Acceptance and Commitment Therapy and Motivational Interviewing in the Treatment of Alcohol Use Disorder in a College Woman: A Case Study

Abstract

Alcohol abuse is common among college students. Acceptance and commitment therapy (ACT) is widely supported as a treatment of alcohol abuse. However, little research has examined how ACT may be paired with other techniques traditionally applied to treat substance abuse, such as motivational interviewing (MI). This clinical case study describes the use of ACT and MI to facilitate treatment of a 20-year-old woman who was referred for treatment for alcohol abuse. The client remained in treatment in spite of her initial self-reported belief that treatment was unnecessary. At follow-up, the client reported increased present moment awareness, particularly of her drinking habits, and demonstrated the ability to behave in ways consistent with her values. At the completion of treatment, the client reported fewer episodes of alcohol consumption and less severe drinking. Implications of these findings are discussed, with an emphasis on the potential benefits of pairing MI techniques with ACT.

Keywords

acceptance and commitment therapy motivational interviewing alcohol college students

1 Theoretical and Research Basis for Treatment

Acceptance and Commitment Therapy (ACT)

ACT is a transdiagnostic third-wave behavioral therapy grounded in functional contextual behaviorism (Hayes, Strosahl, & Wilson, 1999). The goal of ACT is to increase psychological flexibility, or one’s ability to engage in behaviors guided by self-identified values as well as being able to mindfully participate in the present moment (Hayes, Strosahl, & Wilson, 2011). To shape behavior in this fashion, ACT focuses on six core processes: present moment awareness, acceptance, defusion, self as context, values, and committed actions. Rather than applying a linear or step-wise approach to treatment, ACT’s six core processes may be emphasized to varying degrees in treatment to tailor therapy to the client’s individual struggles (Hayes et al., 2004). As such, the therapeutic process is one which involves the identification of processes or behaviors, which are difficult for the client, or areas in which deficits in these processes inhibit his or her psychological flexibility. Clients then practice increasing their ability to engage with these processes in therapy through experiential exercises, mindfulness skills, psychoeducation, metaphors, clarification of values, and behavioral engagement with those values (Harris, 2009; Hayes et al., 2011; Hiraoka, Cook, Bivona, Meyer, & Morissette, 2016).

It should be noted that the primary goal of ACT is not to reduce symptoms or symptomatic distress, but rather to facilitate clients’ ability to engage in valued actions even in the presence of distressing thoughts or sensations (Hayes et al., 2011). Nevertheless, a large body of research has demonstrated that ACT is associated with significant reductions in symptoms within the domain of substance abuse (Batten & Hayes, 2005; Hayes et al., 2004; Heffner, Eifert, Parker, Hernandez, & Sperry, 2003; Lee, An, Levin, & Twohig, 2015; Luoma, Kohlenberg, Hayes, & Fletcher, 2012; Petersen & Zettle, 2009; Luoma, Kohlenberg, Hayes, Bunting, & Rye, 2008). In particular, ACT is associated with fewer days of substance use, increased treatment attendance and utilization, increased client-reported quality of life, increased participation in sobriety, lower specific substance use, and lower overall substance use (Hayes et al., 2004; Heffner et al., 2003; Lee et al., 2015; Luoma et al., 2012). In addition, posttreatment effects of ACT appear positive and relatively strong and tend to be further increased at follow-up (Lee et al., 2015). As such, it appears that the positive effects of ACT may have a “sleeper effect,” wherein skills learned in therapy not only increase over time but also continue to lead to positive growth and behavioral change after the completion of therapy sessions (Lee et al., 2015). In addition, ACT has been demonstrated to be effective for clients with comorbid depressive and substance use problems, reducing both self-reported symptoms of depression and alcohol use (Petersen & Zettle, 2009).

In spite of the success of ACT as a treatment for various forms of substance abuse, it should be noted that individuals with substance use problems often report low motivation to seek treatment, as well as low motivation or interest in participating in mandated treatment (Meyers et al., 2002; Ryan, Plant, & O’Malley, 1995). This can be especially problematic, as a large body of research has demonstrated the importance of motivation as a factor to facilitate behavioral change (DiClemente, 1999). Low motivation can result in lack of treatment seeking, increased treatment dropout, failure to comply with treatment, relapse, and other problematic behaviors (Ryan et al., 1995). One method for combatting motivational issues is through the use of techniques such as motivational interviewing (MI; Bricker & Tollison, 2011). Although limited research has examined the use of these two therapies in conjunction with one another, it has been suggested that MI techniques might be complimentary to ACT therapy, particularly in the context of working with individuals with substance abuse problems (Bricker & Tollison, 2011). Additional research is, nonetheless, necessary to examine the differential benefit of utilizing MI techniques in the context of ACT for substance abuse issues.

MI

MI is a set of treatment techniques and strategies developed to increase clients’ motivation to change (Miller & Rollnick, 2012). Strategies used in MI include empathic listening, affirming client’s autonomy with regard to change, responding to resistance by “dancing with discord” or limiting struggling with resistance, reflective listening, and eliciting and supporting change statements from clients. MI is typically described as client centered and focuses on enhancing motivation by “exploring and resolving ambivalence” (Miller & Rollnick, 2012). In particular, MI seeks to enable clients to become aware of discrepancies, which may exist between their current behavior and their goals or values (Bricker & Tollison, 2011). Throughout treatment, clients may be categorized based on their self-reported willingness and motivation to change, as well as behavioral steps they may be contemplating or may have taken to initiate change (DiClemente et al., 1991). These five “states of change” may then be used to assess clients’ progress through therapy and to determine what skills or tools should be utilized to most effectively facilitate clients’ recovery (DiClemente et al., 1991).

