Substance Use & Ambivalence
Carlos, 38, electrician, self-referred
Fictional teaching case
Compare the formulations ↓Presentation
Drinking 6-8 beers nightly, more on weekends. Two DUIs in three years. Wife gave an ultimatum. Says: 'I don't think I'm an alcoholic; I just drink to unwind. But I can't lose my family.' Minimizes consequences but showed up voluntarily.
Read the full case history and clinical context
Mexican-American, first-generation. Father was a heavy drinker ('but he worked every day'). Started drinking at 15 with cousins. No prior treatment. Union job with high-stress culture where drinking is normalized. Two kids, ages 4 and 7. Wife is Anglo, non-drinker.
Compare how approaches understand this case
Two approaches to begin with; change them below. These are starting examples, not a clinical ranking.
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Showing 2 of 7 formulations.
Contingency Management
Drinking is maintained by immediate reinforcement (tension reduction, social reward) that overpowers delayed consequences (DUI, marital problems). The reinforcement schedule needs restructuring: abstinence needs immediate, tangible rewards to compete with the immediate reward of drinking.
Concrete incentive system: regular monitoring (breathalyzer or urine), tangible rewards for abstinence periods (vouchers, privileges, recognition). The rewards must be immediate and meaningful. Often combined with other approaches.
"Here's the deal. You blow into this twice a week. Every negative reading earns a draw from the prize bowl, and each one in a row adds a draw on top of that. One positive and you're back to a single draw. It sounds almost insultingly simple. It also outperforms most of what else is in this building."
CBT
Drinking is maintained by automatic thoughts ('I deserve this after a hard day,' 'One beer won't hurt,' 'Real men handle their stress'), positive outcome expectancies, and lack of alternative coping skills. High-risk situations (after work, weekends with friends, conflict with wife) trigger the behavior chain.
Functional analysis of drinking: triggers, thoughts, behavior, consequences. Cognitive restructuring of permission-giving thoughts. Develop alternative coping for stress (the unwind function). Drink refusal skills. Relapse prevention planning.
"Let's map out last Tuesday evening. You got home from work, what happened next? What were you thinking? What were you feeling? ... So the thought was 'I earned this.' What would happen if you tested that thought?"
DBT
Carlos uses alcohol as his primary emotion regulation strategy. He likely has underdeveloped distress tolerance: the transition from work to home is a vulnerability point. The cultural context (machismo norms around emotional expression) means he has few sanctioned ways to process stress, fear, or vulnerability other than drinking.
Distress tolerance skills for the transition moments. Mindfulness to notice urges without acting on them. Interpersonal effectiveness for the marital relationship. Emotion regulation: naming and tolerating what drinking is medicating.
"Six o'clock is the hinge. You're wound up, you're home, the beer is right there, and it works. So let's plan the hinge rather than the drinking: what happens in the twenty minutes before you open the first one, and what could go in that gap that you would actually do?"
Seeking Safety
Nothing in the referral establishes trauma, so this is a hypothesis to check rather than a formulation to act on. Growing up around a heavy-drinking father, a trade with a high injury rate, and two DUIs are all places something could sit without ever having been named. If the drinking is medicating something, treating the drinking alone will fail. Seeking Safety works both at once and does not require a trauma narrative: safety comes first and stays first.
Safety as the overarching goal: safety from substances and from trauma responses. Coping skills that address both: grounding, asking for help, setting boundaries, creating meaning. Psychoeducation on the link between trauma and substance use.
"Sometimes people drink because something underneath is too hard to feel. I'm not saying that's you, but I'm curious: what does the drinking turn off? What would you have to feel if you couldn't drink?"
Motivational Interviewing
Carlos is ambivalent, and ambivalence is the ordinary condition of someone considering a change rather than a stage he is stuck at or a symptom of denial. He can see reasons to change (family, the DUIs) and reasons not to, and he has been arguing the second set to himself for years. Whoever voices the case for change is the one who gets persuaded by it, so if the therapist takes that side Carlos will take the other. His own change talk is the only kind that predicts anything.
Engage first: a man who has never been in treatment and does not accept the label decides in the first session whether this is safe. Focus on what he is actually willing to work on. Evoke, by developing the discrepancy between what he says matters (his kids, his marriage, his license) and where the drinking has taken him, and by pulling for change talk rather than supplying it: 'What worries you most about your drinking?' When he minimizes, that is sustain talk, not resistance, and the response is a reflection rather than a correction. Plan only once he is talking about how rather than whether.
