Dual Diagnosis Role Play
Learning Team B
Scenario for Role Play
Samantha Riley (a fictional character) is a 28 year old, African American, married mother of 2 children, ages 6 and 9. She is a stay at home mother who is not employed outside of the home. Samantha has experienced anxiety throughout her life but it only became problematic after her father died in a horrible car accident, six years ago. Since that time Samantha has been on shaky emotional ground. She experiences full-blown anxiety attacks daily. She lives in dread of when the next attack will occur. Her attacks have become debilitating and because they most often occur in public places she has completely stopped leaving her home alone (she will venture out with her husband). She no longer drives because of her overwhelming fears. This has been very frustrating to her husband who has to leave work several times a week to deal with the needs of the children and Samantha’s anxiety. He is now turning to extended family for relief. As tension has grown in their relationship, Samantha has turned to alcohol as a form of relief from her anxiety and stress. As long as she is intoxicated she feels some temporary relief but as soon as she starts to sober up her anxiety is intensified. She begins to feel an irregular heartbeat, chest pain, sweating, dizziness and paranoia. She literally becomes terrified by the thought of many normal activities. Her drinking has increased to the point that the children are being neglected and often take the role of her caregiver. Her attempt at self-medication has only made her disorder worse.
Scene begins in Samantha’s living room as her husband Larry comes home from work. He finds the children (Chessa age 6 and Kyle age 9) in front of the television eating a bag of potato chips. They jump up and hug him.
Larry: Hey guys (hugging them both). Where is your mom?
Chessa: She’s in bed. I tried to wake her up when I got home but she didn’t even move.
Larry: (taking the bag of potato chips) You guys hang out here for a few minutes and then I will make some dinner.
Kyle: Hurry dad, I am starving and I need help with my homework.
Larry leaves the living room and enters the bedroom where he finds Samantha. She is passed out on the bed. He shakes her several times.
Larry: Wake up Sam!! (getting louder) WAKE UP!!
Samantha: I’m awake!!! You don’t have to yell.
Larry: Sam, the kids came home 3 hours ago. You didn’t even wake up. They are hungry and have school work to do.
Samantha: Sorry it was just a hard day.
Larry: Sam your “hard days” are happening more and more all the time. I am not only worried sick about you, I am scared for the kids. They are too young to be left unsupervised. I noticed that you have been drinking a lot. We need to get some help.
Samantha rolls onto her pillow and sobs.
Samantha: You just don’t understand. At this point I don’t believe there is anything that can help me. The only time I feel half way alright is when I have a drink and now you want me to stop drinking?
Larry: I don’t want to take away the only thing that makes you feel better. I am just saying that there must be another way. Please Sam, lets try and find help. If you refuse I am going to have to hire someone to take care of the kids because I don’t feel safe leaving them with you like this.
Samantha: (yelling loudly) GET OUT!!! GET OUT!!!
As Larry exits the room Samantha pulls a bottle of vodka from beside the bed and takes two big drinks. Then she grabs the telephone to call her best friend Katie. (She has been friends with Katie since high school). She plops back on the pillow with the phone to her ear.
Samantha: Hey Katie its me (sobbing in between words).
Katie: What is the matter Sammy?
Samantha: Larry wants to send me to the funny farm.
Katie: What are you talking about?
Samantha: You know how I keep having panic attacks. Well like I have told you the only thing that helps is having a drink. Today I guess I had a couple because I passed out and didn’t wake up when the kids came home from school. Now Larry is all freaked out and thinks I need some kind of mental help. He even threatened to get somebody else to watch the kids because he says he can’t trust me.
Katie: Sammy as a dear friend I’ve always supported you and your family throughout all your endeavors. I have watched and shared in your transitions throughout life, some good and some bad. Regardless of the challenges, you have always found a way to overcome all the obstacles you’ve faced in life. But this time it is different. It has been six years since your dad died and it just keeps getting worse.
Samantha: So you think Larry is right? (Samantha’s voice gets louder) You think I am crazy too?
Katie: No, I don’t think you are crazy but I do understand the magnitude of the challenges you now face and what Larry has asked you to do. I believe in you and I will support you all the way.
Samantha: What are you saying here Katie? (still sobbing, breathing hard, voice elevated).
Katie: (speaking calmly) All I am asking is that you give Larry the chance to assist you in finding the help you need.
A long pause ensues. Samantha is still crying and audible sobs are heard.
Samantha: Katie, will you go with me? I mean to the appointments and stuff?
Katie: You know I will girl. I will support you every step of the way.
Samantha: Alright, I will tell Larry that I will get help.
Katie: I am so proud of you right now. This will be one of the best decisions you will ever make.