A large body of research has demonstrated that MI is effective in increasing motivation to attend and engage in therapy among individuals with substance use disorders, as well as decreasing problematic substance use (Borsari & Carey, 2000; Carroll et al., 2006; Dietz & Dunn, 2014; LaBrie, Lamb, Pedersen, & Quinlan, 2006; Madson, Schumacher, Baer, & Martino, 2016; Rubak, Sandbæk, Lauritzen, & Christensen, 2005; Tollison et al., 2008). In particular, MI has shown to be particularly effective in reducing problematic drinking among college students (Borsari & Carey, 2000; LaBrie et al., 2006; Tollison et al., 2008). Participation in MI treatment was associated with significant reductions in overall alcohol consumption and number of drinks consumed per week, as well specifically reducing the number of self-reported episodes of binge drinking (Borsari & Carey, 2000; LaBrie et al., 2006). Moreover, MI has been demonstrated to be particularly effective even when administered in a brief format, including as little as a single 15-min session (LaBrie et al., 2006; Rubak et al., 2005). This may be especially effective in college populations, who often report numerous barriers to treatment seeking (Czyz, Horwitz, Eisenberg, Kramer, & King, 2013; Eisenberg, Golberstein, & Gollust, 2007). As such, we hypothesized the following:

Hypothesis 1: MI would serve as a useful compliment to ACT in the treatment of substance use problems in a college sample with low motivation to attend or participate in treatment.

The College Context

There is a wide body of research demonstrating that problematic drinking is incredibly common among college students in the United States (Borsari & Carey, 2000; Hingson, Zha, & Weitzman, 2009; Knight et al., 2001; O’Malley & Johnston, 2002; Vicary & Karshin, 2002). The abstinence model, which asks individuals to abstain from consuming an alcohol or other drugs, is one of the oldest methods of treatment for alcohol abuse (Marlatt, Blume, & Parks, 2001). This method of treatment unfortunately can be prohibitive for college students, many of whom report numerous positive consequences from drinking such as meeting new friends, increased social enjoyment, and increased ability for self-expression (Parks, 2004). In fact, due to the social context of college in the United States, which typically involves alcohol consumption, one might even argue that moderate drinking (i.e., not binge drinking or other frequent heavy drinking) is to a degree developmentally normative. Research has demonstrated that anywhere between 60% and 80% of college students have consumed alcohol in the past month (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014), and although a percentage of those individuals report risky drinking habits (e.g., approximately 39% report having engaged in an episode of binge drinking in the past month), the vast majority are able to consume alcohol without persistent negative physical, social, or emotional outcomes. Given the perceived potential social importance of moderate alcohol consumption, it is important to consider the potential of nonabstinent or harm-reductive therapies for alcohol abuse in this population (Marlatt & Witkiewitz, 2002).

Harm-reduction strategies, or protective behavioral strategies, came about as a response to the abstinence-only model of alcohol consumption, which has often been characterized as “one size fits all” and, thereby, ineffective at assisting individuals across the broad continuum of alcohol abuse problems (Marlatt & Witkiewitz, 2002). Rather than requiring abstinence from individuals in them, harm programs emphasizing protective behavioral strategies focus on decreasing drinking overall, decreasing problematic episodes of drinking such as binges, increasing moderated drinking, increasing knowledge about the effects of alcohol and potential consequences of its use, and increasing skills to better enable individuals to drink safely (Ambrogne, 2002; Gastfriend, Garbutt, Pettinati, & Forman, 2007; Marlatt, 1996; Marlatt et al., 2001; Marlatt & Witkiewitz, 2002; McBride, Farringdon, Midford, Meuleners, & Phillips, 2004; McBride, Midford, Farringdon, & Phillips, 2000; Neighbors, Larimer, Lostutter, & Woods, 2006; Saladin & Santa Ana, 2004). Among college students, studies focusing on harm-reduction and protective behavioral strategies have demonstrated significant reductions in drinking rates up to 2 years postintervention (Baer, Stacey, and Larimer, 1991; Marlatt et al., 1998). In addition to reduced drinking rates, studies emphasizing protective behavioral strategies have demonstrated increased knowledge about alcohol, increased likelihood of engaging in abstinence or moderated drinking, and fewer episodes of problematic or binge drinking (Borsari & Carey, 2000; McBride et al., 2004; Weitzman & Nelson, 2004). As such, it appears that protective behavioral strategies are likely to be effective when working with college individuals struggling with alcohol use problems (Baer et. al., 2001; Marlatt, Blume, & Parks, 2001).

Another serious issue that affects college students’ mental health is depression. As with the population at large, a significant percentage of college students experience symptoms of depression, with prevalence rates ranging anywhere from 11% to 83%, depending on the measure and severity of depression measured (Beiter et al., 2015; Garlow et al., 2008; Pedrelli, Borsari, Lipson, Heinze, & Eisenberg, 2016; Selkie, Kota, Chan, & Moreno, 2015). As with the general population, this issue tends to effect more women than men (Beiter et al., 2015; Pedrelli et al., 2016) and is associated with numerous other issues including increased risk of self-reported anxiety, self-reported suicidal thoughts and behaviors, and alcohol abuse (Chia-Chen Chen, Szalacha, & Menon, 2014; Furr, Westefeld, McConnell, & Jenkins, 2001; Garlow et al., 2008; Selkie et al., 2015). In particular, the issue of comorbid depression and substance use has been demonstrated to be especially problematic for minority students who may struggle with these issues as a response to perceived discrimination or challenges with acculturative stress (Chia-Chen Chen et al., 2014). Moreover, minority students, particularly those of Asian American decent, appear to score higher on self-report measures of depression than their White peers, even when controlling for other demographic variables (Okazaki, 1997). As such, when working with college students, particularly those who are of ethnic minorities, clinicians should be particularly aware of the high likelihood for clients to experience at least some depressive symptoms. In these groups, particularly those college students who struggle with comorbid depression and alcohol abuse, mindfulness-based interventions, and those that incorporate at least a brief MI component have been found to be particularly effective (Merrill, Reid, Carey, & Carey, 2014; Preddy, McIndoo, & Hopko, 2013).

