DiscoverCounselor Toolbox PodcastAddiction Case Study Using the PACER Method
Addiction Case Study Using the PACER Method

Addiction Case Study Using the PACER Method

Update: 2019-11-13


440 – Addiction Case Study

Using the PACER Method

Counselor Toolbox Podcast Episode 440

Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC

Executive Director,

Podcast Host: Counselor Toolbox and Case Management Toolbox

Sponsored by

Manage your practice securely and efficiently. Two free weeks of TherapyNotes with coupon code “CEU”


– Review a case study using the transdiagnostic, transtheoretical PACER approach

– As they say on Law and Order…

– The following story is fictional and does not depict any actual person or event.”


– John is 37 years old and presents for marijuana use as a requirement of his probation. He has a wife and 2 kids, 4 and 9.


– Sleep

– On an average night how much sleep do you get- 6 hours

– On an average night how many times do you wake up- __not often

– After an average night’s sleep how do you feel- Tired ___ Okay __x_ Energetic ____

– When you wake up feeling refreshed, how much sleep do you get- 8+

– Sleep hygiene self assessment.


– Nutrition

– Using a free app like SparkPeople, track your nutrition for a week.

– Which nutrients do you get less than 75% the full RDA- D, Calcium, potassium

– Which nutrients do you get less than 25% of the RDA- None

– When was the last time you had a full panel blood test to examine your kidney and liver function, thyroid and vitamin D levels- ___- months

– Describe your eating habits: I eat a lot of fast food and meat

– Do you eat due to stress or for comfort when you are upset- yes

– Do you drink at least 64 ounces of noncaffeinated, nonalcoholic beverages each day- No

– How much caffeine do you have on an average day- (100-150 mg/8oz of regular coffee; 35-50 mg/8oz of soda) 300 mg


– Nutrition

– How much nicotine do you have on an average day- (1 mg/1 cigarette; 6-24mg/vaping cartridges, 100mg/cigarillo) __200mg___

– Are you currently over or under fat- (Note: People can have a lot of muscle and not be unhealthy) _yes I need to lose about 30#____

– Have you recently had any problems with excessive thirst or hunger- __no

– Do you have problems with hypoglycemia (your blood sugar dropping)- _no

– Has your doctor tested your blood sugar lately (fasting blood test)- __no

– Do you mainly gain weight around your belly- __yes__

– Referral to PCP for physical to include nutritional evaluation, hormone evaluation and possible addition of multivitamin to address nutritional deficiencies.



– Pain

– Do you have any chronic pain- __no__

– If so what causes it-________________ How long have you had it- ____

– What makes it worse- ___________

– What makes it better- _____________________

– How has it impacted your mood/relationships/energy/sleep/self-esteem-


– Exercise/sedentariness

– Do you exercise- ____no______ If yes, how often and for how long- _________

– How is your energy, mood and appetite after you exercise- ___N/A________________

– Do you sleep better on days you exercise- __N/A___ Does muscle soreness make it harder to sleep- __N/A___


– Energy

– Which best describes your average energy level Low___ I can get through the day_x__ Great! ___

– Have you had your thyroid levels tested lately- __N__ If so were they in normal range- __-__

– Using a pulse ox monitor: What is your resting heart rate- __75_ What is your O2 saturation- __98___

– Do you have high blood pressure- _Y__ (medicated) Heart conditions- _N____ if so, what


– Libido/Sex hormones

– How is your sex drive- Low __ Good _x__ Incredible__

– Has there been any change in your sex drive- __Y___ If so when and what caused it- ____-__

– If you are over 45 have you had your sex hormone levels tested in the past year- ___N___

– How often do you engage in sexual activity- ___1-2x / week


– Do you tend to feel on edge and startle easily- ___N___

– Do you have a history of trauma- ____N___

– Do you have any autoimmune issues/inflammatory conditions like psoriasis, rheumatoid arthritis, Chron’s disease, lupus etc.- ___N_

– Have you ever had a concussion or other traumatic brain injury- ___N_____

– How often do you have headaches- ____Y__ What triggers them- _stress_

– What helps them go away- ______neck massage or ice/heat___

– Do you ever see spots or floaties when you get a headache- Y__

– Do you get migraines- ___N_____

– How often do you drink alcohol- _daily_ What do you drink- Beer/wine _X_

– How many drinks do you have in an average week- __2-3/wk

– Do you gamble or play the lottery- __Lottery___ How much money do you spend on it each week- ___$20____


– For each of the following feelings, identify how often you feel it each week, what triggers it and what makes it better.

