Patricia Fearing

CNS 765 EG SU 16
Assignment 7.4: Final Case Paper: Johnny Cash in Walk the Line
14 August 2016

The life of celebrity and fame has often come with a cost. Generations of singers, actors
and musicians have struggled with alcohol and substance abuse in their hectic lives in the public

eye and on the grueling road. The same can be said for the infamous Johnny Cash, as portrayed
by Joaquin Phoenix in the 2005 film Walk the Line. In his mid-thirties, with a traumatic and hard
past behind him and a strained marriage and family life before him, Cashs music career
launched quickly with more than just the stresses of the road for him to cope with. Exhaustion
from the grueling life of a touring musician left him vulnerable to the wailing women and the
siren call of drugs and alcohol. As quickly as one Black Beauty, or another amphetamine did its
job, the next would be made readily available to keep him awake on the road and at home. When
he wanted to rest, jittery with withdrawal from amphetamines, barbiturates brought him back
down and sedated his drug induced mind. Johnny Cashs story of addiction is one that many in
his line of work has experienced, with the rare exception of a happy ending.
Section 1: Conceptualization of client
The client is a 36 year old caucasian male born in Kingsland, Arkansas during the era of
the Great Depression. He is the second oldest of seven children. At the age of 12, he watched his
older brother die from a traumatic injury with a saw. His father was an abusive alcoholic during
his childhood and teen years, and blamed the client for the death of his older brother. The client
enlisted in the Air Force, but saw little to no time in battle. Client married shortly thereafter, and
struggled financially in a career as a salesman, putting pressure on his relationship with his wife
and young children. The client had always found solace in playing and writing music on his
guitar, and with his bandmates.
Alcohol was the only substance present outside of tobacco until the clients mid-thirties,
when his singing career launched quickly and life on the road because a professional reality.
When realizing the stress and exhaustion of the road, as well as dealing with an unhappy

marriage and being turned down by a woman he liked on tour, the client turned to amphetamines
and barbiturates to keep him awake on stage, and sedate him when he needed to sleep. Alcohol
and tobacco stayed present in the clients life alongside these new additions. The client found
himself acting erratically, including, but not limited to, trashing dressing rooms, having affairs,
trying more and more drugs and, finally, passing out on stage. His bandmates ended the tour, and
the woman who had turned him down flushed all of his drugs.
After getting arrested for smuggling drugs across the border, his wife and children left
him. With continued erratic behavior, such as buying a new house and walking across town to
see the woman he loved, June Carter, the client had a tractor accident on Thanksgiving Day
while high. At this point, his friend June helped him begin the detox process. The client has
appeared for voluntary treatment, with the presence of an ultimatum from his girlfriend, June
Carter. He also had the encouragement of his band mates and managers to seek help with similar
ultimatums. He realizes that the addiction has taken over his life, but the intensity of withdrawal
makes him want to continue with the drugs.
The presenting concern is that the client is experiencing withdrawal symptoms from three
different substances after trying to get clean without the help of medical professionals. The first
are amphetamines, particularly in the form of Black Beauty pills. The clients initial reason for
the use of these drugs, which, most of the time, came in prescription form, was to stay awake on
stage and at home after exhausting, long nights on the road. In order to sleep, as he is jittery and
erratic from the effects of the other substances, the client takes barbiturates to sedate himself and
come down from the amphetamine high. The final substance present is alcohol, which initially
was present as a social substance, but as the other drugs became addictive, the alcohol would
intensify the effect of the barbiturates.