2 Case Introduction

“Jessica” was a 20-year-old single Asian American woman referred by her parents to an outpatient psychological services center in spring of 2017. At the time of the initial intake, Jessica was a sophomore in college. During the first part of treatment, Jessica lived independently by herself in an apartment; however, later in treatment, Jessica was encouraged by her parents to move in with friends of the family (an adult married couple and their children) for increased supervision.

3 Presenting Complaints

A week prior to the intake, Jessica was found unconscious in downtown area of her college town. Bystanders contacted emergency services, and Jessica was taken via ambulance to the hospital, where she was treated for alcohol overdose. Due to the fact that she was underage at the time, Jessica’s parents were contacted. At this time, Jessica’s parents informed her that if she was to maintain her independence (i.e., continuing living alone and attending the university), that they wanted her to attend therapy.

At the intake, Jessica indicated that she did not believe she needed to attend therapy and felt her parents were overreacting, but that she was willing to come in to maintain her privileges. Despite this, Jessica was open with her clinician, and maintained good rapport, as evidenced by answering questions in a relaxed and friendly manner and occasionally joking with the clinician. At the time of the intake, Jessica reported regular episodes of binge drinking, which usually occurred 2 to 3 times a week depending on social functions. During these episodes, she would consume upward of 15 standard drinks over the course of 4 to 5 hrs. In the past 4 months, Jessica indicated she had experienced at least four major blackouts following these alcohol binges, where she had no memory of what occurred the night before. In addition, the previous fall, during one of her drinking binges, Jessica had engaged in self-injurious behavior. Jessica reported that while drinking at a party with friends, she became emotionally distraught, after which she locked herself in the bathroom, broke the bathroom mirror, and attempted to cut herself on the arm with the broken glass. After this, Jessica indicated she blacked out and had no further memories of the incident. Jessica’s cuts were superficial and did not require stitches; however, she described the incident as frightening and disconcerting. Jessica denied having engaged in self-harm prior to this incident or following it; she additionally denied past or present suicidal ideation, intent, or plan.

At intake, Jessica was assessed using the MINI 5.0 and, with respect to her alcohol use, Jessica met full criteria for alcohol use disorder, severe. Jessica endorsed the following criteria for this disorder: Alcohol is often taken in larger amounts or over a longer period than intended; a great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects; continued alcohol 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; tolerance; and important social, occupational, or recreational activities are given up or reduced because of alcohol use. Moreover, given the severity of the episode that prompted her attendance to therapy (i.e., alcohol overdose, which was severe enough to warrant hospitalization), there was sufficient evidence to warrant concern over Jessica’s alcohol use. However, it should be noted that Jessica indicated that she did not believe her alcohol use was problematic. In fact, she reported that she believed it was normative, given her status as a college student at a large university. She additionally reported occasional marijuana use; however, she did not meet criteria for a related substance use disorder. In addition to her alcohol use problems, Jessica endorsed numerous symptoms of depression currently including excessive sleeping, difficulty concentrating, anhedonia, and avolition. However, Jessica did not meet current criteria for a major depressive episode. Jessica did report experiencing multiple depressive episodes in the past. As such, she met criteria for major depression, recurrent, in partial remission.

4 History

Jessica was adopted as an infant and brought to the United States by her parents who were Caucasian. Jessica reported that she got along well with her father, but that her relationship with her mother was often strained. Jessica had a younger nonbiological sister who was similarly adopted. Jessica reported that she liked her sister, but was often frustrated by how “perfect” she perceived her sister to be. Jessica repeatedly described her sister as the “good Asian” with herself being the “bad Asian.” In addition to this disparity in their personalities, Jessica also indicated that her sister often sided with their mother in family disagreements, whereas Jessica often sided with her father, creating a tense dynamic at times.

With regard to her family history and alcohol, Jessica reported that her father had often struggled with problems with alcohol in the past. She described him as being a “successful alcoholic,” indicating that he drank excessively and often, but was able to do so without impairment at work. Jessica reported that her father often reminisced about his youth and his college days, and would often tell Jessica about how he partied and drank with his friends. This mentality was something that Jessica indicated identifying with a great deal. She reported that in college, “everyone drinks,” and when asked whether she would ever stop drinking, she indicated that her entire social life revolved around drinking and parties, and she was not even certain what else there was to do in her college town.

Jessica herself had begun drinking approximately at age 17. Jessica denied ever having had legal troubles associated with her drinking, though she did report having driven under the influence on several occasions. Jessica reported that her drinking occasionally caused her to miss class; however, in spite of this, she was still maintaining above average grades (mostly As and Bs). At the time of treatment, Jessica was single, though she reported being sexually active. Jessica was in her sophomore year at the university and was majoring in Arabic. She reported a desire to live abroad in the Middle East once she graduated, and hoped to be involved in some sort of nonprofit work there. Jessica had been sent by her parents to a counselor who provided “talk therapy” when she was in high school to help her manage her depressive symptoms; however, Jessica reported that she was unsure whether or not this experience was actually helpful. Although Jessica reported that she did not believe her drinking was problematic, she did report that she was struggling to have meaningful relationships, both romantic and with friends, and that she was willing to discuss this with her present clinician. In particular, Jessica noted that when she was drinking, she did have a bad habit of “drunk texting” individuals, typically men, and that this often resulted in uncomfortable situations. Jessica also reported a habit of lashing out at others, both verbally and physically, when she was drinking, and had indicated that she had upset friends in the past by being overly blunt or “bitchy” while under the influence. It was these relational difficulties that Jessica expressed a desire to work on in therapy. It should be noted that, although Jessica did believe she had a problem with her interpersonal relationships, she repeatedly expressed that these issues were not related to her alcohol consumption, even when she acknowledged that the issues primarily happened when she was under the influence. As such, with regard to her alcohol use specifically, Jessica was judged to be in the precontemplative stage.

