September 10, 2012
Shutter Island: Movie Review
In the movie “Shutter Island”, main character, Andrew Laeddis struggles with recognizing reality because he suffers from paranoid schizophrenia. The movie is set in 1954 at Ash Cliff, a treatment facility on Shutter Island for the “criminally insane”. Laeddis believes himself to be a U.S. Marshall who has come to the island with his partner, Chuck, to investigate the disappearance of one of the patients. As Laeddis continues the investigation, he reveals that he is actually investigating the island because he suspects that there is a conspiracy occurring in which all of the staff is involved. He suspects that clinicians are conducting inhumane experiments on patients and sending them back into the world as “ghosts” with their memories erased due to brain surgery. Laeddis often links this to the Nazi experiments on human subjects and is especially angered by this because of his experiences fighting for the United States in World War II. Throughout the film, Andrew Laeddis refers to himself as Edward ‘Teddy’ Daniels and believes that Laeddis is a man who killed his wife, Dolores, in a fire. At the end of the film, the psychiatrist reveals that he is actually Laeddis and that there is no missing patient, Rachel Solando, but only that Andrew created this fantasy so that he would not have to remember that his wife was “manic-depressive” and murdered his children, after which he murdered her.
Laeddis suffers from paranoid schizophrenia. According to the DSM IV-TR (2000), schizophrenia is a psychotic disorder characterized by at least two of the following five symptoms: hallucinations, delusions, disorganized speech, disorganized behavior, and negative symptoms (anhedonia, avolition, alogia, and flat affect). Symptoms also must impair social or occupational functioning, last longer than six months, must not be due to substance use or a general medical condition, and there must not have been any mood episodes (manic, depressive, or mixed). Laeddis qualifies for a specific type of Schizophrenia, referred to as the paranoid type. People suffering from paranoid type are highly suspicious and engage primarily in their delusions and hallucinations and do not have prominent symptoms of disorganized speech and behavior. Schizophrenia is prevalent in roughly 1% of the population and can be one of the most costly disorders due to need of repeated hospitalizations because of suicidal or homicidal behavior. Schizophrenia is also one of the most deteriorative disorders, and once there has been one episode, clients most often do not return to baseline and decompensate more and more as the disorder progresses.
Schizophrenia symptoms present differently in all clients. In “Shutter Island”, the symptoms that Laeddis experienced were more on the positive spectrum (delusions and hallucinations), and he did not present with as many negative symptoms. In clients with schizophrenia, it is much more common for clients experiencing more positive symptoms to have better life outcomes and return to baseline. However, in the film, Laeddis had been at the facility for two years and had been delusional for almost the entire time. The end of the movie remains ambiguous as to whether or not he was finally aware of reality. Also, in the film, Laeddis experienced many visual hallucinations, referred to as “walking nightmares”. In the general population, this is much more uncommon. Most people diagnosed with schizophrenia only experience auditory hallucinations. Laeddis also qualifies for a specifier, the paranoid type because he is highly suspicious of everyone around him. At first, he is kind to staff and then decides they are trying to hurt him. He believes that his partner has turned on him, and he is suspicious about everything that is happening on the island. Please see the chart below for other symptoms that Laeddis experienced.
DSM IV-TR Criteria for Schizophrenia How Symptoms Met Criteria in “Shutter Island”
Hallucinations: Laeddis experiences visual hallucinations of his wife, daughter, and a psychiatrist in a cave.
Delusions: Laeddis believes that he is still a U.S. Marshall investigating a case on the island. He believes that his Psychiatrist is his partner and that when speaking to clients, he is investigating them. He also believes that he murdered many people in WWII, which the psychiatrist denies at the end of the film.
Disorganized Speech: Laeddis found a note (left by himself) that read, “The rule of 4. Who is the 67th patient?” Other than this, Laeddis does not engage in other characteristic disorganized speech, such as neologisms, tangential speech, or loose associations.
Disorganized Behavior: Laeddis’ psychiatrist states that he is often agitated and easily provoked. Laeddis engages in violent acts when agitated, such as blowing up a car, attacking a guard and a patient, and injecting a Psychiatrist with a sedative.
Negative Symptoms: (anhedonia, alogia, avolition, flat affect) Laeddis does not demonstrate any negative symptoms. His affect is labile as he is calm and contemplative one moment and aggressive the next. Client still engages in pleasurable activities (investigating crimes), and he does not have any speech impairments.
