors, as well as risk.

Risk and Resilience Assessment for the Onset of Depression

RISK

*Biological Factors
Female gender
Family history of mental illness

*Social Factors
Emotional abuse by Lauren’s mother (harsh and critical)
Parental divorce (not clear when this occurred relative to depression but assumed it was before depression started)

PROTECTIVE

*Psychological Factors
Leadership as a class president and leader of the school band (before age 12)

*Social Factors
Financial well-being
Participation in extra-curricular activities (music, dance, ice-skating, horseback riding)

Risk and Resilience Assessment for the Course (Adjustment or Recovery) of the Depression

RISK

*Biological Factors
Early onset

*Psychological Factors
Multiple episodes (and hospitalizations)
Residual symptoms
Co-morbid disorders (history of anorexia and cutting; current presence of obsessive-compulsive disorder)

*Social Factors
Lack of social support network
Poor employment history

PROTECTIVE

*Biological Factors
Intelligence

*Psychological Factors
Insight
Creativity (writing)

*Social Factors
Educated (bachelor’s degree from prestigious university
Financial support from family (this is assumed)

Acceptance of Diagnosis

In Lauren’s case, the problem is not acceptance of the diagnosis. Rather the problem is that her identity has evolved around her depression, which is likely, in part, because it descended on her at a young age (12) and she admits to feeling unhappy even further back as a young child (age 6 or 7). Lauren expresses ambivalence about losing her identity as a depressive and with it all the creative energy she believes it brings. This experience of ambivalence about recovery from mental illness is one of the themes of PROZAC DIARY.

Lauren says that when she does her creative writing it is from the different personas that live inside her (e.g., the blue baby). Lauren was in a graduate creative writing program but was unable to continue because of the symptoms of her mental illness. She is impaired to the point of being unable to keep even a menial-level job. Despite these impairments, she does not embrace getting well for fear of what she might lose. However, she does keep taking Prozac as recommended and for her, it does indeed act like a miracle drug; she describes the sudden lifting of depression that the antidepressant brings about within a couple of weeks.

The Frame or Structure of PROZAC DIARY

PROZAC DIARY opens with Lauren seeking help from a psychiatrist who specializes in the then new antidepressant, Prozac, for the recent emergence of Lauren’s obsessive/compulsive symptoms. PROZAC DIARY spans over several years of her life in which time Lauren completes a Masters degree in psychology and becomes involved in a long-term romantic relationship. As the title implies, PROZAC DIARY is organized around Lauren’s experience with Prozac. She was one of the first people in the United States to be on Prozac and was part of a clinical trial (although she does not describe the experience of being part of the research). Clinical notes from her treatment are provided intermittently throughout the book at the start of some chapters.

Next post: Struggling with recovery from mental illness

Reasons for Diagnosis

Here is the rationale for the DSM diagnosis:

Axis I: The diagnosis of Major Depressive Disorder was made because Lauren’s primary symptoms revolve around her feelings of emptiness and hopelessness. She talks about having a “hole in [her] soul” (p. 8) and being invisible. She relates a time when she was so invisible she could not even set off the motion detectors set-up by her apparently ill mother to protect the family from the ‘return of the Nazis.’ Lauren describes her adolescence and young adulthood as if she has having never been free of these mood symptoms.

Lauren reports major depressive symptoms since childhood. The presence of major depressive episode is supported by the following symptoms as reported by Lauren:

1) Lauren suffers from a depressed mood most of the day, nearly every day by her own subjective report in her memoir. She has feelings of emptiness and describes on-going depression that is stifling and comforting – “like a blanket” (p. 51).
2) Lauren shows a markedly diminished interest or pleasure in all or almost all activities. She states that she knew nothing of pleasure before taking Prozac.
3) Weight loss: Lauren says that she had a diagnosis of anorexia as an adolescent and states that “in years [she] had not eaten a meal … without anxiety” (p. 37) indicating that weight maintenance is a chronic problem.
4) Worthlessness: Lauren feels invisible. She uses the words ‘emptiness’ and ‘dwindling’ to describe depression.
5) Lauren has recurrent suicidal ideation and has made at least one suicide attempt.

