Case Study of Depressive Alcoholic Patient

Ushna Nawaz

A major depressive disorder (depression) is a global-scale and severe public health problem that affects in a negative manner to our feelings, our thinking, and behavior. The rising co-morbidity poses a threat for the community, but luckily, it can be treated. Feeling of sadness and loss of interest in daily activities can isolate an individual and illicit multiple behaviors, mental and psychological issues.

This situation can move towards various emotional and physical problems and can cause a decrease in an individual’s ability to perform well at work and at home as well (American Psychiatric Association, 2013
Depression is also linked with alcohol dependence and substance abuse. Somehow, the relation between depression and substance abuse is vice versa. The co-occurring of depressive disorder and substance abuse are highly prevalent. According to the National Health Survey, 2010, it has been estimated that around 3.4 million adults indulge in substance abuse disorder, among which 16.9% report depressive symptoms. The current case depicted how an adult suffers from a depressive disorder and how the depressive phase leads to substance dependency. The treatment modalities have also been addressed to illustrate the current situation of the client.

Case Study

 The client was 32 years old man. He had issues in his marital life and congenital conflicts. His marriage life was disturbed. He got married at the age of 28, and he had a good time with his wife. They had a loving relationship with each other, with usual small issues. He worked abroad and often came home to meet his wife and family. They had two children. His wife’s family pressurized him and asked for a divorce and demanded alimony for his wife and kids. Both partners were not interested in getting a divorce. Meanwhile, he went abroad for some business issues; during that time, his in-laws persuaded his wife to get a divorce. When he came back home, his wife was not at home; she left home with children. This situation was the main cause of his sadness as he loved his wife and children.

 It was a sudden shock to the client. He tried to convince her wife, but it was not getting better. He became tense about all these things. The client isolated himself even from his family with whom he had a strong bond. He spent most of his time in his room. He had two suicidal attempts, but his mother saved him both time. He had lost his interest in all activities even he did not want to continue his life. He lost all his hopes and gave up. He quit his business and cut his bonds with his relatives and friends. He missed his marriage life, his wife, and their children. He just wanted to end his life. He was diagnosed with depression when his father brought him to the hospital. During this time he met some drug addicts. In the early stage, he started to smoke, and after some days he started other drugs like powder sniffing and alcohol. He took extra doses of medicines prescribed by the doctor for depression. On check-up, he was diagnosed with depression along with drug abuse. His depression led him to drug abuse. 

Conner, Pinquart, and Gamble (2009) explained the relationship between depression, alcohol, and substance abuse. This meta-analysis hypothesized that there exists a relationship between depression, substance abuse, and alcohol abuse. By accepting this hypothesis, this study proved that depression, substance abuse, and alcohol abuse are linked.

According to the American Psychiatric Association and Mental Health Foundation, depression can happen due to genetics, biochemistry, personality, and environmental factors. In this study, the prominent reason for depression is life events, the pressure faced by the client from his in-laws, the separation from his wife and from his children. According to Haris (1976), those who face long term issues (pressure from in-laws, not being with his wife and children) are more likely to become disturbed. The comorbidity of depression, alcohol, and drug abuse is also approved by (Booth, Walton, Barry, Cunningham, Chermack, & Blow, 2011). 

Case Formulation

Interventions

The following interventions have been implement to reduce the chances of relapse prevention or current symptoms.

Pharmacological Treatment

Tricyclic medication, and Serotonin reuptake inhibitors has been used to reduce the symptoms of patients during active phase.

Psychological Therapies
The therapist including individual, group or family therapies has implemented multiple therapeutic modalities. Cognitive behavior therapy and thought restructuring found to be effective for the treatment of suicidal ideation.

Psychological Intervention
Psychoeducational techniques for the orientation or education of patients regarding depressive symptom helps in the treatment plan. Support for integration in community, and psychological rehabilitation also facilitated their client to overcome his depressive symptoms.

