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CNS 765

Assignment 7.4 Case Study: Johnny Cash


Brian Mann
Conceptualization of client
Johnny Cash, as portrayed in the movie Walk the line is the subject for this paper.
Johnny was born into a poor family in a rural farming community. His father was an alcoholic
who was unable to provide ample resources for his family to rise up above their poverty. Also in
his family was his mother, who was a meek individual that cared after the children, Johnny and
an older brother Jack. Johnny admired his older brother Jack, who was smart, responsible, and
the apple of his fathers eye. One day when Johnny was 12, he and his brother were working in a
wood-mill to earn money to help support the family. Jack told Johnny to go fishing while he
finished up the remaining work, and as Jack finished, an accident occurred which took his life.
That day, not only did Johnny lose his brother, but his father displaced blame onto Johnny for the
accident. From that day forward, his father had nothing but contempt for Johnny. This haunted
Johnny and left him feeling empty with survivors guilt and unworthiness in the eyes of the only
man in Johnnys young life. He did not mourn completely, and was unable to express himself
emotionally.
One day many years later, during his tour in the Air force, Johnny began writing songs
which he discovered was an outlet through which he could express himself. After he left the Air
force, he was married and began work as a salesman. He was not successful, and quickly found
himself under pressure to provide for his new family. His wife echoed familiar sentiments to
those he heard as a child from his father, about him not living up to his responsibility. Out of
desperation, Johnny focused on music. His singing and songwriting career took off shortly after

that, and his family life smoothed out. After having two daughters, Johnnys home life took a
turn for the worse, when his wife accused him of not being involved enough with her, their
daughters or their home. Johnny was discovering that through his songs and performances, he
was getting acknowledgement from his fans, he was getting accolades and admiration that he had
not had since his brother died, not even in his home life with his wife. This was filling a part of
the void which was left from his childhood. His home life fell apart before his eyes, and began to
be interested romantically in another performer, June Carter. She rejected his advances which left
him feeling the widening gap in his home life, and a sense of emptiness beyond his stage
connection with fans. He began using alcohol and amphetamines to cope with this discomfort.
The alcohol is used to bring about a sense of euphoria and the amphetamines to stimulate him so
that he can keep functioning for extended times without crashing.
Johnny is coming to counseling voluntarily to get his life back on track. He has lost
control of his behavior. His drug and alcohol use has ruined his marriage, ruined his ability to
perform on tour, and led to the rejected by the women whom he loves, leaving him with the
familiar emptiness that he has had since childhood.
Johnnys addiction can be framed up through the psychological model of addiction. His
addiction is driven through the stress caused by psychological factors. His incomplete grieving
over the loss of his brother, guilt he claimed and the ensuing self-concept that he developed
through his fathers response to the loss of his son, left Johnny suffering. He found addiction to
alcohol and amphetamines to be a coping mechanism that lessened this pain. Johnny used this in
similar fashion to how his father used alcohol to cope with the stresses in his own life.
The psychological model can be used in this case to address the primary psychological
concerns in Johnnys life as a way to help him reduce his need to cope. Getting to the root of his

suffering which in this case is his guilt, and the emptiness he feels from the loss of his brother,
and addressing them, will alleviate the need to use alcohol and amphetamines.
Screening and assessments
The DSM-V lists 11 criteria for substance addiction. The first is whether the substance is
taken in larger amounts over longer period of time than intended. Johnnys alcohol and drug use
escalated steadily over the years. He was taking larger amounts and was under the influence at all
times. The next criterion is whether there is a persistent desire with unsuccessful efforts to cut
down or control using. He had made promises several times to quit, but was unable, and quickly
returned to heavy use. The third criterion is also met. Namely, he spent a lot of time obtaining,
using or recovering from use. He spent lots of time on the road travelling from tour stop to tour
stop. This left him with lots of free time. He filled this down time with drug use as part of the
culture he was a part of. He was passed out when he wasnt under the influence. He also had to
arrange for drug dealers to provide him with a supply of pills. Fourth, his cravings, urges or
desire to use led to his use routinely, even during times when he should otherwise be content
without using. Fifth, his use resulted in failure of important life roles as a father, and as a reliable
musician. Sixth, he continued using despite being arrested, losing his family, his home and
everything else he had. Seventh, he needed to leave the tour on several occasions due to his use,
thereby giving up important social and occupational activities. Eighth, he often put himself in
hazardous situations through his use. He was homeless for a while; he smashed things, and went
into dangerous situations relating to using or acquiring drugs. Ninth, he knew that drugs/alcohol
were exacerbating his problems, but was desperate to continue using because he had become so
dependent on them to cope. Tenth, his tolerance had increased to the point where he was taking