Lauren’s symptoms have been present over many years more or less constantly; therefore it appears that Lauren suffers from chronic major depression.

She has mood-congruent psychotic features associated with her mood disorder. She has delusions that eight people live inside of her and that these individuals talk to her (auditory hallucinations) and help her define herself. Lauren’s delusions are of a bizarre nature but they are congruent with her depressive mood. An example of congruence is this stanza about loss from a poem that Lauren reports was written by the ‘Blue Baby’ that lives inside her:

“Mother of many
Watch your children play
Hightailing across a field, leaving you
With nothing but a spray of snow.
So cup your hands and try to catch all that’s left
Of your children” (p. 45-46).

Lauren does not seem to meet the criteria for Schizophrenia because Major Depressive Episodes have occurred concurrently and for a long time relative to the duration of the active and residual periods of delusions and hallucinations. However, it is not clear that the psychotic symptoms occur exclusively during periods of mood disturbance. If this were found to be true with additional information from the client, the diagnosis of Major Depressive Disorder could be confirmed.

Lauren’s symptoms seem to meet Criterion A for Schizophrenia but are better described by Major Depressive Disorder with Psychotic Features than Schizoaffective Disorder because the emptiness and other depressive symptoms appear to be primary. Her depressive symptoms are not superimposed on Schizophrenia, or Schizophreniform Disorder.

Delusional Disorder was considered and ruled out. Lauren’s hallucinations can be considered bizarre. In addition, Lauren’s mood episodes are long and appear to be of the same duration as the delusions.

Psychotic Disorder, Not Otherwise Specified was also ruled out because her psychotic symptoms (delusions and hallucinations) appear to be secondary to her feelings of emptiness.

Laura has not reported any Manic or Hypomanic Episodes.

Lauren also has a diagnosis of Obsessive-Compulsive Disorder (OCD) and it is the recent sudden presentation of these symptoms that prompted her to seek additional help and new medication. Lauren reports that she is endlessly counting, touching, checking, and tapping. She also reports repetitively checking the stove to make sure that she has turned it off. These behaviors meet the criterion for compulsion and the compulsions are considered excessive. The content of the compulsions are not restricted to the Major Depressive Disorder.

The current compulsions are causing significant interference with her normal routine causing her to be referred help for this specific condition. There is no evidence that the compulsions are due to substance abuse or any general medical condition.

Axis II: The social worker might also consider the diagnosis of Borderline Personality Disorder and, in fact, Borderline Personality Disorder is listed in the memoir as a diagnosis given to Lauren at age 19. With the information in the case study, Lauren does not seem to meet five of the criteria as required. Although she may meet some of the symptoms (chronic feelings of emptiness, unstable identity as indicated by the people living inside her), there is no evidence in PROZAC DIARY of the defining feature of borderline personality disorder: a pattern of unstable and intense relationships.


Axis III: Lauren provided little medical information but appears to be without problematic medical conditions at this time.

Axis IV: Lauren appears to be estranged from her parents and her sisters. She only mentions them in the past tense. She does not appear to have a social network that she can rely on for support. She does not discuss having any friends and does not date. The client is currently unemployed. She has had menial jobs for short periods of time and been fired or quit. She reports living in a small, dank apartment with bugs and very little furniture.

Axis V: Lauren’s current global assessment of functioning was determined to be at 35. Lauren is not able to maintain a job or personal relationships. She is socially isolated and living in sub-standard housing conditions. She considers her delusions and hallucinations to be a defining factor in her life and the spark for her creativity. While she continues to have thoughts of suicide, she has not made an attempted suicide since she was in high school.

Prozac Diary Multi-Axial Diagnosis

Disclaimer: In order to make an accurate diagnosis, a clinician should have a face-to-face meeting with the person. The following therefore is only being used for educational purposes and is based on the personal experiences of Lauren written in PROZAC DIARY and select clinical notes that she apparently obtained from her records and used to start certain chapters.