 Prevention of substance abuse by using psychological treatment found to be effective in reducing the undesirable behavior of the client. Motivational therapies and twelve steps towards substance abuse reduction is the most effective way for the behavioral treatment for the substance abusers. 
The client is now admitted in the hospital. His condition is moving towards betterment. He is making goals to achieve and planning about his future. He has positivity in his thoughts which represent that he has good influence of treatment. His self-esteem lies in the normal range but the interpretation of HTP still shows some signs of desire of alcohol intake. His family support can play a major role at this point to make him a stable person with new vision and goals.

Impact of Social Support on Depression and Academic Performance

 International Students 

International students poses a  high risk for developing depression due to lack of social support. The students when move from collectivistic culture to individualistic cultures like America, the specifically feel more lonely and depressed. Steptoe, Tsuda, Tanaka, and Wardle (2007) indicated that students who belong to less individualistic cultures reported to have higher level of depression as compared with the students who came from more individualistic cultures.  This indicates that the strong social bonding in collectivistic cultures is missing in individualistic cultures where the students feel more lonely and depressed. Constantine, Okazaki, and Utsey (2004) indicated that the Asian students from the China, India, Pakistan, Taiwan and some other Asian countries were reported to be less depressed when compared with the students of African and Latin American countries. This study indicated useful differences among the level of depression and students of different cultures studying internationally. The prejudice and bias against the blacks might be a reason for the higher level of depression. Wei et al. (2007) in another study indicated that acculturation stress, the stress student’s face when being in another new culture is strongly associated with depression among these students. Lack of adjustments, cultural differences, prejudices, language barriers and inability to make new friends might be the contributing factors.Personal and social loneliness, both could be the causal factors of depression among the international students.  
Social Support
Social support definition refers to the assistance provided by society and the family. Social support analyst, researchers and psychologists  reported four types of social support, i.e. emotional, informative esteem and tangible support.  Literature has postulated the social support benefit on a high scale, by stating numerous social support example from diverse culture. Recent studies depicted that social support measures helps to investigate the level of social support an individual receives in particular culture. These measurements helps in promoting mental health and academic performance of the international students. Social supports is one important factor which is helpful in alleviating depression and loneliness’ and help the students in getting better adjustment in a new culture. When seeking help from the emotional and social problems students tend to turn towards the parents, older friends and other fellow peers to get help (Leong & Sedlacek, 1986). This indicates that social support lowers down the levels of stress being experienced by the students and helps them overcome loneliness. Baloglu (2000) indicated that friends are seen to be the most preferred source when it comes to seeking social support accompanied by parents, teachers. He asserted that friendship provides the most important social network support system to the students. Lack of the social support as its difficult for the international students to make friends leads them towards loneliness and depressive symptomatology.

Social support and depression are strongly linked together. It is estimated that social support helps in countering the experiences of stress as well as enhance the well-being (Dalgard, Thapa, Hauff, McCubbin, & Syed, 2006). Students studying in different cultures have to face a number of problems like academic issues; self-criticism and lack of support which leads them towards avoidance and makes them perceive very low level of social support which further makes them depress (Besser & Neria, 2010). The culture also impacts the way people use social support as a coping strategy to overcome depressive symptomology. For example, studies have indicated that Asians and Asian Americans and Arabs very less use social support as coping strategy for dealing with stress as compared to Eurpoen American’s and Jews (Taylor, Sherman, Jarcho, Takagi, & Dunagan, 2004). Thus, the level of social support, its use as coping and its availability all impact the depression symptoms among the international students.

Academic Performance 

University and college students especially those in early years of education often experience stress as a result of transition in academic life. Many students have moved away from their places and homes and faced with the dire need to develop new social networks (Geiger, 2013). In addition to all these problems, they also have issues in adjusting to the new rigorous academic expectations and also require learning to interact with students from new cultural backgrounds (Day & Livingstone, 2004).  This generates a strong link for vulnerability towards depression and making the students vulnerable towards depression and also academic failure having low social support.