An ACT approach was deemed appropriate in Jessica’s case due to the fact that ACT has been repeatedly demonstrated to be highly effective in cases of substance abuse (Hayes et al., 2004; Heffner et al., 2003; Lee et al., 2015; Luoma et al., 2012). In addition, due to the fact that Jessica indicated a variety of struggles (e.g., risky drinking, negative attributions about self, feelings of isolation, anhedonia, worry, lack of engagement in valued activities), it was believed that an ACT approach would provide Jessica the benefit of increasing psychological flexibility across a variety of contexts. Given Jessica’s reticence to address her drinking, in spite of the issues it had caused her, the therapist and her supervisor deemed the use of MI would be appropriate for facilitating change with Jessica as well as retention in therapy (Borsari & Carey, 2000; Czyz et al., 2013; Eisenberg et al., 2007; LaBrie et al., 2006; Rubak et al., 2005). Moreover, Jessica indicated at the onset of therapy that she would only be able to attend a limited number of sessions as she was going home at the end of the academic semester (only a handful of weeks away at the time of intake), and as MI has been demonstrated to be effective even in a brief format (Rubak et al., 2005), it was deemed appropriate for this case.

5 Assessment

As part of the intake, Jessica was assessed using the fifth version of the Mini-International Neuropsychiatric Interview (MINI). Based on her responses to this semistructured interview, Jessica met criteria for the disorders described above. Jessica’s stage of change was additionally assessed using MI techniques. Given her repeated statements that her drinking was not problematic, in spite of evidence to the contrary (e.g., multiple blackout episodes, driving under the influence, being hospitalized for alcohol overdose), Jessica was assessed to be at the stage of precontemplation.

Jessica was also assessed at intake, and throughout treatment, using the following self-report measures every week over the course of 10 sessions. These measures were administered to assess her self-reported symptoms of depression, anxiety, and stress, as well as her overall self-reported psychological well-being. Jessica additionally self-reported on numerous behavioral targets including alcohol consumption and engagement with values-driven committed actions.

The Depression Anxiety and Stress Scale (DASS-21)

The DASS-21 (Antony, Bieling, Cox, Enns, & Swinson, 1998) is a psychometrically sound 21-item self-report measure designed to assess individuals’ self-reported levels of anxiety, depression, and stress over the course of the past week. Participants answer a series of questions regarding symptoms they may have experienced in the past week on a 0 to 3 scale (0 = never, 1 = sometimes, 2 = often, 3 = almost always). Scores are summed for each of the subscales: Depression, Anxiety, and Stress, and then, these sum scores are multiplied by 2, with higher scores indicating greater distress. These scores can then be ranked depending on the subscale in one of the following categories: normal, mild, moderate, severe, and extremely severe. At the time of the intake, the client scored in the mild range for depression and stress, and the normal range for anxiety.

The Back Depression Inventory–Second Edition (BDI-II)

The BDI-II (Beck, Steer, & Brown, 1996) is a psychometrically sound 21-item self-report measure created to assess individuals’ self-reported levels of depressive symptoms over the past week. Participants answer questions on a 4-point scale, ranging from 0 to 3, with 0 being the symptom is not present to 3 being the symptom being present and severe. Items are then summed with higher scores indicating more symptoms of depression, with the highest possible score being 63. Scores can also be ranked to indicate the likelihood that an individual is suffering from borderline clinical depression, mild, moderate, and severe depression. The client scored in the moderate range for depression on the BDI at the time of the intake (Appendix; Figure A2).

The Beck Anxiety Inventory (BAI)

The BAI (Beck, Epstein, Brown, & Steer, 1988) is a psychometrically sound 21-item measure designed to assess individuals’ self-reported symptoms of anxiety. Participants answer how much they have been bothered by a particular symptom during the past week on a 4-point scale ranging from 0 (not at all) to 3 (severely). Items are then summed to create a total score, with higher scores indicating greater severity of anxious symptoms. Scores can range from 0 to 63, and can be categorized in the following groupings: minimal, mild, moderate, and severe anxiety. At the time of intake, the client scored in the mild range for anxiety on the BAI. It should be also noted that this measure was only used on intake and at termination, as anxiety was not the primary issue reported by the client.

The Outcome Questionnaire (OQ-45.2)

The OQ-45.2 (Wells, Burlingame, Lambert, Hoag, & Hope, 1996) is a 45-item self-report questionnaire designed to be administered repeatedly throughout therapy to assess clients’ progress. This measure consists of three subscales, Symptom Distress, Interpersonal Relationships, and Social Role. The Symptom Distress subscale is designed to assess for client’s self-reported difficulties with symptoms of depression and anxiety as well as substance abuse. The Interpersonal Relationships subscale is designed to assess for problems with loneliness, conflicts with others, and familial or marriage difficulties. Finally, the Social Role subscale is designed to assess for struggles in the workplace, or with daily responsibilities at school or at home. Participants indicate the extent to which they have experienced difficulties over the past week in the aforementioned areas on a 4-point scale ranging from 0 (never) to 4 (often). Extensive normative data have been collected on this measure, and as such, patient’s scores can be compared with both outpatient and inpatient norms. The OQ-45.2 also includes several critical items including those dealing with suicidality, workplace violence, and substance abuse, which can be flagged to indicate areas requiring immediate attention by clinicians. At the intake, the client’s current OQ-45.2 score was 84, indicating significant symptoms of distress. The client also endorsed high scores on critical items related to substance abuse (Appendix; Figure A1).