Impaired Functioning: Laeddis is unable to live in the real world, as his experiences are so far from reality. Laeddis is suspicious of everyone around him and is violent when he becomes paranoid.
Paranoid Type: Laeddis shows complete preoccupation with his delusion of being a U.S. Marshall investigating the island. He is frequently suspicious of those around him and is violent when he feels threatened. While there is some disorganized behavior and speech present, it is not prominent.
For the most part, the disorder was accurately portrayed. Laeddis qualified for the symptoms of schizophrenia, paranoid type, which is how he was portrayed in the film. He did not have an over-abundance of symptoms, as occurs in some films. The only discrepancy would be that clients with less negative symptoms generally have better outcomes, but Laeddis had not gotten better after two years of treatment. However, the movie was set during a time period in which psychotropic medications were just beginning to be utilized, so although psychiatrists had attempted to use chlorpromazine, it may be that the treatment methods of the time were unable to aid clients at the same rate as they can today.
Not much is known about Laeddis’ biology. There is no mention of any underlying general medical conditions. Laeddis did consume large amounts of alcohol and is portrayed as an alcoholic when his wife and children were still alive. Laeddis does not seem to have any physical disabilities or impairments. There is no mention of his parent’s health or mental health. Laeddis is in good physical shape and “highly intelligent”. However, Laeddis was taking an antipsychotic, chlorpromazine, for quite a while and recently stopped which caused him withdrawal symptoms (migraines and tremors). The symptoms of withdrawal caused him to believe that he was being given medications that would allow staff to take advantage of him and use him for experiments. Due to current research on schizophrenia, Laeddis probably suffers from enlarged ventricles and decreased levels of dopamine and serotonin.
Laeddis suffers from many psychological conditions. Other than his diagnosis as a paranoid schizophrenic, Laeddis also suffers from symptoms of Post Traumatic Stress Disorder (PTSD) which co-occurs with his schizophrenia and relates to his psychological themes of guilt and suspicion. While in WWII, Laeddis saw many dead bodies and felt a great amount of stress. He has frequent flashbacks and nightmares about the dead bodies and also the dead bodies of his wife and children. Laeddis engages in great efforts to avoid thinking about his memories from the war and his deceased children by engaging in delusions and avoiding talking about what happened. He is also hyper-vigilant and exceedingly agitated. One of the major contributors to his delusions is Laeddis’ guilt for not helping his wife obtain psychiatric treatment. Dolores had “manic-depressive” disorder and set their house on fire. Because Laeddis knew she needed help before she murdered the children, he takes responsibility for his children’s deaths as well as hers. The guilt he feels is so over-whelming that he does not know how to cope with it, other than by making himself feel like a hero on an important investigation.
Socially, Laeddis did not have much support before he was committed. Laeddis did not have anyone to talk to about Dolores and her mental health or about his horror from experiences at war. Laeddis was quite isolated and remains isolated within his mind on Shutter Island. Not much is said about his relationship with his parents other than that he was “raised by wolves” indicating a negative childhood experience. Although Laeddis felt isolated, he carried a high rank in society, was an esteemed Marshall, and had a comfortable lifestyle (he lived in a large and beautiful home on a lake). His feelings of isolation and the importance of maintaining his image as an important figure of society caused him to ignore his problems instead of face them. Now he is still attempting to use this method by living a fantasy in which he is a hero.
Social Work Prospective
Overall, the writers and directors of “Shutter Island” provided an accurate and believable portrayal of Paranoid Schizophrenia. Although the film is acute, Laeddis does not demonstrate symptoms that are more common among clients with schizophrenia. For example, there are usually more disorganized and also negative symptoms. Another potential problem with the accuracy of the diagnosis is that the movie will likely increase the stigma that “people with mental illness are dangerous” because it is set in a prison for the criminally insane. The general public has a negative perception of those who have mental illness because they believe they are impulsive, dangerous, and commit crimes for no reason, and this movie definitely portrays mental illness in a similar light. When choosing a film for the project, it seems that many dramas present mental illness in a negative light, whereas comedies often are more positive and de-stigmatizing.