In working on academic tasks, social support is one very important factor which helps the students get motivated towards the task. The peers, family, supervisor or teachers and the institution, in which the task is undertaken, all play significant role in determining the academic performance. Perceived social support actually corresponds to the perception that these important members around us are supportive towards us (Reynolds & Clements, 2005). As social support is associated with lowering down the psychological stress, it is highly associated with the better performance and motivation.

Dollete et al. (2004) indicated that social support acts as a protective factor that decreases psychological problems among the students including academic stress and anxiety. Further, it has been found that social support provides and enhances motivation and helps students enhance their performance. Social support significantly impacts the achievement of the students. As family, friends and other significant individuals play an important role and are sources of social support; these sources are found to have significant impact on the academic achievement (Steinberg and Darling, 1994). Thus, lower the level of social support the higher will be depression and poor will be academic achievement and performance. This appears to be more significant for the international students who are facing a number of challenges in the new cultures as well as academic expectations and loneliness, being away from family and home and difficulty in making new friends. Collectivistic and individualistic cultural differences also play their significant role in their psycho social adjustment and thus impact their academics.

 Afro Centric Perspective       

        Considering the Afro Centric perspective, very few researchers have addressed the problems faced by the international students from the African American descend and studying in U.S. It has been found according to the available literature that the common stressors and problems faced by the Afro centric students studying as international students are of discrimination and stress related to acculturation. Being a apart of diverse population, these students have values and beliefs different form the cultures they move into and thus, face a lot of problems in adjustment. Apart from being prejudiced against and being subjected to discriminatory attitudes, the coping strategies of the Afro American groups are different when it comes to responding to the acculturative stress(Finch & Vega, 2003). The Latinos have been found to be more frequent users of social activities and spiritual and religious coping and get support from these domains as compared to white population. They differ not only from the type of social support but also the amount of support they require.

Prelow (1997) indicated that African American and Latino students receive more social support as compared to the White students , having different ethnicity and culture and social support is extremely important for them because of string family support and group orientation in their culture. Smart and Smart (1995) investigated the issues which were unique to the Latino Immigrant students compared to the European immigrants. The study indicated that Latinos have a strong cultural commitment, culture of cooperation, collectivism and intergenerational family structures and experience more stress when in a new culture because of geographically limited ties and more family bonding.

Theoretical Framework

This study takes into account the cultural differences among the international students and acculturation phenomenon which leads towards various different kinds of stressors, including academic stressors and adjustment problems, social support is seen to mediate the role between depression and academic achievement. Conceptually Berry (1997) proposed an acculturation framework to explain the process of the adjustment who tries to establish their lives in a new country. He indicates it to be a long process. Berry while giving his theoretical framework emphasized that the factors before acculturation i-e pre arrival and during the process of acculturation i-e post arrival. In addition, he also highlighted the group and cultural context as well as individual and psychological context. In this study, acculturation framework of Berry can be applied. The lack of social support could be attributed to the differences in cultures like coming from a collectivistic culture and trying to make new friends in an individualistic culture and making friends, which becomes difficult and thus leads to loneness and depression. The problems in psychological well-being and lack of social support then impact the academic performance.

Another theoretical concept important to elaborate and coming from the Berry’s (1997) Acculturation framework is need to belong .Baumeister and Leary (1995) indicated that need to belong is the fundamental human need and is crucial to the cognitive process and in indicating positive affect.  Thus, in a new culture when an individual could not fulfill this need to belongingness, it not only leads to academic problems (poor cognitive processing) and also leads to loneliness and depression or negative affect (lack of positive affect).  Further, the social determination theory SDT (Deci & Ryan) posits that the need and desire to have high quality social relationship is central to the needs of the human beings. This psychological need is central to their academic motivation as well as well-being. Positive supportive relationships in the context of family and peers lead to better emotional adjustment, wellbeing and academic success. In this way, when the international students move to another country for studying, they often have less contact with the significant others, being away from them and often hide their issues from them. On the other hand, they also have problems in making new friends in the new culture as the literature suggests and thus they have less social support which leads to low academic motivation and thus achievement.