Through exterior thoughts of the people around him, the client has experienced the moral
model of addiction. With phrases like, You have a family at home, and Have you quit taking
those pills yet?, the client has taken on a moral guilt in regards to his understanding of his
addiction as it relates to his relationships and interactions with others. However, when he
explains his addiction to his girlfriend, who has at this point flushed all of his pills, he says that
those are his pills that he needs from the doctor and that they are prescriptions. From that
description, the client seems to see the Disease Model when he personally looks at his addiction.
In addition to that, the client has a tendency not to take credit for the things he does, rather, they
just happen to him. For example, he only wheres black because he has nothing else to where,
and he found his sound because he couldnt play better, etc. This would also fit into the disease
model of understanding, taking the moral implications off of the situation and focusing on effects
of the substances on the body.
Although these models may be how the clients friends, and the client himself, see the
addiction, neither has given way to recovery for the client. With such conflicting thoughts
present, I believe it would behoove the client to consider the Biopsychosocial Model as we work
towards recovery. With the presence of historical family trauma and abuse, both physical and
substance, an unhealthy current family system, the exhaustive nature of his career path and the
temptation presented in his career environment, having an understanding of the connection of
how all of these pathways affect his addiction is important.
This particular model provides the opportunity for a myriad of pathways to be
recognized, as well as treatment approaches. A life on the road, and in the public eye, calls for a
team approach to working through an addiction, with both professionals and loved ones. Having
doctor who will not prescribe addictive drugs, a counselor to work through emotional and

addictive realities, and a bus full of supportive bandmates, creates a team approach that could
potentially all be present on the road with him. The presence of medical professionals,
counseling professional, mutual community support and familial support seems to be the best,
well-rounded approach to an addiction that can very easily thrive in his professional
environment.
Section 2: Screening and assessments
Based on the 11 criteria of the DSM-5 for substance abuse, the client meets the
following: 1) Substance is taken in larger amount over longer period of time than intended, 2)
Persistent desire/unsuccessful efforts to cut down or control using, 3) A lot of time spent
obtaining, using, or recovering from use, 4) Craving/strong desire/urge to use, 5) Recurrent use
resulting in failure to fulfill major life roles, 6) Continued use despite recurrent interpersonal
problems caused or exacerbated by substance effects, 7) Important social, occupational,
recreational activities given up or reduced due to use, 8) Recurrent use in situations in which it is
physically hazardous, 9) Continued use despite knowledge of physical/psychological problem
caused or exacerbated by use, 10) Tolerance, and 11) Withdrawal. (DSM-V, 491)
Meeting all 11 criteria, the client would be considered as having a severe substance use
disorder. While alcohol is one of the many drugs the client is addicted to, the use of stimulants
(amphetamines) and sedatives (barbiturates) should be noted. Both stimulant use and sedative
use fall into their own areas of diagnosis within the DSM-5. The client would not be considered
in early remission as of yet, as he has not been clean 3 months in any of the substances listed,
though he is closely supervised by his girlfriend. (DSM-V, 491-567)

While screening this client for a substance use disorder, there are two consideration that
need to be assessed. The CAGE assessment could be a good assessment tool for this client, as he
is just now coming to grips with the intensity of his addiction and the harm it has done in his life
and relationships. This assessment would help the client look deeper into his experiences with
the drugs and begin to note the unique and severe elements of his addiction. Another important
factor to be considered is family history. In the conceptualization of the client, it is mentioned
that his father was an abuser of alcohol, and, potentially, an alcoholic. This piece of family
history makes the client more vulnerable to substance abuse.
In light of the fact that the client clearly falls in the criteria for substance use disorders in
stimulants, alcohol and sedatives, the comorbidity considerations of each diagnosis should be
looked at. Within the three, the client could also be diagnosed with major depressive disorder,
antisocial personality disorder, post traumatic stress disorder and/or anxiety disorder. When
considering the criteria for all four of these potential diagnosis, the client can also be diagnosed
with PTSD (309.81). According to the assessment done and conceptualization of the client, the
event of the clients older brother, and the blame placed on the client for the event, has had a
lifelong impact on the clients relationships and ability to function. For this reason, and the
criteria met, PTSD is an appropriate consideration for diagnosis.
Also from the conceptualization of the client, the case could be made for Substance
Induced Depressive Disorder (F10.24, F13.24, F15.24). However, the depressive behavior occurs
majoritively during intoxication and withdrawal periods, pointing the diagnosis back to alcohol,
sedative and stimulant use disorders. (DSM-V, 179)
Section 3: Counseling strategies