As for the PODS, racial, and sexual issues of discrimination and oppression are not explored, as the characters are generally white and heterosexual. While the psychiatrists are all men, there are both male and female nurses, but issues of gender are not discussed. The main discussion of oppression in the film is that of the patients receiving treatment. Laeddis does not believe that the staff is humane, but is in fact conducting experiments on patients. He is somewhat correct but not in the way he believes. The staff is attempting a new type of treatment, client-centered therapy, which is more moral and humane. Throughout the film the psychiatrists highlight the dark past of mental health treatment and their hopes for the future of the field. In that regard, social justice seems to prevail in the hope that clients will be treated like people, and it may be the one aspect of the film that attempts to remove stigma from mental illness.
While “Shutter Island” is an excellent movie and accurately portrays paranoid schizophrenia, it may not be the best film for the general public to watch to learn about mental illness. It is quite educational relating to symptoms of the disorder, the mindset of a client, and the history of treatment, but it is not uplifting and certainly casts a negative light on clients. It is a good movie for social work students to watch as it relates to many topics in class, deals with diagnosis and treatment, and is a great movie, but I would not recommend it to the general public as a way to learn about mental illness.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th Ed.). Washington, DC: Author.
Scoresese, M. (2010). Shutter island. Paramount Pictures.
Sadock, B. J., & Sadock, V. A. (2007). Kaplan and Sadock's Synopsis of Psychiatry (10th ed.). Philadelphia: Wolters Kluwer.
Example Biopsychosocial Assessment
January 16, 2012 3-4 PM
Present for this assessment are the client, Chloe (pseudonym); and evaluator Alissa Bleecker, MSW intern
Identifying Information and Referral Source
Chloe is a 28 year old African American female presenting for evaluation of possible depression and anxiety. She is referred by her primary care physician, Dr. Albanese.
Chloe reports that since her boyfriend, Eric, has come back into her life, she has been “feeling anxious, overeating and sleeping 10-12 hours at a time”. Chloe is “looking for guidance and direction” in regard to her relationship with Eric, who is also the father of her daughter, Drew. Eric had been absent from her life in the last 10 months and has recently returned stating that he wanted to marry Chloe. Chloe reports often feeling “anxious” about decisions concerning Eric, and that her “over-eating and over-sleeping” are recurring symptoms from times in which he has broken-up with her in the past and also when he has re-entered her life. Chloe also stated that she has withdrawn from her friends because “they don’t support [her] relationship with Eric”.
Chloe was seen briefly at an outpatient facility once because of a professor’s referral “during undergrad. But I wasn’t trying to address issues, and she thought it was just silly college girl problems. She didn’t take me serious”. She has never been hospitalized or prescribed psychiatric medication.
Chloe’s had two abortions, one in 2011 and another during her undergraduate work. Other than this, Chloe’s history is negative for hospitalizations, surgery, or major illness. Due to working third shift, Chloe sleeps during the day and reports sleeping 10-12 hours each day. Chloe is “constantly eating throughout the day, even when she is not hungry”. She reports eating more when thinking about Eric.
Family of Origin History
Chloe states that she has a pretty good relationship with her family. Her mother is “a huge support, even though [she] can’t tell her everything because she can be judgmental” due to her religious beliefs. Chloe’s relationship with her mother was strained when she had her daughter out of wedlock, and said that this was difficult for her mother to accept. Chloe also has a good relationship with her stepfather, although he “works all the time and is not there very often”. However, when he is home, they get along.
Chloe has two siblings, a younger brother and sister. Chloe’s sister is 21 and it’s “a typical sister relationship. She looked up to me growing up”. However, now that her sister is an adult, she “is out of control”. Her sister and mother often argue and do not get along very well. Chloe reports that her relationship with her brother is also good, but “he’s too spoiled”, and he has an “unrealistic relationship with her daughter”. Chloe thinks he has too high of expectations for her daughter, Drew.
Chloe’s daughter, Drew, is three years old, and she “loves her to death”. Although Drew “gets on [her] nerves sometimes”, Chloe thinks they are well bonded.
Current Relationship/Family Issues
Chloe reports that her relationship with Eric has been rocky with multiple break-ups and a history of domestic violence. Chloe and Eric first met when Chloe was 15 and working at a bagel shop. Eric is 12 years older than Chloe and has always been a flirt. When they became friends, he had a girlfriend, and as soon as they broke-up, Chloe and Eric began dating. Chloe believes dating him so soon after his break-up was a mistake because “he had unresolved issues”.