It is also important to include the concept of motivation to explain how social support impacts psychological wellbeing and academic success.  According to theory of motivation (Eccles & Wang, 2012), the relationship between perceived social support and commitment are likely to be mediated by the students’ perception about themselves and the task they are going to perform. Thus, engagement is seen to be a proximal factor and predictor of achievement. When someone is there who encourages us, advises is and guides us, we have more confidence in ourselves and also like and started enjoying the task. Thus, the social support helps us get more engaged in the task which ultimately leads towards better performance and achievement. Thus, keeping in view this theory and applying it to the current study and on the perceived of the international students, it is important because these students often do not have direct contact with the significant others and lack social support. They get less encouraged, have low levels of self confidence in the new environment and thus lack the desire to work hard for the task which leads to poor academic achievement and performance as well as sadness and loneliness which leads to depressive symptomology. Thus, these three theories will inform this research.

Significance of Social Support for International students

Author Sana Rehman

In 2008, it has been estimated that more than 3.3 million tertiary international students are studying worldwide. This shows a very huge percentage(OECD, 2010). The world has become a global village so almost every country is welcoming students, sometimes through scholarships, exchange programs and sometimes through the links between government and universities Overall, half of all tertiary students choose to study in United Sates of America (USA), 10% in United Kingdom (U.K.) and 7% in Germany , France and Australia. Other hosting countries include Canada, Russia, Italy and Japan (OECD, 2010). International students are seen to be important financial service provider for these countries, where almost $19 billion are contributed annually to each Australia and U.S. while almost $14 billion to the U.K (Australian Education International, 2010; NAFSA, 2010; UK Council for International Student Affairs, 2010).

These international students not only are a valuable financial asset but also enrich the countries with their diverse heritage and perspectives and thus lead towards better cultural awareness (Bevis, 2002; Harrison, 2002). The international students also bring along with them wide range of knowledge and skills to the host countries and also serve their work force well. Despite that, it is actually mutually beneficial when two cultures come together and come in contact and share their values etc, living in a different culture is challenging (Berry, 2005). Moving to a new foreign country brings a number of potential challenges including acculturative stress, adjustment problems and academic stressors. The adjustment issues that it initiates could not only have negative consequences for the psychological health of the students, but could also impact their academic achievement and leads to poor academic performance.  Research evidence supports this assertion by indicating that the academic stressors which international students in the US have to contend with are much tougher than the ones faced by American national students (Misra, Crist & Burant, 2003). Literature also establishes the importance of social support by indicating that social support from a variety of sources could help students achieve a substantially better academic output (Rosenfeld, Richman & Bowen, 2000).  The lack of social support, academic stressors and loneliness are the factors which impact the academic performance of the students.  Wang, Lin, Pang and Shen (2007) indicated that in addition to the adjustment issues, international students face some common stressors during their transition. These include academic challenges, the pressure to succeed in unfamiliar educational environments, anxiety related to second language, homesickness, issue self-esteem, housing issues , understanding and accommodating in new culture , lack of social support, discrimination, and stereotypes.  In case the social support could be enhanced, the stressors could be easily overcome and international students can get benefit from their academics in appropriate way. Seeing this, this study is quiet timely in addressing the impact of social support on depression and academic achievement among the international students studying in American, which is the country hosting the largest number of international students.

