Clinical Case Study V
By: EILEEN SIMBULAN
Managing Psychologist, SELF
November 2009
BARRY was admitted to SELF on July 12, 2008 at the age of 18 due to suspected mood disorder, an alcohol problem, and suicidal behavior. Barry had no background with any kind of drugs but his behavior was somewhat similar to that of a drug-dependent. Six months prior to his admission, Barry was brought to the psychiatric unit of The Medical City Hospital for a week as he was becoming violent and was displaying odd behaviors. He was given 75 mg. of Effexor (Venlafaxine) to be taken at bedtime.
Apparently, he responded with the said medications and was discharged a week after. After his discharge from the basement, however, his family didn’t see any progress as he started drinking hard liquor four times a week. He also showed manipulative behaviors and would threaten to kill himself if he didn’t get what he wanted.
Background
Barry is the 2nd born and the only boy in a family of three children. He comes from a traditional Chinese family. His father was a pure blooded Chinese businessman while his mother is a Filipina. His family described Barry as a loving son and brother to his sisters.
A history of family conflict began while Barry was in High School. He learned that his parents were unwed and that they were his father’s second family. Moreover, the family was uprooted from Bacolod to Manila to avoid a legal case against Barry’s mother that was filed by his father’s legal wife.
At the age of 18, Barry made three suicide attempts. It was triggered by increasing arguments with his parents regarding his relationship with his girlfriend. This led him to isolate himself from his family.
Initial Intervention
Upon admission, Barry was uncooperative, adamant and was in strong denial of his need for treatment. Due to this behavior, it was impossible to obtain an Intake Interview. For the first few days, he was made to settle down until he agreed to be subjected to medical, psychological, and psychiatric assessments. But even after receiving these services, Barry continued behaving like a brat who would always complain and would argue with the resident officers and staff.
As a result, he was given a “talk-to” and several motivational talks along with art and writing therapy. That week, Barry wrote numerous letters about hate, disappointment, denial, manipulation, and loneliness. At this point, the motivational talks were increased.
Having responded to this intervention after a week, Barry’s orientation process was initiated. He was briefed about the TC process and basic rules of the House. Following this, he decided to join the TC program. A month after joining the TC, the results of his clinical assessments came out and Barry was diagnosed to have Depression along with a Personality Disorder (Passive-Aggressive type). During this period, medication was not recommended.
It took Barry another three weeks to fully adjust himself to his new environment. He was, however, observed to be participating in community activities, group therapy sessions, and was particularly receptive during individual counseling sessions.
On his 3rd month, Barry was exposed to the normal intensity of the TC confrontation process as he exhibited stubborn and self-righteous behavior. He would be given Learning Experiences (LE’s) but would repeat the same mistakes. In one of his confrontation processes, he claimed that he was not resolved about being in a treatment center. He repeatedly claimed that he was not an addict and that his family was the problem because they would not accept his girlfriend. This was also the time when the psychiatrist recommended Barry to take medication for depressive symptoms. He was placed under 5 mg. of Lexapro (anti-depressant) to be taken at bedtime.
Case Conference
On his 4th month, Barry was given a Case Conference to assess his readiness for a family dialogue. However, Barry failed the test as the quality of his thoughts was not up to par. He was still vindictive and had negative intentions for the dialogue. Furthermore, he lacked insight and remorse about his past behavior.
Family Counseling
Bothered by his lack of motivation, Barry’s family was invited to the facility for Family Counseling. They underwent this process every two weeks while religiously attending the monthly Family Association Meeting (FAM). During these sessions, each member of the family was guided how to better understand Barry’s behavior dynamics.
On November 29, 2008, Barry faced his family for the first time. He attempted to address his complaints but only resolved the matter about why he was brought to treatment. Having remained unresolved about other issues, succeeding dialogues with his family were conducted.
Meanwhile Family Counseling continued. At every session, each member was asked to do assignments, and was guided in understanding their own codependent behavioral patterns. This was also followed by a series of clinical assessments and panel confrontations.
After that long and arduous family intervention process, Barry and his family were able to relate with each other better, consequently improving the way he behaved in the TC program. Due to this positive development, he was awarded his 1st Family Dialogue (a privilege given to a resident in good standing) on December 14, 2008.
Following this, Barry was promoted to the senior phase and his family was able to spend Christmas Eve with him in the facility. Barry had several visitations after this and he was observed to be building his relationship with his family.
Breakthrough
During his first 12-hour day-off with an escort, Barry suddenly tried manipulating his family into pulling him out. He brought out old issues which were deemed resolved in previous dialogues that ultimately confused and disappointed his family. Owing to their trust in the program brought about by their numerous counseling sessions, Barry’s family did not give in to his manipulations and instead opted to bring him back to the facility.
Barry was sent back to the junior phase and was demoted to crew level where he was to reflect on his recent behavior. This was also the time when his Lexapro was increased from 5 to 10 mg. Depakote (mood stabilizer) 500 mg was also added to help him cope with his process.
Even as Barry was demoted to the junior phase for two months, his family never failed to attend FAM meetings and continued to have Family Counseling. At this point, they were encouraged to meet with Barry in an Encounter.
Family Intervention
The clinical department arranged for Barry to face his family in an Intervention Dialogue. There, each member expressed their frustrations and disappointments and ended by reaffirming their decision to have him finish the program. Seeing that his family was relentless in their decision might have caused Barry to “bottom out” because after the dialogue, he started behaving differently in the TC.
In further Individual Counseling sessions, he was challenged to change his thinking process. Slowly, Barry was seen exerting his best effort in accepting this weakness and was observed to be owning-up to his behavior more and more. He was also more receptive to the TC Therapy activities and began sharing openly and honestly. This behavior was consistent for several months, allowing Barry to be further promoted.
As a result, Barry’s relationship with his own family blossomed and this became his sole motivation to go on with his process. On his 15th month in the program, he passed his Case Conference with flying colors and was sent-off to the Reentry phase. He now visits home regularly for 48 hours every week. His meds were also adjusted. Depakote was discontinued while maintaining Lexapro at 15 mg.
Conclusion
Success in treating individuals with behavioral and or personality disorders can be achieved by a balanced program of behavior therapy and clinical interventions. The TC program is a suitable tool for this type of intervention because of its highly structured nature that focuses on personal and group responsibility.
In this case study, however, it must be noted that Family Counseling and Intervention Sessions played an key role in promoting a breakthrough in the case of Barry. Clients with personality disorders can progress in the TC under the following conditions: 1) Vigilance in monitoring and firm persuasion towards daily structure; 2) Family Intervention dialogues; 3) Regular consultation with the attending psychiatrist; and 4) Strict adherence to prescribed medication.