– I feel happy 0-3 days a week __3__ 4 or 5 days a week __ More than 5 days a week __

– What 5 things help you feel happy- ___my kids, my wife, friends_

– I feel sad or depressed 0-3 days a week __0__ 4 or 5 days a week ____ More than 5 days a week ____

– What triggers it- NA

– What helps you feel better- NA

– I feel stressed or overwhelmed 0-3 days a week __X__ 4 or 5 days a week ____ More than 5 days a week _____

– What triggers it- ___Work, my kid struggling in school and being [oppositional] about doing his homework, probation, getting used to being “out”

– What helps you feel better- __Watching TV and smoking


– I feel anxious or worried 0-3 days a week _0_ 4-5 days a week _ >5 days a week ____

– What triggers it- __

– What helps you feel better- ______

– I feel angry, resentful 0-3 days a week __0_ 4 or 5 days a week __ >5 days a week

– What triggers it-

– What helps you feel better-

– I feel guilty 0-3 days a week _1_ 4 or 5 days a week __ >5 days a week

– What triggers it- ___I feel guilty that I was in jail for the past year and wasn’t able to be there for my kid.

– What helps you feel better- ___-_____


– In the past year, I have experienced the following losses which caused me to feel grief: None

– What stressors are currently present- __Trying to not violate probation, adjusting to being back with the family, son’s behavior

– What makes son’s behavior better- When I spend time with him

– What does he like to do- Play basketball at the park

– What is different when you are happy- I can smoke as much as I want and people leave me alone

– How long does it take for you to calm down after you get upset- _20-30min.

– What helps you calm down- __smoking, distracting myself___


– How is your attention/concentration- ___awful___

– Have you ever been diagnosed with ADHD- _N____

– Has there been a change in your ability to concentrate lately- _N__ How long- ___6 months___

– If so, what is causing it- __lack of sleep- Stress- I don’t know.

– Does it seem to be taking longer to process information- _Y_

– How is your memory- __Good______ Have you been more forgetful than usual- ___N_____

– If so, when did your forgetfulness start- NA What is causing it-

– When you think about yourself, your life, the world, other people, do you tend to feel angry, suspicious or hopeless- ___Y___

– If yes, have you always felt this way or did something happen to change your feelings- __Started watching the news and spending time around people__


– Negative self-talk

– Do you frequently judge or criticize yourself- _N_______

– Do you hold yourself to a higher standard than you hold other people- ____N______

– Do you think you are lovable/likeable only if you are perfect (or almost perfect)- ___N_______

– Where did you learn your negative self talk- __N/A


– Pay attention to your thoughts for a week. Place a check by the thinking errors which are most common for you and contribute to your unhappiness.

– All or none thinking Find Exceptions

– Assuming/Jumping to conclusions without all the facts Get the facts

– Focusing on a small aspect instead of the bigger picture Consider alternate explanations

– Expecting life to be fair

– Taking things too personally Consider alternate explanations

– Taking something bad and blowing it out of proportion (catastrophizing)

– Focusing on the negative and ignoring the positive

– Expecting people to be able to read your mind Evaluate how you communicated what you wanted and practice assertive communication

– Assuming you know what others are thinking. Evaluate your evidence and get the facts.

Educate about cognitive distortions and interventions. Provide worksheets to address CDs.

Cognitive: Hardiness


– Time management

– How effective are you at managing your time- ___Good __

– Do you often take on too much and feel overwhelmed or rushed- No

– Are you a perfectionist- __N___ If yes, how does that impact your mood, sleep and relationships-

– Do you procrastinate- __Y__ If yes, how does that impact your mood, sleep and relationships- __I tend to get irritable when I have something to do that I am procrastinating then irritable when I feel rushed.

Develop a schedule that includes the “must dos” delegates and simplifies when possible.


