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Manuel Sanchez Case Study Client Background Manuel Sanchez is a 50-year-old Hispanic man who has been married to his wife, Isabella, for 27 years. Manuel and Isabella live in Columbia, South Carolina, and have two children. The oldest is Peter, who is 26 and lives in Washington, D.C., with his wife and 2-year-old daughter. Peter works in a mid-level management position at a bank, and his wife stays home with their child. Manuel and Isabella also have a daughter, Elliana (Elli), who is 23 and single. She has been a student for several years and is working on a bachelor's degree in social work. Elli lives with Manuel and his wife and they fully support her educationboth financially and in every other waybut this has begun to bother Manuel more and more. He does not see the value in higher education and does not see any end to Elli's academic pursuits. Manuel moved with his parents and two older brothers from Jurez, Mexico, to El Paso, Texas, when he was 6 years old. The entire family found it difficult to adjust to the American lifestyle and traditions; at home, they continued to speak Spanish and follow Mexican customs. Manuel's oldest brother joined the military and was killed in action when Manuel was 13. In the aftermath of this loss, his other brother began selling drugs and was eventually arrested and incarcerated. Manuel graduated high school and started working in construction when he was 18 years old. He enjoyed the work and the comradery with his coworkers, many of whom shared his immigrant background. However, one day at work there was an accident with heavy machinery that killed Manuel's best friend and left Manuel with several injuries. Manuel recovered but lives with chronic pain and painful memories of witnessing his friend's death. Several years later, Manuel met and fell in love with Isabella, who was visiting relatives in El Paso at the time. He followed her to South Carolina, leaving his father and mother behind. Manuel was hired by a large shipping company as a delivery driver and has remained in the position for the past 25 years. He has always enjoyed the work because his daily schedule is predictable. He can "do his thing" without having to talk to and engage with others or listen to supervisors boss him around all day. Although he considers himself an outgoing person, Manuel has experienced numerous racial and ethnic insults from customers, supervisors, and neighbors and has become wary toward others. As a driver, Manuel knows exactly what to expect: He has his route, he is able to listen to music as he drives, and he does not have to worry about anybody else. Present Functioning Ever since their son Peter married 3 years ago, the relationship between Manuel and Isabella has changed. Isabella says that she wants more out of life, that she is too young to "just be sitting at home" and that she wants to "better herself." Manuel has felt surprised by these comments, as he feels like things are fine the way they are and doesn't wish for anything to change. When Manuel tries to talk to Isabella, Elli has

begun to back her mother up, which Manuel finds frustrating. Manuel feels unsettled about the possibility of losing the life he has built with Isabella and finds himself up many nights unable to sleep as his mind races between fears about the future and painful flashbacks from the past. A big issue between Manuel and Isabella is what Isabella calls Manuel's "drinking problem." She says Manuel drinks way too much. Manuel admits to drinking two to three beers with dinner every night, and then maybe one or two more as he watches TV before bed. Manuel has consumed beer throughout his adult life, just like his father did. If he is honest, Manuel agrees that he has been drinking more lately, but that's because things are so stressful at home. He has even begun to have a couple beers at work during his lunch break. Manuel believes his alcohol consumption is not a problem and that he could easily stop whenever he wants to. However, the other day, Manuel got in trouble because a customer called the office to complain that "the delivery driver smelled of alcohol when he came to the door." Manuel was able to smooth things over with his boss, but his boss told him that he must make an appointment with the Employee Assistance Program (EAP). Manuel did so, and the counselor asked all sorts of questions Manuel found very intrusive about his childhood, his father's disciplining practices, his relationship with Isabella, and his drinking habits. The EAP counselor's report indicated that Manuel may have a substance use disorder and recommended that he seek further assessment and counseling. Manuel's boss stated that these recommendations are mandatory if he wishes to maintain his employment. Manuel believes that his private life should be off limits to people at work and that the few drinks during lunch should not be such a big deal. Manuel feels he has been an exemplary employee for decades: he never calls out sick, he has never been late, he goes above and beyond to ensure timely delivery of his packages, and he has never received a ticket. To make matters worse, Isabella has begun talking about divorce. Manuel feels betrayed and frustrated. He does not understand why everybody is against him. But to save his job, he is willing to seek counseling. Week 5 Update: Recent Developments Manuel did not immediately act on the Employee Assistance Program social worker's recommendation that he obtain further assessment and treatment. He had found the meeting annoying and unhelpful, and he continued to believe that his alcohol use was fine. He told his boss that the first available appointment was a few months out, but in reality, he had not actually called. However, tensions with Isabella continued to grow and he found himself drinking a six pack of beer followed by shots of vodka most evenings to numb his fear and stress about the state of his marriage. When Isabella would find him intoxicated, she often would exclaim, "what's wrong with you?" or "why didn't you stop sooner?" These comments would swirl in his head throughout the evenings and keep him from sleeping. When he'd finally fall asleep, he often heard her comments echo in his dreams. Ever since the work accident that killed his best friend,

Manuel has experienced nightmares about the incident and the things he could have done differently to prevent the fatal outcome. Manuel tries hard not to think about the accident, and sometimes succeeds during the day. But he occasionally experiences intrusive flashbacks when he's awake and he can't seem to stop dreaming about it at night. One day Manuel's mother called and asked him to fly home to visit. Manuel has rarely traveled home to El Paso as he associates his childhood city with painful memories of loss; he lost his eldest brother to war, he lost his other brother to prison, and he lost his best friend in the accident that continues to haunt him. Manuel did not feel eager to fly home amidst his current stress, but he could hear in his mother's voice that something was wrong, so he booked a flight for the weekend. As soon as he arrived, Manuel could see that his father was in poor health: he had lost a considerable amount of weight, his ankles were swollen, his skin had a yellow tone and appeared covered in bruises. "I saw a few doctors this past month," his father said. "Told me last week that I have cirrhosis of the liver and liver cancer. Things aren't looking good son." As the weekend wore on, the two men talked in greater depth. Manuel's father expressed discouragement about his health decline and awareness that his current health problems may have been aggravated by his alcohol consumption. He told Manuel that he wished he'd done things differently and cautioned Manuel to take better care of himself. Manuel hadn't intended to tell his parents the embarrassing story about his boss and the EAP counselor, but as his father reflected on his regrets, Manuel found himself sharing his own update. "Honestly son," his father said, "you should do what they say. Go see someone. Get your drinking to a better place now. You don't want to end up like me." Manuel flew home and tried to cut back on his drinking, but found it was much harder to do than he anticipated. He continued to struggle with sleep, nightmares, professional stress, and marital tension and found himself automatically reaching for a drink whenever these stressors arose. After a few weeks of trying and failing to reduce his drinking he decided to actually call the number the EAP social worker had provided and inquire about an assessment. The receptionist arranged a series of screening and assessment appointments for Manuel with a team of clinicians that included an older bilingual social worker. This social worker had immigrated from Mexico to the United States as a young adult and had a keen understanding of Manuel's cultural background. Manuel felt understood by this clinician and grew less defensive as they got to know one another. He was still unsure if his alcohol consumption was truly a problem, but he was willing to fill out numerous screening forms, participate in lengthy interviews, and generally give her ideas a chance. One of the tasks he was asked to do as part of the screening and assessment process was to go to his recycle bin and set aside all the alcohol-related items and count them. Manuel found this experience sobering as he realized just how much he consumed in a typical week.