Samantha hangs up the phone. She gets out of bed, and looks in the mirror. She straightens out her clothes, combs her hair and enters the living room. The children both run up, excited to see her. They both give her a hug. Kyle shows his homework to her and she spends a couple of minutes listening to the children tell about their day. Larry is in the kitchen, at the stove cooking. Samantha walks up behind him and puts her arms around him from behind. She lays her head on his back.
Samantha: Larry, as hard as it is to admit, I do need help. I know you are right. Things have gotten out of control and I don’t know how to make it better.
Larry turns and hugs Samantha.
Larry: A guy at work gave me the number for a counselor named Blaine Yokum. He is supposed to be real good. I will schedule an appointment tomorrow.
Samantha: Katie said she would go with us. I know I can do it if she comes too. I always feel safe when she is around.
Larry: Sounds like a plan.
The next scene is the day of the counseling appointment. Larry, Katie and Samantha attend the appointment together. The counselor lets them stay in the office for the first five minutes of the appointment. He then asks Samantha for permission to meet with her alone. The counseling session begins.
Individual Counseling Session with Blaine Yokum, LCSW
(The counselor, Blaine Yokum is seated in a black, leather chair. In front of him is a large, wooden table with some pens and papers on it. Samantha enters.)
Counselor: (Standing and giving Samantha a hand) Hello, how are you doing? I read your intake and understand that you are struggling with anxiety and have been using alcohol to calm your symptoms.
Samantha: I am nervous and not sure I should have come here. What can you possibly do to help me?
Counselor: Samantha don’t worry. You can be helped out of this situation. I promise you that people with much worse cases of substance abuse and anxiety have been helped.
Counselor: (Leaning forward). First, you need to believe that this can get better. I understand what you are going through and with your cooperation, you can get the help you need. You need to understand that you cannot solve one proble problem by another. Alcohol cannot solve your anxiety issues. As you might have noted, it just increases the already existing problem.
Samantha: I realize that it doesn’t “cure” anything but it sure helps me feel better in the moment. Things only get bad again when I sober up.
Counselor: Since anxiety has led you to alcohol abuse. The anxiety must first be dealt with. You stated in your intake that you anxiety symptoms increased following the death of your father. I would like to continue seeing you to help you deal with the grief and loss you experienced. You have a wonderful natural support system in your family. Spending time with your family, who understand your loss will help a lot in stabilizing your emotions. Do you think you can reach out to your family when you are feeling anxious or lonely due to the loss of your dad? Samantha: I can reach out but I don’t think they can relate to how I am feeling. It just seems like they all think I am crazy.
Counselor: I can work with your family members to help them understand how to be a good support system for you.
(Samantha begins to sob and the Counselor consoles an emotional Samantha)
Counselor: In addition to doing grief work with me, I would like to refer you to Dr. Taylor. She specialized in dual diagnosis. What that means it she will be able to help you with your alcohol issues and she can advise you more on the medications that are available to reduce the symptoms of anxiety. She will know the best type of medication and will inform you of their effectiveness and possible side effects. But understand you will still have work to do.
Samantha: It all sounds so overwhelming. I don’t know what to do next.
Counselor: You don’t have to do it all at once. I suggest you check out Alcoholics Anonymous (AA) meetings. There you will find people in similar situations and thus encourage each other on alcohol withdrawal and thus overcome the challenges that accompany the decision. This will help build a support system for you while you wait for your appointment with Dr. Taylor. (Counselor hands Samantha an AA schedule).
Samantha: I know that I need to do this for the sake of my family. I just hope I can make myself go.
Counselor: Using your family as a source of motivation is a good idea. Your children need their mother’s care. Remember your loving husband who is willing to stand beside you as you work through these issues. He will be a good support for you. I know that you love them but remember that you need to get healthy before you worry about meeting everyone else’s needs. You have a good support system while you are working hard to get sober and deal with your anxiety issues. (Samantha gets her referral packet from the front desk and leave the office with her husband feeling hopeful )
Meeting with Samantha, her family members, Blaine Yokum, LCSW and Dr. Taylor (substance abuse counselor & psychiatrist):
Psychiatrist: Hi Samantha, I am Dr. Taylor—it is a pleasure to meet you. Can you introduce your family please?
Samantha: This is my husband, Larry, and my best friend Katie.
Dr. Taylor: Hello everyone—please have a seat and make yourselves comfortable. I know a little about you from the assessment forms you filled out and I want you to know that we are here for you. We want to the best thing for you and your husband and family are here for the same reasons.
Samantha: I am embarrassed that this is happening and everyone is so worried…(stutters through her sentence) I really will be fine, I am just going through a rough patch.
