Clinical Case Study I

EDITOR’S NOTE: In our last issue, we reported that SELF had begun to treat a number of dual diagnosed clients. Under the new development of combining clinical approaches with behavior therapy, SELF has been successful in addressing some of these challenges. The following article is a case study of a resident in this category.

Sam was admitted in SELF on March 7, 2005. Prior to this, he had been admitted to the psychiatric unit of Makati Medical Center on two separate occasions due to strong hallucinations. His parents took him to SELF due to alcohol abuse and a severe attitude problem. They suspected him of taking drugs but Sam never admitted this for many months to come. There was no medical abstract available at this time. He was under Olanzapine but it was reported that he was not taking it religiously. In addition to this, Sam was taking alcohol on a regular basis.After allowing Sam to settle down at the Pre-Admission Department (PREAD) for several days, he was given the standard medical and clinical assessments by the facility doctor and psychiatrist. Sam’s initial diagnosis was Schizophrenia, undifferentiated type. At the time of his admission, he had a flat affect, marked with social aloofness and withdrawal symptoms.

Initial Interventions

Based on initial findings, he was prescribed Risperidone and Olanzapine. Due to his auditory and visual hallucinations, it was advised that Sam remain in the PREAD until such time that these medications would show positive results. During this time, however, Sam was encouraged to learn about the TC program through group sessions conducted by senior residents but he was unresponsive at this point. Sam kept on denying that he had a problem and was insisting that the staff send him home.

From that point on, he had sessions with the psychiatrist three times a month due to reported strong auditory and visual hallucinations. Because of this, his medications were increased to maximum doses over the next six months.

Modified Approach

On his eighth month, after a series of consultations with the attending psychiatrist, a modified approach was taken. This time, he was coached to adhere to a light schedule of activities doing basic household chores. He was also made to observe personal hygiene and forced to take his medications. Frequent counseling sessions were also conducted along with group therapy. Though he was not receptive to sharing during therapy, he would listen.

Discovering that Sam’s interests revolved around his qualification as an architectural student, Sam was given materials necessary for him to draw things. In addition, he was made to join creative art therapy groups together with some senior residents and it was observed that he liked to play basketball and tennis. During this time, his medications were maintained at high doses and it was observed that his hallucinations had decreased and hence he became more manageable. With this observation, Risperidone was discontinued leaving him only under Olanzapine.

Initial Breakthroughs

On his 14th month, based on good behavior, Sam was allowed family visits. Although this did not resolve denial issues, he was able to tell his parents that he is beginning to like SELF. He claimed that he was being cared for by the staff.

After a series of family dialogues and therapy sessions thereafter, Sam exhibited the following breakthroughs: 1) he admitted his problem with alcohol dependency; 2) he was receptive to the daily structure of the PREAD and claimed that the program was “a good training ground for individuals like him”; 3) he further claimed that this place helps him meditate and relax especially when he is triggered by his auditory and visual hallucinations; 4) he told his parents that he wants to join the TC program so he can meet other residents and eventually graduate.

Sam joined the TC family eventually and progressed remarkably. Under a less rigid approach, he went through the phases of the TC program to include earning the privilege of days-off and visitations. Through a series of dialogues with his parents, he was able to achieve closure for the bad behavior he displayed prior to his admission in SELF.

Major Breakthrough

On his 21st month, Sam fully admitted that he took marijuana and shabu (methamphetamine) aside from drinking. This revelation occurred when he suddenly shared his life story in plenary to family members during the Family Association Meeting (FAM). He claimed that he was surprised how he suddenly recalled all the details of his substance use at that moment.

This development was reported to the attending psychiatrist who later determined that Sam’s train of thoughts was beginning to become lucid and insightful. As Sam exhibited more acceptance of his disorder, his medications were decreased. His auditory and visual hallucinations ceased completely.

In March 2007, Sam worked in the facility as the Property Custodian under the supervision of an admin staff. He progressed to the Aftercare stage of the SELF TC program and takes his 48 hours days-off regularly. He is currently preparing for his graduation.

Conclusion

Success in treating dual diagnosed clients can be achieved when the pharmacological concerns are addressed together with behavior therapy. An ideal scenario can be achieved by developing a balanced program of clinical and behavior therapy.

The TC program is a suitable tool for this type of intervention because of its highly disciplined nature that focuses on personal and group responsibility. Through longer periods of treatment, dual-diagnosed clients can progress under the following conditions: 1) regular monitoring and consultation with the attending psychiatrist; 2) strict adherence to prescribed medications; 3) vigilance in monitoring and firm persuasion towards daily structure; 4) regular social interaction; (5) family therapy and involvement.

EILEEN P. SIMBULAN
Staff Psychologist, SELF
May 2007