We present the case of a 41-year-old male.
She lives alone in Barcelona and has no partner.
It works in the military field, which implies availability to travel to other countries frequently.
At the time of attending the clinic, a stable location change is proposed in the workplace.
Her family lives in another city and is also closely related to the military sphere.
Their social environment is closely linked to alcohol consumption in leisure time, as well as their work environment.
It has a low level of satisfaction in their personal and work life.
The main demand focuses on the treatment of alcoholism and mental disorders, as well as on behaviors encompassed as a disorder in their lives in general.
Regarding alcohol consumption, the client cannot be more than two days in a row without drinking for seven years.
A baseline of 8 daily alcohol consumptions is established, reflected in the state of drunkenness in which they come during the first evaluation sessions.
Consumption increased 12 years ago, with a decrease in bulimic behavior.
When you go to a bar alone, try to go to different places so you don't see your friends.
If you drink accompanied, you usually do it with colleagues and your friend, but also in other leisure situations.
The pattern of consumption would fit with the alcohol consumption disorder defined in DSM-5 (APA, 2014) as “a problematic pattern of alcohol consumption that causes clinically significant deterioration or distress”.
It includes a series of diagnostic criteria, having to meet at least two of them for at least 12 months.
The client meets most of the criteria, including the temporal criterion.
On the other hand, prescriptions begin when the patient is 19 years old and decrease considerably over a period of 3 years.
In the last 2 years he has purged himself again after bingeing at a frequency of 3 times a week, all of this elicited by verbalizations of failure as “I have passed”, “I have uncontrolled myself”.
Nerve disturbance is characterized by recurrent binge eating episodes accompanied by inadequate compensatory behaviors, such as self-inflicted vomiting or laxative use (DSM-5; APA, 2014).
The severity of the disorder is diagnosed based on the frequency of these compensatory behaviors, which can be mild, medium or severe.
In this case, the client would meet criteria to be diagnosed with mild nerve damage.
Evaluation
For the evaluation we used the unstructured interview, complemented with self-reports.
This phase extends formally during the first three sessions.
After the evaluation, the work line and the central objective are established, which will be fundamental for the fulfillment of other objectives: to increase self-control.
The periodicity of the sessions begins weekly, but as the treatment progresses, it becomes mandatory every two weeks until the end of a monthly follow-up starting from the eighth session.
Acquisition is important to analyze the results achieved during the intervention.
As the client does not present health problems, the goal in relation to the drinking pattern is to modify the consumption situations instead of proposing a reduction, although this reduction is achieved as a result of the work performed.
Given that it is a reinforced behavior in their environment, it would be inappropriate to address the objective to abstinence, since what is intended is to eliminate the pattern of problematic consumption, assuming it generified by a more controlled discomfort than not.
Thus, the client can achieve consumption outside the problematic parameters as well as maintain access to their social reinforcers related to alcohol consumption.
That is why therapy is aimed at facilitating discrimination against mental illness.
Functional analysis
The functional analysis of the case is presented below, based on the model proposed by Segura, Sánchez et al. (1991).
Dispositional variables
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Within their learning history highlights the high compliance with standards, which has been greatly strengthened in the family and work environment, given the demands that both contexts require related to the military.
This means that their conduct, to a greater extent, has been governed by external discriminative factors.
All this, coupled with the absence of internal discriminative behaviors, with an essentially non-working behavior control elements (such as living alone, not having a partner, traveling often) outside the learning environment, has precipitated an absence of self-control.
Certain conditioning conditions precipitate a lack of control and binge eating.
On the other hand, the absence of consequences related to uncontrolled behaviors also contributes to the continuous emission of this response pattern.
The low rate of reinforcers precipitates that the client present in a low mood state and increases the reinforcing value of drinking behavior, because alcohol is one of the few reinforcing factors to which it is easy to maintain.
A work environment perceived as undemanding facilitates the consumption of alcohol, as there are no consequences harmless to the professional work.
Another added factor is that the social relationships that occur at work are developed mostly around drinking and food.
All this has facilitated the idea that leisure and leisure time are associated with alcohol consumption, which precipitates that people drink alone when they have free time.
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Functional variables: binge eating and vomiting
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Acquisition hypothesis: it is based on a previous pavlovian association between caloric food intake and malaise responses.
To eat caloic food, however little, elicits verbalizations of failure and guilt (“I have passed”).