Social Support

Kahn (1979) conceptualized social support as involving the expression of positive effect towards someone, or the promotion of another individual’s behaviors or views (p. 85). House (1981) links social support to be acontract in which emotional concern and aid is exchanged between two individuals bonded together. Interpersonal relationships are very important. They make the  social support at available throughof information, emotional concern and help are seen to promote health by imparting feelings that one is being cared for, beliefs that one is esteemed, and a sense of belonging to a reciprocal network (Aro, Ha¨nninen, & Paronen, 1989; Cauce, Felner, & Primavera, 1982)

There are various factors which are associated with the better adjustment, mental health and ability to overcome the problems. Of these factors one important factor is social support. Social support is associated with higher level of adjustment and better ability to cope with stressors. As international students have to face a number of stressors while studying abroad like cultural change, being prejudiced, language barriers and adjustment problems etc, social support can be a protecting factor for these students.  The role of social support is central to the international relocations because the overseas students have to face the disruption of established social support and face the challenges to meet the new ones (Copeland and Norell, 2002).  Within the framework of stress and coping, social support is considered and found to be an important predictor of psychological adaption especially during the cross cultural transitions. It is found to have positive impact on the psychological adjustment and better coping in new culture (Brisset, Safdar, Lewis, & Sabatier., 2010 & O’Reilly, Ryan, & Hickey, 2010).

Summer, Poyrazli, & Grahame (2008) examined the social support in relation to depression and anxiety along with some demographic variables like age, gender, length of stay and English proficiency among international students. 440 international students participated in the study. It was found that lower level of social support is associated with higher levels of anxiety and depression among the international students. Similarly, in another study Basol (2008) carried out a study on validity and reliability of multidimensional scale of perceived social support among students of Turkey. This study also indicated significant role of social support in psychological adjustment.

O’Reilly et al (2010) used the multidimensional scale of perceived social support to explore the social support from significant others like friends, family, relatives etc and its impact on variables like psychological well-being, loneliness , stress and sociocultural adaptation among the international university students. This study gave a significantly different findings indicating that though the students had high level of social support and low level of loneliness and stress, still they were experiencing problems in cross cultural adjustment and psychological distress. Another study by Brisset et al (2010) also gave mixed results. They studied trait anxiety, distress, social support, cultural adaptation and identification among 112 Vietnamese students studying in France and also French students undergoing transition in French university. This study found that the higher the social support, the lower the psychological distress among the international Vietnamese students, however the hypothesis was not proved for the French students undergoing transition in their own universities.

Yusoff (2012) conducted a study on self-efficacy, perceived social support, and psychological adjustment in international undergraduate students in a public higher education institution in Malaysia. This study also addressed the international students studying in Malaysia. As globalization is increasing almost all countries facilitate the foreign students to join their universities.  Total 185 international students from different universities were addressed. It was found that self-efficacy and the dimension of friend and significant others support while addressing social support were significantly related to better psychological adjustment. Sawir, Marginson, Deumert, Nyland & Ramia (2008) indicated that 88% of the international students who felt lonely turned towards social networks in order to overcome their loneliness. The social support sources most commonly reported were the friends, family and relatives. Actually this study indicated that the relationship with co nationals were not enough to overcome the loneliness and problems in new culture and actually the students who felt loneliness also had encountered problems in making new friends in the cross culture. Thus friendship with host national is important for reducing the levels of stress and loneliness.

Romantic Relationship Development

Author: Amina Mustafa

Everyone wants to seek love, and the intensity or progression of love or romantic relationship increases with age, duration, and experiences. Love is the most common emotion in all human beings, which helps in the formation of a romantic relationship (Langeslag, & van Strien, 2016).  There are several types of love, but many people find its expression in a romantic relationship with a well-matched partner.

Romantic relationships include many essential aspects of life, provide the source of self-accomplishment. The need for love is appeared to be innate, but the capability to structure healthy and loving relationships is learned (Eimer, 2000).

Some studies show that a steady relationship is a start from infancy, where the child seek care, warmth, love, affection, protection, and social contact by the caregiver (Moser, 2014). Such links are not fate, but they are theorized to establish extremely fixed patterns of relating to others.

There are many reasons for failed relationships, and the failure of a relationship is often a source of great psychological grief. Most people have to work consciously to master the skills necessary to make relationships continue and flourish.