Chloe says that the first time that there was conflict in their relationship was when she became pregnant with Drew. After learning of her pregnancy, Eric left her for a year, and Chloe moved in with her parents. After his return, things were better until Eric’s mom passed away. After her death, “he wouldn’t communicate”. They were in danger of losing their home, so Chloe put her and Drew’s things in storage. Then Chloe did not see Eric for 10 months until he recently returned stating that he wanted to marry her.
Chloe states that she and Eric have “normal sexual health”, and she had only been with one man until the most recent break-up. After the break-up, she slept with another man but “didn’t enjoy it”.
Spirituality- Chloe is a Christian and states that her beliefs are important to her. Her beliefs cause her to feel “guilt over the abortions, premarital sex, and having a child out of wedlock”.
Peers-Chloe reports having a couple of really good friends whom she “sees from time to time”. She can “rely on them to vent” but has recently “pulled back from them” because they do not approve of her relationship with Eric.
Culture-Chloe identifies as African American. Chloe reports no concerns or stressors related to cultural or ethnic factors.
Strengths- Chloe reports that her strengths include that she “gives everyone the benefit of the doubt”. She also is “intelligent, a hard worker, and a good mother”.
Chloe completed her bachelor’s degree in Philosophy and would like to obtain a master’s degree in health administration. She currently works for the State Government “as a paper pusher”, as she is in charge of the mailings. Chloe has been employed here for eight years, and is not very enthusiastic about her job. Chloe reports that she does not get along with her supervisor and “calls off a bit when dealing with Eric”.
Chloe denies any history of involvement with the legal or criminal justice system.
Chloe and Eric have a history of domestic violence. When Eric becomes angry he often is destructive and has destroyed her glasses and laptop. Chloe reported one incident of domestic violence to the police, in which Eric was arrested and took anger management courses. Although there has not been an incident since then, Chloe is worried that “he might do it again”.
Chloe denies homicidal ideation, plan or intent, as well as current or past abuse or trauma. She denies current suicidal plan or intent. Chloe is able to contract for safety at this time.
Substance Use/Abuse History
Chloe denies any substance use for herself, Eric, and her immediate family.
Mental Status Exam
At the assessment, Chloe’s appearance and grooming were appropriate and casual. Physical abnormalities were not observed. Psychomotor activity was within normal limits. Tics/stereotypes were absent. Behavior and responsiveness to examiner was subdued but cooperative. Consciousness and orientation were alert. Affect was limited and mood was “anxious”. Thought processes seemed normal, as did thought content and perception. Cognitive functions, while not formally measured, seemed appropriate. Chloe displayed excellent insight and psychological mindedness.
Chloe identifies as an African American female. She does not note any concerns related to her cultural identity. When asked about why she believes she is experiencing her presenting symptoms, Chloe attributes her current difficulty to Eric, saying “he tells me the type of life he wants to lead, but he doesn’t act it. He seems changed now though because he’s talking about marriage. I used to be the only one talking about getting married. I just don’t want to make another mistake”.
Chloe has treated her feelings of anxiety by eating and sleeping. She states that sleeping helps because she when she is asleep, she does not have to think about Eric. She recognizes that her anxiety is negatively impacting her life because “any time not devoted to [her] daughter is negative.”
Chloe has chosen to participate in therapy with the hope that a therapist can “help [her] make a decision.” She says she “needs a sounding board for a new perspective.”
Chloe is a 28 year old African American female presenting with symptoms of depression and anxiety. The following symptoms and findings are prominent and clinically significant: over-sleeping, over-eating, isolative behavior, and feelings of anxiety. The symptoms are relatively acute. Protective factors include supportive family and friends, as well as Chloe’s insight and motivation for treatment. Significant Biopsychosocial stressors include absences from work and her relationship with her supervisor. Other stressors include her relationship with her partner and a history of domestic violence. Differential diagnosis should include depression as well as anxiety.