Based on the conceptualization, the client has not had a safe place to deal with his past
and present concerns. With strong family divide and abuse, including divorce, and living life in
the public eye, the client is constantly judged and feels, and is told, that he is not enough. In light
of this information, a client centered approach is crucial. The client will need to feel the space is
safe, empathetic and non-judgmental in order to bring his concerns to a place of change and
growth. This is particularly the case in the regards the clients sense of self worth. Noting the
support that he does have in his girlfriend will also be crucial.
Another strategy, which includes client centered thinking, is motivational interviewing.
This process include eliciting, focusing, evoking, and planning. Eliciting a full understanding of
the clients current, and past situation will help the session include the clients own language.
Focusing on the addiction and its impact will help keep the client on the path to recovery and
discovery. The client has a desire for change, mostly due to his desire to marry his girlfriend.
Evoking the client to speak of these arguments will help the client better understand his one
wants. Once these steps have been worked through in session, the opportunity for planning will
come up. At this point, based on the level of severity, creating an action plan for further treatment
and a commitment to change his abuse will be in the best interest of the clients welfare. (Miller
and Rollnick, 2013)
Among the counseling strategies used, relapse prevention is vital to this client. The client
suffers from a low sense of self worth and relapse only furthers the destruction of his self-esteem.
This particular client lives on the road as a performer and struggles with a different set of
temptations, triggers and environmental realities. Developing coping skills for moments of stress,
cravings or social pressure will be imperative to the clients success. The creation of coping skills
that will help the client with this, such as not attending a certain event in order to get sleep rather

taking a stimulant to compensate for exhaustion. Examining the environmental elements that can
be changed could also help the client with recovery. This could be making the tour bus a dry
space or having code words with bandmates and loved one when triggers happen to get extra
support.
Goals for this client need to be initially obtainable for the sake of the clients confidence
and the building of self worth. With this in mind, helping the client understand that a lapse
doesnt have to become a relapse could help prevent confidence killing moments. Coming up
with a plan for the client with his loved ones and bandmates for what happens when a lapse
happens creates a supportive, understanding community in his everyday environment. Progress
would need to be based on baby step success, building self esteem, as well as level of recovery,
over time.
Section 4: Modes of treatment
First and foremost, I feel that it is vital for the client to receive significant in patient
rehabilitation services due to the severity of his substance abuse problem. This would take place
as have entered the transition stage of his recovery. A 60 or 90 day program may be necessary
due to the intensity of his addiction as well. In these programs, clients are often introduced to the
12 steps and the concept of having a sponsor. These programs will help the client transition out
of residential treatment into outpatient treatment, programing and counseling.
In the case of this client, I believe there are a few different levels of treatment that would
be appropriate for recovery. With a Biopsychosocial Model as a framework for understanding his
addiction, multiple pathways of treatment would be complementary in practical allocation of
services. Counseling would come in the form of individual session, as well as working with the

client and his girlfriend and family sessions. There is enough family history of trauma and abuse
that the process of healing together could help with both his PTSD and substance abuse recovery.
Working with his girlfriend will help her to continue to not being an enabler, but a
reinforcer of sober living in his life. Some sort of training may also be helpful for his managing
team and bandmates, as they are staple figures in his everyday environment. Creating safe, sober
space for him to work the steps in, as well as learn coping skills for his triggers will be vital to
his recovery.
References
Diagnostic and statistical manual of mental disorders: DSM-5. (2013). Washington, D.C.:
American Psychiatric Association.
Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change. New
York, NY: Guilford Press.
Miller, W. R., Forcehimes, A., & Zweben, A. (2011). Treating addiction: A guide for
professionals. New York: Guilford Press.
Mangold, J. (Director), Mangold, J., & Dennis, G. (Writers), & Konrad, C., & Keach, J.
(Producers). (n.d.). Walk the Line [Video file].