6 Case Conceptualization

Jessica’s difficulties can be conceptualized using ACT’s six core processes of psychological inflexibility. Jessica came to therapy with a high degree of cognitive fusion, for instance, Jessica often took thoughts such as “drinking is part of the college experience,” “If I don’t drink I’d be missing out,” and “everyone parties this much” as fact. This led to Jessica misinterpreting her behavior as normative, which, in turn, led her to continue to drink even when it was problematic or dangerous. Under the disinhibitory effects of alcohol, Jessica would engage in maladaptive behaviors, such as sending overly emotional text messages to men she was romantically interested in, or verbally lashing out at friends. On hearing about these incidents the next day, Jessica’s negative content related to herself, such as ideas that she was a “f**k up kid,” would be reinforced in her mind. Jessica’s drinking also often served as a mechanism by which she could engage in avoidance, rather than awareness, of present moment experiences. For example, when she struggled to manage negative self-content, such as “I’m a f**k up kid,” or when she wanted to avoid judgment by her peers by being the “life of the party” Jessica would drink. Ultimately this pattern of avoidance, alcohol abuse, maladaptive behaviors, and emotional fallout became a negatively reinforcing cycle for Jessica. Moreover, because Jessica was highly fused with the idea that if she did not drink or party, she would be “missing out on the college experience,” Jessica struggled to identify or make contact with her values. From an MI perspective, Jessica’s repeated assertions that her drinking was not a problem, as well as her limited willingness to work on changing this behavior indicated that she was in the stage of precontemplation. This conceptualization served to compliment the ACT conceptualization, as it further highlighted Jessica’s struggles with inflexibility in thinking and behavior.

Ultimately, Jessica’s case could be conceptualized as requiring two issues to be addressed, both her primary problematic behavior, drinking, as well as her less apparent behavior of fused thought content about drinking and herself (i.e., everyone in college drinks like this, if I don’t drink like this I will miss out on the college experience, I don’t need to change). Although there is a large body of research that indicates that MI would be successful in assisting in preparing Jessica to change her drinking behavior, without addressing her fused thought content, it is unlikely that such a treatment would be effective. Thus, using ACT to address this content through defusion exercises (e.g., perspective taking) and through an emphasis on values and committed actions, which Jessica was not engaging in due to her alcohol use, allowed the therapist simultaneously to address the problematic drinking and fused thought issues. Thus, a strength of the present work is the case conceptualization integration, which, in turn, informed treatment goals and the work done in the session integrating MI theory with ACT.

Given Jessica’s presenting problem and the aforementioned conceptualization of her case, the goals for therapy fell in a few distinct categories. There were those goals associated with Jessica’s ambivalence about therapy generally, as well as her ambivalence about her drinking behavior. Such goals included maintaining Jessica’s attendance in therapy and increasing change-related talk. Another category of therapy goals included those goals related to increasing Jessica’s psychological flexibility. These goals included decreasing Jessica’s cognitive and behavioral fusion (e.g., thoughts such as “if I don’t drink, I’m missing out” or “I have to drink to have fun with friends” and behaviors such as only engaging in social activities that involved alcohol), decreasing her avoidance (i.e., drinking to be “the life of the party”), and, conversely, increasing her present moment awareness and expanding her behavioral repertoire through exploration of her values and increasing her engagement in committed actions. Finally, the most long-term therapy goal was to decrease Jessica’s engagement in risky behavior (i.e., binge drinking, mixing alcohol with marijuana) and increase her use of protective behavioral strategies as well as helping her develop more effective coping strategies. However, it should be noted that Jessica’s ambivalence toward her alcohol use, and her own stated belief that her drinking was not a problem, meant that the majority of therapy needed to be tailored to focus primarily on the first category of goals, while supplementing this with work on the second two categories when possible.

7 Course of Treatment and Assessment of Progress

Postintake, Jessica received 10 1-hr sessions of individual therapy over the course of 3 months. Her treatment was conducted by a master’s-level psychology graduate student (the first author) under the supervision of a licensed psychologist.

Course of Treatment

Sessions 1 to 3

The first three sessions focused on providing Jessica with psychoeducation on normative alcohol use, as well as the broad and specific risks associated with her current drinking patterns. The ACT matrix was used in multiple sessions to help Jessica better understand her own behavioral patterns and begin to recognize the unworkability of her current use of alcohol. The MI technique of creating a decisional balance was used to prompt Jessica to engage in contemplating change. MI was additionally used in conjunction with the ACT matrix, to explore the discrepancies between Jessica’s current behavioral patterns and her stated values and goals. This activity further served as a method of exposure to difficult or uncomfortable emotions, where Jessica was asked to consider what her life would look like if she chose not to drink, or to drink less. For Jessica, drinking was often associated with a desire to be liked and included, and so, considering a world in which she did not drink required Jessica to practice exposing herself to negative thoughts about herself and separating herself from the content of these thoughts. Moreover, Jessica was challenged to practiced defusion, by unhooking herself from thoughts such as “everyone in college drinks,” “if I don’t drink I’ll miss out,” and “one more beer won’t kill me.” Much of these initial sessions also involved the therapist demonstrating psychological flexibility by “dancing with” Jessica’s resistance to discuss her alcohol use. To increase her present moment awareness, Jessica was encouraged to monitor her alcohol consumption throughout the week, as well as her engagement in values-driven committed actions (e.g., having meaningful conversations with friends, exercising, attending church services or Bible Study, participating in activities/clubs related to her major).

During this phase of treatment, Jessica was resistant to discussing her alcohol use, and would often redirect conversation in therapy to her interpersonal concerns or other topics. Jessica repeatedly expressed that her drinking was not a problem, and indicated that she believed her hospitalization for alcohol overdose to have been an isolated incident. As such, much of the work done in these sessions, particularly in the second and third sessions, focused on Jessica’s lack of engagement with her values, rather than directly targeting her drinking behavior. In spite of Jessica’s refusal to acknowledge that her drinking was problematic, she and the therapist maintained a positive rapport, as evidenced by Jessica showing up to therapy in a timely fashion, answering all questions put to her openly, and occasionally joking with her therapist.

