Assessing clients with addictive disorders: Levy Family case

Five episodes, five sets of questions, and two to three pages — which works out at roughly half a page per episode and makes selection ruthless. The structure is fixed by the brief, so build the paper with a heading per episode and answer only what is asked under each. What makes the assignment unusual is that the questions change register as they go: Episodes 1 and 2 ask what you *observed*, Episode 3 asks for physiology and an evidence-based treatment judgement, Episode 4 asks how you would respond clinically to a disclosure, and Episode 5 puts you in the supervisor's chair. A paper written entirely in one register — usually reflective commentary — will answer perhaps two of the five properly. Count the questions before you start: there are more than a dozen across the five episodes, and a paper that treats them as prompts rather than as items will run out of pages before Episode 4.

Episode 1 asks for three distinct things: Mr Levy's perception of the problem, Mrs Levy's perception, and the implications for the family as a whole. The gap between the first two is the clinical content, and naming it precisely matters more than describing either one. Partners typically differ on what the problem *is* — the drinking itself, the behaviour around it, the secrecy, or something the drinking is managing — and that disagreement predicts what will happen in treatment. For the third part, use a family systems frame rather than listing consequences: roles reorganise around a member's substance use, children take on functions they should not, and the family's stability may come to depend on the problem continuing. Say which perception you would work with first, since aligning with one spouse's account before the other has been heard is one of the fastest ways to lose a family from treatment.

Episode 3 contains the assignment's oddest requirement and its easiest marks: *informed by your knowledge of pathophysiology, explain the physiology of deep breathing, and how changing breathing mechanics can alter blood chemistry*. This is a physiology question sitting inside a psychotherapy paper and it wants a real mechanism. Slow diaphragmatic breathing shifts autonomic balance toward parasympathetic dominance, increases respiratory sinus arrhythmia and heart rate variability, and engages baroreflex sensitivity. The blood chemistry half is the part usually missed: rapid shallow breathing lowers arterial carbon dioxide, producing respiratory alkalosis, cerebral vasoconstriction and the paraesthesia and light-headedness patients report as symptoms of panic — so slowing the breath restores carbon dioxide as well as calming the nervous system. Both halves are needed because the brief asks for both, and an answer that stops at relaxation has skipped the phrase about blood chemistry entirely.

The exposure therapy question is asking you to take a position and defend it, not to describe the modality. Exposure-based treatment has strong evidence for post-traumatic stress disorder, including in combat-related presentations, and that evidence has to be cited rather than assumed. But the case complicates it: where alcohol use is active and functioning as avoidance, the sequencing question is real, and the literature on integrated versus sequential treatment of comorbid PTSD and substance use is precisely the evidence base to cite. Whether you would use exposure with Mr Levy is a legitimate yes or no; what is not legitimate is answering without saying what you would need to be true first. Say it as a condition rather than a refusal — that you would use exposure once stabilisation criteria are met, and what those criteria are — which is a clinical answer rather than a hedge.

Episodes 4 and 5 are the ones where clinical judgement is most visible. The disclosure about Kurt is a moment where the intervention is largely what you do *not* do — do not redirect, do not reassure prematurely, do not chase detail the client has not offered — and saying that, with what you would say instead, is a stronger answer than a plan. Episode 5 flips the role: as supervisor to a therapist struggling with the client's story, the response addresses the therapist's own reaction as clinical material rather than as a failing, and names the supervisory structure that contains it. The brief requires evidence-based literature throughout, so both answers need citations, not just the physiology one. Name what supervision would look like in practice too, since a supervisory response with no structure behind it is advice rather than supervision.