Case laboratory · fictional case
Imran: work stress, rising alcohol use and high blood pressure
A 45-year-old manager referred for hypertension and stress has been drinking more. Screening, motivational approaches and health-behaviour change are central.
Stage 1 of 7
1 Observe
Presenting concerns
Imran says work is 'non-stop', he cannot switch off and he 'needs a few drinks' most evenings to relax. He is irritated that the doctor 'thinks everything is stress'.
Observations
- Checks his phone repeatedly.
- Speaks quickly; jokes about drinking.
- Becomes defensive when alcohol is mentioned.
Your turn: How might you respond to his defensiveness?
Teaching discussion for this stage
Defensiveness often signals ambivalence. A non-judgemental, curious stance — reflecting his reasons for drinking and his frustration — is more likely to engage him than confrontation.
2 Gather information
History
Drinking increased over two years after a promotion. His father had alcohol problems. He has had arguments at home about late nights.
Screening
- An alcohol screening questionnaire, completed with consent, indicated hazardous use according to the developer's guidance.
- He reports drinking more than he intends on weekends.
Your turn: How should screening results be shared with him?
Teaching discussion for this stage
Share results factually and collaboratively ('How do you make sense of this?'), emphasising that a screen is not a diagnosis but points to health risks, especially with hypertension.
Missing information
- Pattern and quantity of drinking, adapted to local drink sizes.
- Any withdrawal symptoms in the mornings (requires medical attention).
- Mood and sleep.
- Other substances, including tobacco.
- His own goals.
3 Generate hypotheses
Your turn: What hypotheses link his stress, drinking and blood pressure?
Teaching discussion for this stage
Consider bidirectional links rather than a single cause.
Hypotheses
- Alcohol used as a coping strategy for work stress, maintained by short-term relief.
- Hazardous drinking contributing to hypertension and poor sleep.
- Possible developing alcohol use disorder (requires fuller assessment).
- Depression or anxiety masked by drinking.
- Family conflict as both consequence and stressor.
4 Formulate
Your turn: Draft a formulation linking work, drinking, sleep and health.
Teaching discussion for this stage
Work pressure produces sustained arousal; evening drinking brings quick relief (negative reinforcement) but disrupts sleep and raises blood pressure; poor sleep reduces coping, increasing stress; family conflict adds strain. A family history and workplace drinking culture may contribute.
| Factor | Biological | Psychological | Social / cultural |
|---|---|---|---|
| Predisposing | Family history of alcohol problems | High-achieving, self-reliant style | Workplace culture of after-work drinking |
| Precipitating | — | Increased responsibility after promotion | Promotion; longer hours |
| Perpetuating | Sleep disruption; tolerance | Drinking as main coping strategy | Family arguments; little leisure time |
| Protective | No serious complications yet (to confirm medically) | Values his children's respect | Concerned physician; supportive spouse |
5 Plan assessment
Your turn: What further assessment and collaboration would you arrange?
Teaching discussion for this stage
Collaborative care with the physician is central.
Next steps
- Fuller assessment of alcohol use and dependence features.
- Physician assessment of physical health and of withdrawal risk before any reduction plan.
- Drinking diary.
- Mood and sleep measures.
- His own goals: reduce, or stop?
6 Consider interventions
Your turn: What options could be offered, and how would you respect his choices?
Teaching discussion for this stage
Interventions should follow his readiness and safety.
Evidence-informed options
- Brief intervention and motivational interviewing.
- Goal-setting for reduced or no drinking, with medical guidance on safety.
- Stress management and alternative evening routines.
- Sleep improvement strategies.
- Couple sessions to address conflict, if both wish.
- Referral to specialist addiction services if dependence is significant.
7 Review outcomes
Fictional follow-up
After three months, Imran drinks on two evenings a week instead of six, walks after dinner and sleeps longer. His blood pressure readings have improved, according to his physician. He had one weekend lapse after a difficult deadline.
Your turn: How would you respond to the lapse?
Teaching discussion for this stage
Treat a lapse as information, not failure: explore triggers, adjust the plan, and reinforce progress. Relapse prevention planning around predictable high-stress periods is key.
Ethical questions and references
Ethical questions to discuss
- What information can be shared between the psychologist and physician in collaborative care, and on what basis?
- How should cultural or religious attitudes to alcohol be handled respectfully?
- What if he discloses drinking before driving?
References and resources
- Babor, T. F., Higgins-Biddle, J. C., Saunders, J. B., & Monteiro, M. G. (2001). AUDIT: The Alcohol Use Disorders Identification Test — Guidelines for use in primary care (2nd ed.). World Health Organization. Official link (opens in a new tab)
- Plante, T. G. (2005). Contemporary clinical psychology (2nd ed.). John Wiley & Sons.