Axis l: 300 Anxiety Disorder NOS Axis ll: deferred Axis lll: deferred Axis lV: mild-moderate stressors: work difficulty, relationship conflicts Axis V: 60
1. Weekly individual psychotherapy to reduce depressive symptoms and improve social and occupational areas.
2. Psychiatric evaluation to address potential use of antidepressant medication.
3. Biweekly couples Therapy session
4. Meeting with PCP to rule out any medical etiology for symptoms.
May I Sit Down? Safety vs. Dignity Engaging Clients during ACT Home Visits
At Assertive Community Treatment (ACT), social workers provide mental health care to clients both in the office and in the community. During the hours of 9:00 AM to 11:30 AM, the ACT Ypsilanti team travels to the homes of 7-12 clients each day to provide at home care. During this visit, social worker provides Am eyes-on medication and observe the client set-up his/her medication in a med box up to the next time s/he will be visited. The social worker also conducts a mental status exam and inquires about whether the client needs any resources or assistance. The whole visit lasts approximately 10-15 minutes, and for the entirety of the visit, the social worker remains standing, while the client often sits.
Current ACT written policy states that the social worker should remain standing as a personal safety precaution (ACTA 2011). Other similar safety precautions involve keeping the client’s door open, and standing between the client and the door. These written policies are in place to protect the social worker from potential violence. Unwritten policy states that the social worker should remain standing so as not to contract bed bugs (White 2012). While this unwritten policy may not be true for all ACT teams, it is one that is viewed with great importance by Ypsilanti ACT team. The threat of bed bugs residing in seat cushions and cloth fabric, or even carpet causes much distress to the Ypsilanti team, and the team takes great precautions to remain standing with pant legs rolled up.
The issue of a standing social worker first came to my attention when conducting a home visit. The client, who often presents with labile affect, yelled “just come in. You people never sit down, so let’s go to the kitchen”. For a social worker to remain standing while having a fifteen minute conversation with a seated client is controversial because of the research that has been conducted on the importance of being on the same level as clients. Although safety concerns are valid, standing while clients sit may not be conducive to helping clients. Even though written and unwritten policy states that the social worker should remain standing during home visits, standing causes a disconnect between the client and social worker because it creates a power dynamic in which the social worker is superior to the client.
Although there is already a power dynamic in place when a social worker visits a client’s home, this power can change based on the type of interaction between the individuals. In fact ACT strives to alter the power relationship between the helpers and help-seekers through home-based treatment. Home based treatments allow clients to continue to reside on their own and give them back independence over their lives, empowering them and allowing them to maintain dignity. This is based on the mission of ACT which is “to promote, develop, and support high quality assertive community treatment services that help improve the lives of people diagnosed with serious and persistent mental illness” (ACTA 2011). With a mission statement promoting the improvement of those with mental illness, it seems clear that empowering clients to be independent would be one way to achieve this mission.
One of the best evidence-based practices for improving relationships between case workers and clients during home visits is for the social worker to act as a guest and allow the client to act as the host (Muir-Cochrane 2000). By acting as a guest, the social worker relinquishes power and gives it to the client, creating a more balanced relationship. This can be especially helpful for clients who have an alternative treatment order (ATO), and do not want treatment, and who find having a social worker at their home to be invasive. In a study of nurses who conducted home visits, Muir-Cochrane (2000) found that acting as guest in a client’s home made a profound impact on the client’s mental health because it shifted the power dynamic and empowered the client. The client felt that s/he had control over his/her home and life. However, acting as a guest also involves sitting down when invited to by the client. Similarly, clients could choose not to ask workers to sit down, and by having control over this decision, there was a more evenly balanced power dynamic between the worker and client.
Other research has also discussed the importance of being at the same eye level as a client. Lawrence-Weiss (2010) has found that regardless of the client’s age, one of the most effective ways to assist a client in building self-esteem is to speak to them at eye level. Lawrence-Weiss suggests that if a client stands, then stand; if a client sits, then sit, kneel, or bend over because this allows a client to feel validated. Furthermore, speaking to a client when not at eye level can induce frustration at not being truly heard or understood. It creates an unbalanced power relationship in which the social worker is superior to the client.
Standing while a client sits may also have important cultural implications that lead a client to feel inferior to the social worker. According to Cultural Competency Guides, it is important when working with clients of other cultures, that the social worker shows utmost respect for a client (Saldaña 2001). It further states that a client may not be as engaged in treatment if s/he perceives social distance between self and the worker. It seems that by communicating on different planes, and not maintaining the same eye-level, that the client may suffer as a result of a worker’s unwillingness to meet him/her at eye-level.
