Clinical Case Study III

Victor is a 23 year old male who was diagnosed to be both drug and alcohol dependent. His drugs of choice were shabu (methamphetamine) and marijuana, but he had tried other drugs such as downers, cocaine, ecstasy, cough syrups, Valiums and Ketamine. He would also mix these drugs with beer or gin.

A child out of wedlock, Victor refused to have anything to do with his father. He grew up with his mother and 40-year-old brother. His family had long planned to put him in rehab but never had the courage to do so.

Victor had a major car accident and almost died. He fractured his hips, left leg and pelvic socket. After this, he managed to finish his high school at International School Manila. He went to Canada for college, but dropped out due to continued drug use. He was eventually confined in a medical ward for two months due to hallucinations and was diagnosed as having Drug-Induced Psychosis.

In 2006, his mother brought him back to the Philippines but less than a year later, he had to be confined again at the Medical City Hospital psychiatric ward. At this point his attending psychiatrist recommended him for rehab.

On February 1, 2007 Victor was admitted at SELF. He was pale, lanky, snobbish, and had a flat affect. He was made to settle down at the Pre-admission (PREAD) unit where medical, psychological and psychiatric tests and assessments were conducted. For the next three weeks, his mood was dysphonic and restricted. He was very angry, refused to talk and even had crying bouts. He showed arrogance, defiance and non-cooperative manners in the upkeep of his room. But soon after he learned that his mother pre-paid the entire treatment, he agreed to join the TC program.

First TC Program

The first months of Victor’s process in the TC were a roller coaster ride. He claimed that everything he did was hard to do and not to his liking. He also tried to manipulate the psychiatrist into giving him certain choices of medication. He was defiant and refused to follow orders. His defiance came in all forms. He refused to move out of his bed even to simply take a bath. Other times, he was rude and would resort to spitting at his superiors earning him a short stint in the reflection room.

Soon after, Victor promised to give the program another chance and seemed to cope much better. He worked hard to be awarded his 1st Family Dialogue and was even promoted to the Senior Phase where he gained more privileges. Then, one day, during his visitation, he declared outright that he had learned enough and wanted to get on with his life outside. This came in the wake of a series of violations of the House Rules. At this point, he admitted he was just pretending to do the program.

His mother, on the other hand, had religiously been attending the family program where she learned about an addict’s manipulation. Strengthened with this training, she refused to pull him out.

Around his 10th month at SELF, Victor just refused to talk, work or move out of his bed. One day, out of desperation, he kicked one of the residents in the leg as a form of protest and rebellion. Thus, he was placed on reflection status and later sent back to the PREAD unit for further psychiatric evaluation. There, he was not allowed to interact with peers and allowed only to write his thoughts and feelings on paper. Apart from his regular sessions with his psychiatrist, he was allowed to do art therapy. For the next two months, Victor’s medications were adjusted and his reactions were closely monitored by the clinical team.
 

Turning Point

In November 2007, Victor wrote a reflection paper where he expressed his desire to write about his own life. He claimed that he wanted others to learn from his experiences. He was allowed to do this and was even encouraged to explain the details of his drugging life. By the first week of December, Victor was already planning how he would be able to return to the TC program. The following are some of the notable changes displayed by Victor at this time: 1) He was calmer and did not disrespect his superiors; 2) He met the minimum standards in accomplishing his duties at the PREAD without resistance; 3) He realized that he had toyed with his life and tormented his family (particularly his mother) and had no right to be angry for being in rehab, and 4) He wanted to complete his program and finish his book.

With this development, a modified treatment approach was drafted and presented to him. Victor agreed to the format and immediately prepared to join the SELF Family. Within the following week, he submitted himself to a Family Confrontation Process where he appealed for his return to the TC Family. Subsequently, he was accepted and was assigned as Business Crew where he began his recovery program from the beginning.

It is now April 2008 and up to now Victor has consistently trodden a slow but sure path to recovery. He has developed a keen relationship with his peers and is open to concerns. He is highly participative and shares insights about his personal growth. He has found a new high in his process and has continued writing about his own life on drugs.

Summary

SELF facility psychiatrist Dr. Arlene Briones diagnosed Victor as having substance induced psychosis with marked depression. His medication was maintained on Zyprexa and Depakote on the first month.

As time went by his medications were adjusted according to his progress and minimum and maximum dosages were determined in order to bring his paranoid thoughts and violent tendencies and agitation under better control. His medications were worked around Risperdal, Seroquel, and Zyprexa until he became settled with Zyprexa and Lexapro. In the end, the dynamic approach of combining medications with modified behavior therapy worked well.

Conclusion

The treatment of dual-diagnosed patients is indeed very challenging. In a facility that only runs a TC program, a case like this would have only worsened if not referred to psychiatry. The absence of clinical therapy would have made progress impossible.

While Victor has not formally finished the program yet, he has reached a major milestone. He seems well on his way towards a successful recovery as manifested by his consistent positive behavior.

 

LEA TUMBADO CSW
Program Manager, SELF
May 2008