Dr. Taylor: Samantha, please be assured that you are not alone, there are many people who suffer with the same type of issues you are having, everyone’s situation is unique, but there are similarities.
This clinic is what we call an integrated care clinic—there is a whole team of professionals who are here to help you understand the illness you are suffering with. We specialize in clients with a dual diagnosis. Meaning people who are suffering from mental health issues and substance abuse issues.
Samantha: (sounding indignant) I am not crazy, I don’t even understand why I am here.
Dr. Taylor: Nobody thinks you are crazy, just because you are having anxiety and some issues with handling stress does not mean you are “crazy”. I have a questionnaire that I would like you to work on that will help me better understand how severe (or not) you anxiety issues are. It is called Beck’s Anxiety Inventory, it is more of a rating of some problems; like sleeplessness, nervousness, and fear of terrible things happening.
Dr. Taylor goes on to explain that a “dual diagnosis is used to describe people with mental illness who also suffer with drugs and/or alcohol abuse”. He also tells Samantha that the mental health issues could come as a result of her abuse of alcohol or her use of alcohol could be her trying to “self-medicate”. In either instance the issues should be treated simultaneously to have the best result.
He also relays that there are prescription medications that can help with anxiety that are low-risk for abuse. This may be something that could help her.
Beck Anxiety Inventory 1
Dr. Taylor explains, below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by that symptom during the past month, including today, by circling the number in the corresponding space in the column next to each symptom.
|Not at all||Mildly, but it didn’t bother me much.||Moderately, it wasn’t pleasant at times.||Severely, it bothered me a lot.|
|Numbness or tingling||0||1||2||3|
|Wobbliness in legs||0||1||2||3|
|Unable to relax||0||1||2||3|
|Fear of worst happening||0||1||2||3|
|Dizzy or lightheaded||0||1||2||3|
|Terrified or afraid||0||1||2||3|
|Feeling of choking||0||1||2||3|
|Fear of losing control||0||1||2||3|
|Difficulty in breathing||0||1||2||3|
|Fear of dying||0||1||2||3|
Scoring – Sum each column. Then sum the column totals to achieve a grand score. Write that score here 35
Dr. Taylor spends some time silently going over Samantha’s answers and writing on her assessment.
Dr. Taylor: Here is the interpretation of your results Samantha.
A grand sum between 0 – 21 indicates very low anxiety.
That is usually a good thing. However, it is possible that you might be unrealistic in either your assessment which would be denial or that you have learned to “mask” the symptoms commonly associated with anxiety. Too little “anxiety” could indicate that you are detached from yourself, others, or your environment.
A grand sum between 22 – 35 indicates moderate anxiety.
Your body is trying to tell you something. Look for patterns as to when and why you experience the symptoms described above. For example, if it occurs prior to public speaking and your job requires a lot of presentations you may want to find ways to calm yourself before speaking or let others do some of the presentations. You may have some conflict issues that need to be resolved. Clearly, it is not “panic” time but you want to find ways to manage the stress you feel.
A grand sum that exceeds 36 is a potential cause for concern.
Again, look for patterns or times when you tend to feel the symptoms you have circled. Persistent and high anxiety is not a sign of personal weakness or failure. It is, however, something that needs to be proactively treated or there could be significant impacts to you mentally and physically. You may want to consult a physician or counselor if the feelings persist.
You fall between the second and third category. Do you have any questions regarding your results?
Samantha just shrugs and looks down.
Dr. Taylor: I would like to meet with you again next week to complete a substance abuse evaluation. As stated previously there are medications that can help with your anxiety but I am hesitant to prescribe any at this time due to you disclosure regarding the amount of alcohol you are consuming. Following the substance abuse evaluation we can develop a treatment plan that will address your substance abuse issues as well as your anxiety.
Samantha: (Feeling hopeful) Do you really think you can help me? At this point I am willing to try anything to get some relief. I want to be the mother and wife I know I can be.
Dr. Taylor: Samantha, I will simply be providing the tools. You can do this and once we have everything lined up you will begin to experience very quickly as long as you follow your treatment protocol.
Kushner, M. G., Abrams, K., & Borchardt, C. (2000). The relationship between anxiety disorders and alcohol use disorders: a review of major perspectives and findings. Clinical psychology review 20, no. 2 (2000): 149-171.
Stewart, S. (2008). Anxiety and substance use disorders the vicious cycle of comorbidity. New York: Sprinkler.
(n.d.). Retrieved from https://dih.wiki.otago.ac.nz/images/8/80/Beck.pdf
Substance Abuse Treatment and Family Therapy (2011). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK64258/
(2014). Retrieved from National Alliance on Mental Illness: http://www.nami.org
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