handfuls of pills and drinking hard liquor. Finally, he was physically dependent, and would
shake, sweat, and feel terrible in the absence of these drugs.
Having satisfied all eleven of the criteria, Johnny would be diagnosed with Severe
Substance Use Disorder 304.4 (Amphetamine type substance), and Severe Alcohol use Disorder
303.90. There would be no specifier at this stage.
Additionally, a co-occurring Adjustment Disorder 309.9, unspecified, might also be
indicated. The event of his brothers death brought with a sense of loss that persisted beyond
what might normally be expected, and the stressors associated with his fathers reaction have had
lasting impact on Johnnys diminished view of himself. This co-occurring disorder is very
significant in that it relates to the psychological model of addiction mentioned earlier. In this case
Johnnys substance use disorder likely relates to his self-medicating to deal with his Adjustment
disorder issues. Addressing the substance use issues alone would simply bring him back to face
his primary issues, and without improved coping strategies, there will be continued pressure for
him to relapse. A treatment plan involving addressing his disorders in parallel is appropriate here.
Counseling strategies
A Cognitive Behavioral Therapy approach would be used as the central strategy in
Johnnys case. Exploring his dysfunctional thoughts, empowering him to express them, clarify
fact from fiction, and come to terms with them can be done in through a number of activities. For
example, we might work on curtailing some of his self-destructive thoughts through letter
writing. We could improve his coping skill through visual imagery or role-playing. We could
reinforce positive change through the use of affirmations. And, we could work on improving his
thinking through relabeling and reframing. These techniques apply both to his adjustment
disorder and his addiction disorders.

Goal setting would be done once Johnnys motivations were clear. We would work
together to support his motivation to establish a meaningful life, in a loving relationship in the
absence of pain associated with the emptiness that he currently suffers. This might lead to several
different goals that he identifies as short and long term items. We will work together to be sure
that they are achievable, rewarding, measurable and specific. An example may be that by the end
of next month, Johnny has attended AA meetings 5 days a week for a month. This would be seen
as measurable progress toward his commitment to doing the things necessary that he knows will
lead to abstinence and recovery. From a broader perspective, Johnny may view progress in terms
of where he is now, versus how he wants his life to be. Every step in that direction is progress
towards the goal. Milestones can be identified in terms of reduced drug use, relationships with
people around him, reduction in suffering, improvement in general sense of well-being, etc.
As Johnny works in the CBT sessions, its important that relapse prevention strategies are
in place. Some examples include developing effective alternative (positive) coping techniques to
replace his drug use, monitoring his emotional states, maintaining high motivation, establishing a
protocol for managing cravings, and reinforcing Johnnys sense of self-efficacy. For Johnny, one
specific example may be to replace his drug use with exercise as a way to redirect his attention
and physical urge.
Modes of treatment
Johnny was showing symptoms of physical withdrawal, so I would have classified him
under ASAM guidelines as Level II = Intensive outpatient/ partial hospitalization. This would
provide an opportunity to safely detoxify, and stabilize his situation as he headed into recovery
and establish an integrated plan to address his disorders.

Individual counseling would be appropriate for Johnny. He needs to address the issues
surrounding the loss of his brother, process his guilt, his relationship to his father, and grieving
properly in order to facilitate his recovery. He also needs to find the motivation and hopefulness
that his life will be better when he is able to step beyond these issues.
In addition to the individual treatment, involvement in a Twelve Step Program would be
indicated. Having co-occurring disorders, Johnny has the added burden of re-learning effective
coping strategies that involve abstinence from alcohol and drugs. This program will focus more
on his drug addictions, and will provide on-going involvement and focus on recovery. By
connecting with others in a mutual support group he will be supported by a network of people
who are equipped to help him. This will replace the social network that Johnny was connected to
which had drug/alcohol use as its cultural focus.
Following successful treatment for a client such as Johnny Cash, it may be helpful to a
creative public figure to reinforce the importance of sobriety by promoting it to his fans, or
telling his story as a way of conveying hope to those who need it. Writing songs to express those
sentiments or performing may be the natural outlet that he can tap into as a means to sustain his
treatment goal.