Based on the research, it seems painfully obvious that clients greatly benefit from having a social worker sit down to speak to them when they are also seated. This lends to the question, why don’t social workers just sit down if it’s so important? The answer is unfortunately, personal safety. Although Sadock and Sadock (2007) maintain that the amount of crimes committed by the mentally ill are not statistically different than those of the general population, other sources provide different statistics. Trainin Blank (2006) provides statistics that reveal that “51.3% of the sample reported feeling unsafe in their jobs. Nearly one-third have experienced some form of violence, including verbal abuse... Nearly 15% reported at least one episode [of violence] in the field”. Crime among the mentally ill is viewed as more dangerous than the general public because of the perceived randomness and lack of an understandable motive. Because of these safety concerns, practitioners are encouraged to take great caution when conducting home visits.
Although ACTA (2011) policy states that social workers should remain standing, Trainin Blank (2006) encourages social workers to remain at eye-level with clients to de-escalate clients. Other home visit procedures also state that sitting in a hard-backed chair may be beneficial (Multiple Program Worker Guide 2011). It does discourage sitting on cloth seats but states that this is due to the possibility of sharp objects being hidden beneath the cushion, rather than bed bugs. The guide also states that before sitting down or entering the home, the social worker should observe the surroundings for safety concerns and cleanliness.
Another important consideration is the National Association of Social Worker’s (2008) Code of Ethics. For example, NASW code 1.01 states that “Social workers’ primary responsibility is to promote the well¬being of clients”. If a client is not engaging in treatment because of an uncomfortable power dynamic in which the social worker is perceived as superior and imposing him/her self on the client in the home, then it seems as though the social worker would not be meeting the first standard in the code of ethics. Because a client’s wellbeing comes first and foremost, social workers need to consider the possible implications of standing while a client sits and critically analyze if this is hindering the client’s treatment. Secondly, under 4.05, it states, “social workers should not allow their own personal problems, psychosocial distress, legal problems, substance abuse, or mental health difficulties to interfere with their professional judgment and performance or to jeopardize the best interests of people for whom they have a professional responsibility”. Unpacking this standard is more problematic because of it begs the question, would fear of bed bugs or fear of personal safety fall under the category of psychosocial distress? If a social worker assesses the client as they enter the home and finds that the client does not seem threatening or agitated, there are not visible weapons, and the house is not overly unclean, is it then an irrational fear and personal psychosocial distress which causes the social worker to remain standing despite the safe surroundings?
In the end, the simple decision about whether to sit or stand when working with clients is actually much more complicated and requires a great deal of thought because it significantly impacts the power dynamic between the client and social worker, which then impacts the client’s level of engagement with the social worker. Being a social worker, and following the NASW code of the ethics means making the client the primary priority, which means that social workers may be placing themselves in risky situations from time to time.
While ACT home visit policies state that the social worker should remain standing for the duration of the home visit, current evidence-based practices show that this may not be the most conducive way to work with clients. ACT needs to review current evidence-based practices and adjust written policy in order to follow the NASW code of ethics and provide the best possible services to clients. Safety for social workers still needs to be a concern, but there are ways of assessing risk that can be incorporated into new policy. For example, assessing a client’s mental status and observing the surrounding area for cleanliness and potential weapons can be the determinant for whether a social worker should sit down (if the client is sitting) or remain standing. Respect should be the utmost priority, especially since the social worker is in the client’s home, so it is also important to ask if you may sit, if the social worker typically remains standing.
Clients are most engaged and thus receive the best treatment when social workers show respect to clients and ‘get on their level’, so that the client and social worker have good eye contact, and so that there is not an unfavorable power dynamic. One way to measure client engagement is to observe the length of time spent at a client’s home. On the ACT Ypsilanti team, the length of time is closer to 7 minutes on average, rather than the full 15. Changing one simple interaction, from standing to sitting with a client, can make a huge difference in a client’s recovery and mental health maintenance. Sitting with a client will also encourage conversation and the client’s level of engagement. While social workers need to maintain personal safety, it seems that the positive aspects of sitting outweigh the risks, so long as the social worker is able to assess the condition of the client and the home.