It is hypothesized that this association keeps the client in a state of deprivation regarding these foods: it avoids eating them.
This association also leads to feelings of guilt when consuming these foods, discriminated against this behavior due to boredom.
Maintenance hypothesis: the state of deprivation of the client increases the reinforcing value of the caloric food.
Once the intake, guilt and discomfort have occurred, they finally elicit verbalizations of permission and anticipation of vomiting, which discriminate binge eating behavior, maintaining the enhanced binge eating effect.
This leads to a series of unpleasant, conditioned and unresponsive sensations that discriminate vomiting in order to reduce the discomfort caused by them.
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Functional variables: alcohol intake
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Acquisition hypothesis: the client presented alcohol consumption within normal parameters, related to social situations of leisure.
The maintenance of this type of leisure can lead to the perception of alcohol as a way to obtain social reinforcement, in addition to the reinforcing agents of alcohol (knowing, effects).
Consumption began to increase at a time when binge eating disappeared.
Drinking became a subject of eating, with the consequent negative reinforcement of feeling full without eating.
The increase in consumption began first at home, then began drinking alone in bars for obtaining social reinforcement and spending less time in their homes.
It is worth mentioning the influence on the increase in consumption of some dispositional variables.
For example, a certain deficit of reinforcers could precipitate a higher consumption of alcohol because it would lead to obtaining them at a lower cost.
Maintenance hypothesis: the dispositional variables mentioned above would also be exerting some influence on the maintenance of the problem.
When you drink accompanied is usually in leisure and leisure time situations associated with consumption.
Instead, when you drink alone, you feel bored.
Consumption is also discriminated against by certain routine situations.
There are a number of stimuli that discriminate control behaviors of alcohol consumption: healthy eating at work, going to the gym, having a partner, performing household chores nothing more.
They will be very important for the start of the intervention.
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Treatment
Based on the previous functional analysis, a series of treatment objectives are proposed:
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Focus on a more organized lifestyle.
It focuses on achieving the client to be able to follow a stable schedule between week, arriving punctual to work and attending the gym, among other activities or tasks.
It is also sought that the client has a more ordered and planned eating pattern, as well as healthier.
This objective has great relevance in this case, as it is assumed that general disorganization and lack of control have precipitated other problematic behaviors.
Decrease alcohol consumption and increase control capacity.
The decrease in consumption is oriented to the frequency and situations in which it occurs.
Thus, it changes from an unjustified pattern of consumption to a more normalized one, and can drink in social or leisure situations where appropriate.
The most important part is the control over consumption, understanding as such that the client can decide to drink or not and be aware of this decision.
Atracones and vomiting.
It focuses on the elimination of binge eating behaviors as well as submissive purges.
It also includes the introduction of a greater variety of foods in the diet.
Loans guaranteed by reinforcing sources
This objective is central in the case, since the deficit in this area has been able to influence the increase in consumption.
It is divided into three sub-objectives: carrying out gratifying activities alone, performing social and leisure activities unrelated to alcohol and, finally, seeking a partner.
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To achieve these objectives, a series of intervention techniques are developed and implemented, both inside and outside the session, in the latter case, using them as tasks for the week:
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Objective 1 is working through the establishment of a behavioral organization or planning calendar.
The implementation of this calendar, and therefore the achievement of the first objective, facilitates change in other problematic areas.
Objective 2 is achieved by implementing different strategies.
First, a molding of drinking behavior with control is performed.
Second, a training in the detection of discriminative stimuli of drinking behavior is developed inside and outside the session, through therapeutic interaction and self-reports.
Third, the client is trained in self-control, seeking that his own verbalizations acquire discriminative value to guide his behavior.
Objective 3 is carried out by means of exposure technique with response prevention, focused on increasing the amount and frequency of calorie intakes without compensatory behaviors.
The sub-objectives included in Objective 4 are achieved with specific guidelines related to each of them: to insert in the calendar certain moments to carry out activities alone, to guide social contact pages and to use pages of group.
During the achievement of this goal, new problematic behaviors emerge in relation to the search and maintenance of couple relationships.
For this reason, from the ninth session, these behaviors are evaluated and treated as a new demand, being of great importance for the maintenance of the other objectives.
