Robert is a 36-year-old attorney presenting at the urging of his husband, who unexpectedly came home during a weekday and discovered Robert smoking cocaine in their living room. Robert reports a 5-year history of cocaine use, beginning with casual use at a party with colleagues from his law office. He descries a pattern of use that was initially in his words, “recreational,” using intranasally every 1-2 weeks on Friday or Saturday nights. Shortly thereafter, he began to take an occasional “bump” at work, with the goal of enhancing energy and productivity. This pattern of use remained fairly stable for about 2 years, when he began to experience increasing stress and dissatisfaction at work, irritable and depressed mood, and increased frequency of cocaine use. In the past year, he used more days than not, generally in 2-to-3 day episodes of heavy use followed by abstinence for a few days to recover from the effects of cocaine. He has started to smoke “crack” cocaine and is now missing work on a frequent basis. Because of his husband’s concerns, Robert had recently been free of use for a period of 6 weeks, during which time he began attending Cocaine Anonymous.
While abstaining from cocaine, Robert experienced persistent low energy, poor concentration, depressed mood, and a loss of interest and appetite over the course of 6 weeks, and he then resumed use. He reports past episodes of reckless behavior, irritable mood, and high energy interfering with sleep, largely in the context of escalating cocaine use. He also reports a history of depression in college, preceding any regular substance use. Known family history is significant for alcohol use disorder in paternal aunts and uncles. Robert reports a desire to stop using cocaine because of problems at work and in his relationship. However, he worries about how to cope with low energy, depressed mood, and diminished sexual function that he experiences when not using cocaine. Robert reports surreptitious use of cocaine to enhance sexual experiences but denies sexual activity outside of the monogamous relationship with his husband.
1. What diagnoses would you consider for this client? Explain your rationale with scholarly sources and describe information that supports these findings based on assessment information.
2. What are medical concerns that you have for this client?
3 . What modes/levels of treatment would you recommend for this client? Be sure to list them in the priority in which they need to be addressed