Multi-Axial Diagnosis

Axis I: 296.21 Major Depressive Disorder, Severe with Mood-Congruent Psychotic Features, Chronic

300.3 Obsessive-Compulsive Disorder

Axis II: V71.09 No diagnosis on Axis II

Axis III: None (Self-reported)

Axis IV: Problems with primary support group: (No apparent relationship with family)
Problems related to the social environment: (Weak social network)
Occupational problems: (Unemployed; poor work history)
Housing problems: (Inadequate living situation)

Axis V: GAF = 35 (current)

Next posting: What is the rationale for this diagnosis?

The first memoir is PROZAC DIARY by Lauren Slater (1999, Penguin)/ This description is a snapshot in time when she came for treatment as an adult written as a case study.

Lauren is a 26 year old, single, white, female who lives in Boston. She is a graduate of Barnard University. Lauren has been referred by her primary care physician for a recent and sudden emergence of compulsive symptoms. She complains of a nattering need to touch, count, check, and tap.’

When the social worker begins to talk with Lauren, she learns that Lauren has a long history of mental illness and that these new symptoms are overlayed on many years of feeling that she has a “hole in her soul.” Lauren has feelings of “emptiness.” She recalls feeling this way since she was as young as six or seven years old. She also expresses feeling invisible. She says that when she was growing up her mother put an alarm system in the house (to protect against the return of the Nazis) with many motion detectors; Lauren believed that, being invisible, she was unable to set them off. At 12 she says she was “thin, cutting, and knew nothing of pleasure.” Before age 12 Lauren was class president, leader of the band and considered herself to be a ‘brave girl.’

Lauren hears natural sounds repeat themselves in her head; her own voice, screeching of breaks, birds. She hears rushing and whirring. She has eight people living inside of her, although she claims to know that they are not real. Some of the people inside (the “blue baby” and the “girl in the glass case”) speak with her and are responsible for her journal writing and some of her creative writing, including this stanza from one of her poems:

Mother of many
Watch your children play
Hightailing across a field, leaving you
With nothing but a spray of snow.
So cup your hands and try to catch all that’s left
Of your children (pp. 45-46).

Lauren knows exactly when the “blue baby” entered her; it happened at the moment she ate a chocolate baby in elementary school. It was not clear how long the other people have been with her. Lauren fears losing them if she gets well.

Lauren has been hospitalized five times for depression and related problems; she was 14 when she was hospitalized for the first time. She describes depression as “stifling and comforting – like a blanket.” She has attempted suicide at least once. As an adolescent she was involved in self-mutilation, including cutting and anorexia. Lauren reports that she has not eaten a meal in years without anxiety. She has no history of drug or alcohol abuse.

Lauren claims that her mother and father both seem to have suffered from mental disorders. Her father, she says, is dysthymic and she describes him as “so sad.” Her mother was “intense,” emotionally distant and abusive. There is a reference to her forcing Lauren to drink detergent but Lauren cannot seem to articulate this clearly. She remembers her mother “screaming, screaming in the middle of the kitchen.” Her mother was afraid that the Nazis were going to return and come to her neighborhood; she made Lauren watch movies of Nazi concentration camps. Lauren reports that she never got along with her mother and that her mother said that the two of them clashed because they were the “most alike.” Lauren was the middle child of three girls and always considered herself to be “the bad girl.”

Lauren provided no additional information at all about her sisters and no current information about her mother or father. Their marriage dissolved when she was 11 years old and Lauren says she was fostered out as a young teen. Her parents were financially well off and even though she has had spotty employment, Lauren does not mention current financial hardship, so it appears as if she may be supported by her parents.

Lauren lives alone in a small, basement apartment. She reports that she has little furniture and that there have been centipedes crawling on the ceiling for years. She has few friends; she does not date. She spends her time reading philosophy and does some creative writing. Lauren has worked at a variety of menial jobs. She has either quit or been fired. She is currently unemployed.

The prospect of getting well scares Lauren because the world of illness is the one that she has known almost all of her life. However, she seems motivated to try to overcome this fear and work with a professional to overcome her symptoms.

Next posting: What is Lauren's DSM mental health disorder?