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An objective that works in parallel to the above, and transversally during therapy, having more weight in the last sessions, is the detection and coping of risk situations, which is known in the literature as prevention of relapses PalmerL 1999.
coping strategy: coping strategies presented by Marlatt et al.
If you do, your perception of self-efficacy will increase and decrease the chance of a relapse.
However, if adequate responses do not appear, the opposite effect will occur.
It is based on the approach of Bandura (2005) that perceived efficacy or self-efficacy is not a global or stable feature of the person, but a set of self-beliefs linked to differentiated functioning areas depending on the situation.
It works in this line from the eighth session, in which the difference between a relapse and a fall is explained, reorganizing verbalizations of failure or regression, taking the negative value for proper management during the same week and highlighting.
This would improve the self-efficacy and sense of control perceived by the client.
In previous sessions, relapse prevention is also carried out, with tasks and discriminative tasks being guided by both strategies, which the client detects risk situations and emits control and coping responses in them.
This part of the therapy is especially important in this type of problem, since if in a risk situation the subject manages to emit an adequate response to avoid consumption, the sense of self-control and self-efficacy increases and the probability of relapse.
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Results
To analyze the results, we focused on the first three objectives: to achieve a more organized lifestyle, decrease alcohol consumption by learning to control it and eliminate vomiting and binge eating.
The fourth objective, increased sources of reinforcement, would be reflected within the establishment of a more organized lifestyle, worked with the behavioral organization calendar.
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Throughout the treatment it is observed how problematic behaviors have evolved, reworking its emission as the therapist guides consumption parameters for weeks.
There is a decrease and withdrawal of alcohol consumption, obtaining more normalized consumption parameters.
Alcohol intake when only at home was eliminated from session 7 and alcohol intake was controlled when it was out of the home alone between session 7 and 8, having previously reduced the frequency.
Figure 4 shows the second objective of reducing and controlling alcohol consumption.
This consumption of alcoholic beverages decreases as consumption parameters are guided.
Figure 4 shows that during the first treatment sessions (week 1 to week 3, most frequently occurring in weeks 4, 5 and 6), the largest units of alcohol consumed and the lowest amount of wine consumed were those with a higher frequency of alcohol consumption.
The data for sessions 7 and 8 (weeks 5, 6, 7 and 8) reflect a reduction in the frequency of consumption per day, considerably decreasing during the week and weekends.
Finally, data from session 9 (week 9 to week 15 of treatment) indicate that the client not only reduces the consumption of alcoholic beverages, but also incorporates a greater variety of alcoholic beverages with brewery or soft drink.
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The perceived excess of consumption is reflected in Figure 5, which represents the verbalizations that the client issues in session in relation to their perception of having exceeded alcohol consumption and records related to specific tasks that indicated the therapist.
It can be observed that in the marks corresponding to session 8 and 9 (from day 40 to 80) this perception of excess continues to appear, but this time associated with a lower and more controlled consumption.
This implies a change in the perception of alcohol consumption and in relation to cessation of drinking.
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Figure 3 shows the performance of activities in a behavioral organization calendar related to the objective of promoting a healthier lifestyle, including reinforcers.
The maximum number of daily activities is indicated by a maximum score of 10 indicating the number of items to be met.
What is relevant in this case is the reduction of days that may indicate lack of control by not fulfilling any item.
In measurements from 1 to 20, corresponding to the days between sessions 4, 5 and 6, days of non-compliance with tasks are observed with a weekly frequency and consecutively.
In the measures corresponding to sessions 7 and 8 (from day 20 to 50), there is a considerable reduction in the number of days in the non-compliant item scores, which means that those days with family and work events make compliance more difficult.
Finally, in the period between day 50 and day 80, corresponding to session 9, a more stable compliance can be observed, although with exceptions of non-compliance tasks related to the presence of social events hinders or work journeys.
The pattern change in relation to binge eating and vomiting is also evident and very early in time.
They only occur on two occasions, when symptoms appear at weeks 5 and 6.
The elimination of binge eating is worked from the sixth session, with a total achievement from the beginning of the application of the exposure technique with response prevention, introducing more and more calorie-controlled foods perception to reach 10 session.
Vomiting is eliminated from session 3.
These results indicate, tentatively, the presence of high compliance with the guidelines, as well as a high commitment to therapy.
The results indicate a significant improvement in relation to the acquisition of a more organized lifestyle and greater self-control in relation to alcohol consumption and compliance with activities.