– Do you feel safe most of the time- _____y___ If no, where do you not feel safe and why-

– What helps you feel safe- __My dogs. My neighborhood.__

– Are you able to have peace and quiet when you want it and when you sleep- ___No_____ If no, what can you do to reduce unwanted noise- Headphones

– During the day are you able to access natural light, or at least a really bright working area- ___Yes_

– When you sleep, are you able to make your room totally dark or block out the light- _Y_

– Do you eliminate blue light from television and electronic devices at least 2 hours before bed- ___N__


– What smells are you regularly exposed to-

– Noxious/unpleasant/irritating _asphalt and roofing tar__

– Triggering (reminds you of something unpleasant) __musty smells (old buildings) remind me of jail

– Happy/relaxing/energizing __barbecue, home cooking

– Are you able to keep your environments at a temperature you find comfortable- __No, trying to keep utility bills down___


– Do you feel you are capable, lovable and deserving- _y____ If not, why not- ___

– Do you have healthy relationships or regularly fear abandonment- ____Healthy overall______

– Can you effectively identify and communicate feelings and thoughts and get your needs met- ___y_____

– Do you have a social support system that can provide practical assistance and emotional support- __practical assistance, yes…emotional support not as much___

Addiction Specific Questions

– Acute Intoxication and/or withdrawal: Can be managed in outpatient

– Biomedical complications impacting recovery: None

– Emotional, behavioral and cognitive conditions: Stress and anxiety that is self-medicated with cannabis and nicotine

– Readiness to change: Action due to wanting to stay out of prison

– Relapse/continued use potential: High

– Recovery Environment: Significant other smokes pot, friends smoke pot. Won’t smoke in front of kids

Addiction Specific Questions

– Relapse Prevention

– When you are not using what is different

– Kids are around

– I am at work

– I am in jail

– How do you deal with stress and cravings in those situations-

Addiction Specific Questions

– Emotional: Relief to be off probation

– Obstacle: Anxiety/stress

– Mental: Belief that I can stay clean until I get off papers. I will probably be able to concentrate a little more

– Obstacle: Knowledge of ways to defeat drug tests

– Physical: More energy/less fatigue

– More anxiety

– Social: Be able to be there for my kids.

– Obstacle: Friends use

– Environmental: May be able to move into a better place once I’m off probation

– Obstacle: Lots of drugs in the neighborhood

Initial Tx Plan goals

– Referral to PCP for hormone evaluation and nutritional assessment

– Tagamet lowers T. which can increase cortisol and anxiety. Cannabis increases T which lowers cortisol and anxiety.

– Vitamin D deficiency can lead to or worsen anxiety and hypertension

– Calcium deficiency inhibits production of serotonin

– Potassium helps regulate serotonin

– Remove all cannabis from the house

– Begin helping Sam with his homework each night and taking him to play basketball after dinner if he does his homework

– Learn about cognitive distortions and start addressing one each week.

– Learn distress tolerance skills to teach your son

– Make a list of things to do when you are feeling stressed besides smoke

Initial Tx Plan goals

– Specific Worries for Discussion (Beginning Week 1)

– Getting through probation without violating

– One day at a time

– View it as a challenge

– Psychological flexibility

– Getting my son’s behavior under control

– Positive reinforcement

– Potential LD assessment

– Not smoking pot even though my wife is smoking

– Finding other “rewards” for not using

– Talking with her about not using at the house

– Dealing with having to stay at this crappy job for the next 18 months

– Mindful focus

– Positive review and forecasting


– PCP assessed hormone levels and determined levels to be on the extreme low end of the normal range. No intervention

– Has lost 12# since starting to play basketball with his son in the evenings, reduced blood pressure medication.

– Arguing less with his wife since his son is behaving better, although she is still smoking, just not at the house.

– Has not used, but is still not intrinsically motivated to quit.


– Substances are often used to self medicate

– Helping him identify previous coping strategies and learn new distress tolerance skills (to teach his son) is helping with his stress at home and at work

– Engaging in activity with his son leaves less time to use

– Marijuana alters not only brain chemicals, but also hormones.

– Marijuana can stay in the body for a long time since THC is stored in the fat.









Addiction Case Study Using the PACER Method

Addiction Case Study Using the PACER Method

Charles Snipes