"On one hand, drinking is how you unwind, it's part of your social world, and you don't think it's that bad. On the other hand, you've got two DUIs and your wife is ready to leave. What do you make of that?"
12-Step Facilitation
Carlos's denial and minimization are hallmarks of the disease of alcoholism. His father's heavy drinking suggests genetic vulnerability. The cultural normalization of drinking ('everyone drinks') supports continued use. Recovery requires accepting powerlessness over alcohol and engaging with a community of others in recovery.
Facilitate engagement with AA or a culturally appropriate 12-step community. Work through Step 1 (powerlessness, unmanageability). Address barriers: cultural stigma, identity as a 'man who can handle it,' fear of losing social connections built around drinking.
"You told me your dad drank every day and worked every day, like the second part settles the first. Your dad didn't have two DUIs. What would have to happen before you'd call it a problem?"
Narrative Therapy
The dominant story is 'Real men work hard and drink hard. That's just what we do.' This narrative is authored by Carlos's family, his work culture, and broader machismo norms. It has no room for vulnerability, asking for help, or admitting that something controls him. The drinking problem is a culturally saturated story, not a character defect.
Externalize the drinking ('When did Alcohol first recruit you? What promises did it make?'). Map its influence on his relationships, his fatherhood, his health. Find unique outcomes: times he chose differently. Explore the cultural stories about men, drinking, and strength. Re-author: what does strength actually look like?
"Your dad taught you that a man works hard and drinks hard. That story has been running your life for a long time. But you showed up here, which means part of you is writing a different story. What's that story about?"
Where Approaches Genuinely Disagree
Ambivalence is the natural state of change. Explore it: the client's own reasons are more powerful than pressure.
Ambivalence can be the disease talking. The person needs to surrender the illusion of controlled use.
Philosophical Lenses
These are not treatment plans. They are ways of seeing — philosophical perspectives that illuminate aspects of this case that clinical modalities may not address directly.
Carlos drinks 6-8 beers nightly. His father drank. His union culture normalizes it. Every clinical lens sees this as a problem to be solved. Bataille would see something else: sovereignty. The restricted economy (work, family, responsibility, the electrician who shows up on time) demands that every expenditure of energy produce a return. Drinking is the expenditure that refuses utility. It is what Bataille called the accursed share: the energy that cannot be absorbed by the system and must be squandered. Carlos's 'I don't think I'm an alcoholic; I just drink to unwind' is not denial. It is an inarticulate recognition that some part of human experience resists being made productive. The DUIs, the wife's ultimatum: these are the restricted economy reasserting its claims. The therapeutic question Bataille would pose is not 'How do we stop the drinking?' but 'What would a form of sovereignty look like that doesn't destroy the things Carlos also needs?'
Carlos is Mexican-American, first-generation. His father was a heavy drinker who 'worked every day': the functional alcoholic as model of masculinity in a community where men's value is measured by labor and endurance. Fanon would locate Carlos's drinking not in individual pathology but in the colonial inheritance that structures working-class masculinity: the demand to produce, the denial of interiority, the anesthetizing of a body that is valued only for what it can do. The union culture where drinking is normalized is not incidental: it is the social reproduction of a workforce that must numb itself to sustain exploitation. Carlos's wife is Anglo, non-drinking. The ultimatum enacts a cultural collision that neither partner fully understands. Treating Carlos without addressing the structural conditions that produce 'the functional drinker' as a cultural ideal treats the individual and ignores the system.
Baldwin wrote that not everything that is faced can be changed, but that nothing can be changed until it is faced. The sentence is careful in both directions, and it is the second half that applies here. Carlos showed up voluntarily, and that matters. But he arrived already performing: 'I don't think I'm an alcoholic.' This is what Baldwin would recognize as the artful dodge of a man who knows something he has not yet found a language for that does not destroy him. Carlos's father drank but 'worked every day.' That phrase is a complete moral system: the drinking is forgiven as long as the body produces. Baldwin would ask what would happen if Carlos were allowed to speak about his actual experience without the script of masculinity and cultural loyalty that currently organizes his self-presentation. The ambivalence is not a clinical obstacle. It is Carlos standing at the threshold between the story he inherited and one he might tell for himself.
Sources & Method
This is a composite fictional case — no real client is depicted. Formulations represent how each modality would typically conceptualize and approach a case with this presentation, based on published clinical literature and training materials. Each formulation draws on the modality's own theoretical framework, key texts, and clinical principles as documented on its modality page. Full source citations for every modality are available on the Sources page.