Session 4

Session 4 was a major turning point in the course of Jessica’s therapy. On the date of this session, Jessica presented as a dramatically different client. Prior to this session, Jessica was animated and energetic in session, and usually presented with a chatty and joking manner. On the fourth session, Jessica was subdued, made limited eye contact, and was occasionally tearful in session. Jessica’s change in demeanor was due to the fact that she reported she had been hospitalized a second time for alcohol overdose the previous weekend. Jessica had been at a party with friends and drank a great deal after which she lost consciousness. Emergency services were contacted, and Jessica was taken to the hospital and treated for alcohol overdose. While under the influence of alcohol, Jessica’s friends informed her that she had behaved extremely poorly. She reported being told that she was verbally aggressive with her friends, and that she had cursed out and attempted to hit one of the nurses in the hospital. Jessica was additionally informed that she had stopped breathing in the ambulance and had to be resuscitated. Moreover, as she was underage, Jessica’s parents were again contacted, and her mother drove from some distance away to reach Jessica in the hospital. Jessica’s parents initially wanted her to take the remainder of the semester off and leave the university altogether. However, they settled on agreeing that Jessica could remain at school, but rather than live independently in her own apartment, they required that she move in with some family friends who lived in town. These individuals were an adult couple with several young children, and Jessica was to live in their guest bedroom for her to be under greater adult supervision. In addition, at this time, Jessica’s father, who himself had struggled with alcohol in the past, voluntarily checked himself into a rehab facility.

The bulk of this session was spent focused on processing Jessica’s response to this incident and engaging in exposure to the challenging and uncomfortable emotions and thoughts it had aroused. Jessica reported feeling overwhelmed, deeply ashamed, and most of all surprised. Jessica indicated that until this incident, she had not really believed she had a problem with alcohol. Moreover, she reported that her father’s self-admission to rehab had caused her to really reconsider her own behavior, and how that behavior was incongruent with her values. Jessica acknowledged the events had also led to an increase in a number of fused thoughts and judgments about herself, including increased belief that she was “a f**k up kid.” Jessica’s goals for therapy were reassessed, and she expressed a renewed desire to commit to therapy, with an emphasis on moderating her drinking, increasing her engagement with her values, and increasing her ability to deal with challenging emotions and situations without the use of alcohol. It should be noted that Jessica’s scores on all outcome measures peaked dramatically on the date of this incident.

Sessions 5 to 10

The remainder of Jessica’s sessions focused on reducing the number of her problematic drinking episodes and increasing her engagement with her values. In terms of goals for moderated drinking, Jessica was encouraged to monitor her drinking behavior and work toward reducing her overall number of standard drinks consumed in each sitting. In addition, she was encouraged to reduce her consumption of hard liquor or mixed drinks, to stop drinking at a specific time each night, and to prohibit herself from consuming alcohol and marijuana simultaneously. These moderation goals were further facilitated by Jessica’s altered living situation, as she currently did not have access to alcohol or marijuana while living with her family friends. Moreover, these individuals required Jessica return home by a curfew of midnight, further assisting with her moderated drinking goals.

With regard to ACT-specific work, Jessica’s fused thoughts of herself as a “f**k up” and a “bitch” decreased as she became able to recognize self as context rather than content (i.e., recognize her thoughts as thoughts rather than as facts). Moreover, once Jessica began to see the link between heavy alcohol use and her pattern of disinhibited communication, she was better able to see that her behavior was drastically effected by contextual factors, which she could control. From an MI perspective, Jessica transitioned from the precontemplation stage, to the contemplation, preparation, and action stages. It should be noted that although Jessica did progress to the action stage over the course of therapy, she often vacillated between stages. Although Jessica drastically altered her behavior around alcohol, she still drank fairly often (2-3 times a week), and did not always stick to the rules she created for herself (i.e., not drinking after a certain time at night, refraining from smoking marijuana and drinking simultaneously). In spite of these struggles, Jessica reported increased engagement with her values, as evidenced by spending more time with her studious “nonpartying” friends, becoming a more active member in her church, increasing developing other healthy habits including the introduction of exercise into her weekly agenda, and increased attendance to and engagement in her classes. Jessica also reported an increased positive mood, fewer feelings of loneliness, and demonstrated increased psychological flexibility by her willingness to make contact with difficult emotions in session.

At the date of her last session, Jessica self-reported that she had not been drinking in the past week as she was on antibiotics for an unrelated issue. This was a notable incident, as Jessica reported that this was the longest she remembered ever having going without drinking in some time. Jessica additionally reported that she aimed to continue her pattern of moderated drinking when she studied abroad in the following semester. Jessica reported that she would be studying in the Middle East, and that she felt that the limited availability of alcohol in the country where she was studying would also serve as a useful contextual piece in assisting her continued progress in safely managing her alcohol consumption. Jessica was scheduled to attend a follow-up session at the beginning of the following semester, before she left for her study abroad, but she ultimately did not attend this session. However, she interestingly did self-refer to return to therapy approximately 1 year later.

Assessment of Progress

Overall, Jessica’s scores on therapy measures were indicative of reduced distress. She went from scoring an 84 on the OQ 45.2 at intake to scoring a 73 at her last session. Jessica’s DASS-21 scores placed her in the mild range for depression and stress and the normal range for anxiety at the time of the intake, and although she did remain in these ranges at her last session, her depression and anxiety scores each went down 2 points. At the time of intake, Jessica scored in the moderate range for depression on the BDI-2, and on her last session, she scored in the mild range. Jessica scored in the mild range for anxiety on the BAI at both intake and at her final session.