Factors for developing Strong Romantic Relationships

Role of Self-Esteem

Self-esteem is reported to be consistent in the development of a romantic relationship. High self-esteem leads to a stable relationship, while low self-esteem is associated with breakups (Tacikowski  & Nowicka, 2010). Self-esteem is critical for the mental health of an individual and increases contentment in relationships. it helps an individual in multiple ways such as to determine

•        Your view of your value as a collaborator.

•        How you think others see you and how that influences your choices.

•        How you see your motivation throughout everyday life.

•        How sensibly you evaluate your qualities and shortcomings

Individuals with high self-esteem are frequently sure, particular about themselves, and exceptionally energetic. High self-esteem is a foundation for growing great connections since it takes into account a more profound association with others.

Role of Acceptance

The purpose of "Acceptance" is significant in any exchange of relationship. It includes both self-acknowledgment and acknowledgment of the other individual.

A fundamental piece of making solid connections has the option to watch your emotions without judgment. Individuals who acknowledge themselves as they seem to be, not as others may need them to be, are commonly more beneficial and progressively content.

It is imperative to have a reasonable feeling of your qualities and shortcomings. While there is consistently opportunity to get better, it is harming to be too self-basic. Change happens after some time, and it is essential to permit yourself at that time (Karen Lawson, 2016).

Self-Acceptance

 A basic requirement for making solid connections is dependent on the ability to assess your emotions without judgment. Individuals who acknowledge themselves as they seem to be, not as others may need them to be, are commonly more beneficial and progressively content.

It is imperative to have a genuine feeling for evaluating your qualities and shortcomings. Change happens after some time, and it is essential to permit yourself at that time.

Acceptance of Other

 It is additionally essential to acknowledge the other individual in the relationship. The relationship doesn’t include sufferings or maltreatment and undesirable control; rather, you need first to ensure yourself. In any case, generally, the partner should attempt to comprehend where the individual is coming from as opposed to passing judgment on them. As you accomplish for yourself, have a reasonable acknowledgment of different qualities and shortcomings of others and recall that change happens after some time (Karen Lawson, 2016).

Compatibility

Compatibility is imperative in a relationship, and partners should be compatible with each other. There should be no risks for negative thoughts and wrong perceptions to emerge about each other. If both have similar needs, thought process and desires result in developing the relationship for a long time. In contrast, the Individual with opposite desires aims and goals encounter the failure.

Communication

Communication is an important part of the relation, both verbal and non-verbal communication develop or distort the relationship. Feelings expressed by the words can create misunderstanding or strengthen the bond. Therefore; partners need to reciprocate and express their feelings through various modes of communication for a long-lasting relationship. Silence can affect the bond, and problems are bound to come. Tone and pitch in communication play a significant role, and partner needs to speak softly in a convincing way. Keep in touch with your partner by telephone, emails, and use the different mode of communications for healthy relationships. The connection provides for the lovers to take an interest in each other, particularly long-distance partners.

Honest

Honesty requires truth and openness and truth rather than lies and cover-ups. Stay honest with your partner. Try to be emotionally honest with yourself and with the partner as well and don’t lie or conceal things from your partner. Don’t use harsh words and never abuse your partner. Clear the conflicts at the spot by choosing the appropriate words. Being honest towards yourself also recommends that stop bottling up your emotions or projecting for a wrong person should be avoided.

Stay calm

Don’t exaggerate the little conflicts in relation. Stay cool. Adjust with your partner. Don’t feel shy to say sorry if you are right. Also, avoid using abusive language in disputes or conflicts. Choice of words should be appropriate in resolving disputes. Verbal or non-verbal aggression may worst the situation; therefore try to the active and patient listener to form a positive and healthy relationship. The ability to understand the point of views of others, even if they are not in your favors are essential to developing a strong link between partners.

Forgiving

Forgiving is the kindest act of human being, which can develop a positive atmosphere all around. The act of forgiveness not merely develop positive relationships but also promotes the feelings of respect and Forgiveness for your partner. Stay with your partner even in the peak of misunderstanding. Be apologetic and always open your arms for each other. Do not spoil your relation to meaningless conflicts, and prefer forgiving in any matter.