In addition to her scores on more formal measures of assessment, Jessica reported a number of behavioral changes as well. By the end of therapy, she endorsed fewer episodes of problematic binge drinking, less alcohol consumption overall, and, as of the final session, she reported having remained abstinent from alcohol for an entire week. She demonstrated increased psychological flexibility as evidenced by her increased willingness to discuss emotionally difficult topics, such as her problematic alcohol use and the issues it had caused. Over the course of therapy, Jessica was able to make contact with the unworkability of her former behavioral patterns, and acknowledge that they were often in conflict with her self-reported values. Jessica additionally reported greater engagement with her values over the course of therapy (e.g., increased involvement in social activities without the presence of alcohol, increased attendance to and involvement in her church, increased engagement in exercise, increased time spent on school-related activities such as homework or networking with other members of her major at related functions). Moreover, she remained in therapy and attended consistently in spite of her initial belief that her drinking behavior was not a problem. Broadly speaking, Jessica went from a period of extreme risk, distress, and not viewing her alcohol use as problematic, to one of moderate distress, lower risk, and acknowledgment of her maladaptive behavioral patterns. Perhaps, the most important outcome of all, is that approximately 1 year after being forced into therapy by her parents, Jessica self-referred herself back to therapy for continued assistance in managing her alcohol use problems.

8 Complicating Factors

The primary complicating factor in the presently described case was Jessica’s initial resistance to engagement in treatment and her repeated desire to discuss subjects other than her problematic alcohol use. Moreover, Jessica was often noncompliant when asked to complete homework to facilitate the work being done in her therapy sessions. Jessica’s homework typically involved simply monitoring her alcohol consumption for the week, as well as her involvement in committed actions. This was particularly challenging, but was also understandable initially, given the fact that Jessica was initially coerced to attend therapy by her parents. Encouraging Jessica to engage in homework when she did not think she needed to attend therapy in the first place, particularly homework related to an issue such as drinking, which she did not perceive as problematic for some time, was incredibly challenging. However, through using MI techniques, the therapist was able to effectively encourage and model psychological flexibility regarding change. It should be noted that Jessica’s ambivalence to homework was likely, in part, due to her ambivalence about drinking, but was not initially directly addressed in therapy. However, when Jessica self-referred for follow-up, the importance of consistently monitoring behavior (e.g., alcohol use, mood, engagement in committed actions) to effectively assess change, was discussed. When this information was presented to Jessica in an open, nonjudgmental fashion, Jessica and her therapist were able to have a discussion about Jessica’s goals and how best to modify homework, so that it was appropriate. By stepping back and modeling psychological flexibility, Jessica and her therapist were able to address the issue, and Jessica was significantly more consistent with filling out her monitoring logs and bringing them to session, as well as engaging in agreed-upon protective behavioral strategies. Moreover, repeated discussions about Jessica’s values and the role her alcohol use had in prohibiting her engagement with them also appeared to increase Jessica’s readiness for change. These factors appear to have primed Jessica, such that when she was hospitalized a second time for alcohol overdose, she was able to acknowledge the problematic nature of her alcohol use, and dramatically increased her engagement in the therapy process.

Yet, in spite of this progress, Jessica often struggled to complete homework (i.e., monitoring drinking, reducing drinking, refraining from drinking after a certain hour at night, refraining from smoking marijuana and drinking simultaneously) even after her hospitalization. This may, in part, be due to Jessica’s strong belief that alcohol consumption is an important part of the college experience. Even after her second hospitalization, she expressed concerns that becoming abstinent, or even reducing her drinking, would adversely affect her social engagement. Given Jessica’s context as a student at a large public university in the Southeastern United States, her concerns about managing alcohol consumption while still obtaining social reinforcers were not unfounded. Thankfully, by exploring Jessica’s values in depth, Jessica and her therapist were able to come up with committed actions she could engage in, to obtain social reinforcement that involved limited or no access to alcohol (e.g., attending Bible study, having one-on-one dinners with friends who did not drink or who typically drank less than Jessica, attending study sessions and events sponsored by her department).

Another barrier to Jessica’s treatment was that Jessica was only able to attend a limited number of therapy sessions before she intended to leave at semester’s end. This is a challenge inherent when working in an outpatient setting that primarily caters to college students on the academic calendar. Despite this limitation, Jessica consistently came to therapy and always arrived promptly. In addition to scheduling issues, another challenge in working with Jessica as a college student was the requirement for the therapist to maintain a balance between the desires of Jessica’s parents, who coerced her into attending therapy, and Jessica’s own desire to be independent and self-sufficient. Jessica waived her right to confidentiality early on, to allow her therapist to contact her parents in the hopes that such communication would “get them off my back.” Jessica’s therapist spoke with her parents once after Jessica’s second hospitalization. At that time, they wished to know the therapist’s recommendation on whether or not Jessica should attend Alcoholics Anonymous (AA) meetings. To preserve Jessica’s autonomy, Jessica’s therapist expressed that she would discuss the option with Jessica in their next session. Ultimately, Jessica chose not to attend AA meetings, but did agree to her parents’ request that she be open to seeking therapy for her drinking in the future (i.e., after she completed her course of treatment at the end of the academic semester).

It should be noted that diversity-related factors were not discussed in detail in therapy with Jessica. This was done due to the fact that Jessica was only able to attend a limited number of sessions due to the structure of the academic calendar. Given the severity of Jessica’s symptoms and the high risk they posed, the therapist and her supervisor considered focusing primarily on willingness to engage in treatment, reducing risky behavior, and developing harm-reduction strategies to be paramount. In the future, Jessica would certainly benefit from addressing culture-related concerns. Given Jessica’s status as a minority at a university and in a region of the United States that is made of primarily Caucasian individuals, many of her concerns about being an outsider were not necessarily unfounded. Moreover, Jessica’s conflicts with her sister, which divided them into categories of the “good Asian” and the “bad Asian,” were certainly culturally loaded. Although these factors were discussed in supervision, they were not directly addressed in therapy. From an ACT perspective, it would be important to work with Jessica around defusing these sorts of thoughts. Moreover, with regard to values, it would be worthwhile to explore what it meant/means to Jessica to be an Asian woman, and how this value might be explored behaviorally through committed actions.

9 Access and Barriers to Care

Jessica was financially supported by her parents, who were upper middle class, and, as such, finances were not a barrier to her obtaining treatment. Unfortunately, due to the nature of the academic calendar, Jessica was not able to continue attending therapy for as long as would have been clinically optimal. At the end of the academic semester, Jessica returned home, and whereas many students seen at this particular outpatient clinic choose to return after breaks in the academic school year, Jessica was scheduled to study abroad the following semester. However, Jessica later self-referred for a follow-up, and continuity of care was able to be maintained, likely facilitating Jessica’s continued progress.

10 Follow-Up

Approximately 1 year following her initial intake, Jessica self-referred to therapy for follow-up. During that time, she was seen for six 1-hr sessions of individual therapy over the course of 6 weeks. Treatment was conducted by the same therapist, now a doctoral-level graduate student under supervision of a licensed psychologist. At the time of follow-up, Jessica self-referred to therapy as she had experienced a blackout episode after drinking. Although this incident had not been serious enough for Jessica to be hospitalized, she reported that she recognized that she had experienced repeated blackouts before her hospitalization incidents previously, and that she had no desire to be hospitalized again. Jessica also reported that she intended to attend several social functions in the upcoming weeks at which she knew there would be a great deal of alcohol available. She reported that her parents expressed significant concerns over her attending these events, and Jessica expressed a desire to demonstrate to them that she possessed the ability to be responsible in these sorts of situations.

Follow-up sessions focused on assisting Jessica with continuing to develop psychological and behavioral flexibility through engagement with her values and informal mindfulness practice, as well as practicing harm-reduction strategies (e.g., limiting the number of shots she took, having a designated driver, making sure to regularly consume water when drinking alcohol, eating a full meal before imbibing, avoiding hard liquor in favor of beer with a low alcohol content) in scenarios where she knew alcohol would be readily accessible, and her peers would likely be imbibing heavily. At the termination of her follow-up appointments, Jessica reported fewer episodes of heavy drinking, as well as reduced alcohol consumption overall. She additionally demonstrated increased engagement with her values, as evidenced by greater self-reported involvement in activities related to her major, her faith, and her general health. Jessica also expressed increased awareness of her own emotional state and greater willingness to be present to and accepting of challenging emotions.

11 Treatment Implications of the Case

The present case adds additional evidence to the data demonstrating ACT is an effective therapy for individuals struggling with substance use problems (Hayes et al., 2004; Heffner et al., 2003; Lee et al., 2015; Luoma et al., 2012). Jessica’s case illustrates positive outcomes associated with exploration of values, cognitive defusion exercises, informal mindfulness exercises, metaphors, and experiential activities to facilitate increased psychological flexibility. Moreover, Jessica’s continued attendance to treatment in spite of her initial reticence to do so illustrates that MI techniques may serve as a useful supplement to ACT when working with clients who are resistant to change or engagement in therapy. MI additionally serves as an effective technique for novice clinicians to model psychological flexibility, by “dancing with discord.” The present case also adds to a growing body of literature, which suggests that harm-reduction and moderated drinking strategies may be more beneficial and feasible for college students than traditional abstinence-only models of substance abuse treatment (Baer, Kivlahan, Blume, McKnight, & Marlatt, 2001; Borsari & Carey, 2000; Parks, 2004; Weitzman & Nelson, 2004).

12 Recommendations to Clinicians and Students

There are a number of recommendations clinicians and students should consider that are reflected in Jessica’s case. The first consideration is that of how to balance the need to prevent or reduce self-harm behaviors in individuals with substance use problems, while being sensitive to clients’ beliefs about the necessity of their own care. Many individuals struggling with substance use may be either coerced into care, as Jessica was, or legally required to participate in it. In situations such as these tools such as MI when combined with ACT can be helpful for clinicians who strive to balance clients’ autonomy with apparent needs. Such a balance is particularly important from a developmental perspective in college populations, as emerging adults are often just beginning to learn how to be independent and self-sufficient. As these individuals are developing their own identity and family boundaries at this time, seeking out treatment may be especially challenging. Moreover, it may be difficult for therapists to establish boundaries with parents, even though the patient is legally allowed privacy, given the transitional nature of this period of life.

In addition to the aforementioned issues, clinicians and students should consider how the context of a college or university setting may affect the therapy process. For individuals who are struggling with substance abuse issues, such as Jessica, it may be difficult to find social reinforcement that does not involve alcohol or other drugs. This issue is, in part, solved by shifting therapy goals from an abstinence-only model to one focused on moderation and harm reduction. However, clinicians may also need to serve a greater case management role in these situations, to help facilitate students’ engagement in developmentally appropriate socialization while still adhering to their treatment goals. This may be done by familiarizing oneself with campus social events, clubs and organizations, and community activities that will be less likely to have alcohol present, or as a focus.

Finally, when working with college students in particular, it can be important for clinicians to be aware of the challenges of working with individuals on an academic schedule. This may require flexibility on the part of clinicians with regard to scheduling. Moreover, as the academic schedule often includes long breaks, clinicians should consider finding resources for clients that they may use when they are away from their college or university outpatient facility. This may involve becoming better acquainted with referral options in students’ home towns, scheduling phone or email check-ins, or providing clients with homework or other therapy resources, which they can work on independently while at home. Moreover, it is important that future research be conducted to examine how such a staggered therapy schedule may affect treatment outcomes and recovery.

Footnotes

Appendix

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Anandi C. Ehman

Author Biographies

Anandi C. Ehman is a graduate student in the Clinical Psychology PhD program at the University of Mississippi. Her research interests are in the areas of sexual aggression, cyberbullying and cyberaggression, and victim blaming.

Alan M. Gross is a professor of psychology at the University of Mississippi. His research interests are in the area of date rape, sexual aggression, and behavior disorders in children.

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