ACTA (2011). Mission statement. Assertive Community Treatment Association.
Lawrence-Weiss, S. (2010). Do you meet your child at eye level? Early Childhood News and Resources.
Muir-Cochrane, E. (2000). The context of care: Issues of power and control between patients and community mental health nurses. International Journal of Nursing Practice, 6, 292-299.
Multiple program worker guide #19. Home Visit Guidelines, 63. 2011.
NASW (2008). Commitment to clients. Code of Ethics of the National Association of Social Workers.
NASW (2008). Impairment. Code of Ethics of the National Association of Social Workers.
Priebe, S., Watts, J., Chase, M., & Matano, A. (2005). Processes of disengagement and engagement in assertive outreach patients: Qualitative study. British Journal of Psychiatry, 187.
Sadock, B. J., & Sadock, V. A. (2007). Scizophrenia. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10, 484-485.
Saldaña, D. (2001). Cultural competency: A practical guide for mental health service providers. Hogg Foundation for Mental Health.
Trainin Blank, B. (2006). Safety first: Paying heed to and preventing professional risks. The New Structural Social Worker.
Assertive Community Treatment: Beneficial for Taxpayers or Clients?
With the creation of Assertive Community Treatment (ACT), many benefited from this new and evidence-based approach to community mental health. ACT provides a much different and progressive type of service than an inpatient facility; it offers community-based, at home care for clients with severe and persistent mental illness. Through ACT, social workers provide mental health care to clients both in the office and in the community. During the hours of 9:00 AM to 11:30 AM, ACT teams travel to the homes of 7-12 clients each day to provide at home care. During this visit, social worker observes clients take AM medications and observes the client set-up his/her medication in a med box up to the next time s/he will be visited. The social worker also conducts a mental status exam and inquires about whether the client needs any resources or assistance; the whole visit lasts approximately 10-15 minutes. In the afternoon, staff involves clients in different support groups such as co-occurring groups, shopping groups, and walking groups. Staff also uses afternoons to see clients in the office and assist clients with miscellaneous appointments and needs.
Although ACT provides clients with unique and necessary services, research studies show that while ACT does prevent hospitalizations, the program does not significantly increase quality of life or reduce symptoms. Although clients benefit from not being hospitalized unless absolutely necessary, this is more of a fiscal improvement than a mental health improvement. Client care should be more focused on symptom reduction and quality of life if it is truly client based. This lends to the question, if ACT is truly an evidence-based approach to improving mental health, what can be done to improve this service so that clients receive the best possible care?
Mental health care has greatly improved over the past few decades, but has recently reached a point where social workers follow the norm of practices rather than using more progressive, evidence-based practices (Mechanic 2008). Although the main focus of these programs is “recovery, community integration, and making services consumer and family centered”, client’s lives are not significantly improved by programs like ACT. For example, in a study of the ACT program in Japan, clinicians found that clients in the program had decreased hospitalizations but no symptom reduction. These findings are similar to data collected in the United States. However, in Japan, clients were given a quality of life interview (QOLI) at 2 weeks and then again 12 months later. Through this survey, Horiuchi et al. (2006) found that clients in ACT in Japan had increased quality of life but that they had decreased family contacts which were a predictor of rehospitalization. In the study, “it was assumed that satisfaction with family relationships indicates an unmet need for care among this population”. Clearly, more research must be conducted to determine the connection between quality of life and family contacts.
One of the major benefits, but also potential pitfalls of ACT, is that ACT policies are much looser than in other organizations (Powell, Garrow, Woodford & Perron). Social workers are able to make street-level decisions about how often clients are seen, what services or resources clients may be offered, and what type of therapy to use during interventions. This amount of freedom may seem like a huge bonus to working in an ACT setting, but it may be the reason that the program does not increase quality of life and symptom reduction. If social workers are able to have that much freedom, they may not be choosing evidence-based therapies when working with clients, or they may not have the proper certifications to be qualified for different types of interventions. This creates an unequal dynamic among staff members as some staff may use different techniques than others.
Although it was previously believed that clients with severe and persistent mental illnesses, like schizophrenia, would not benefit from therapy, researchers have recently challenged these assumptions. It seems that once a client is stabilized, therapy is beneficial in increasing medication compliance for longer periods of time, and therapy increases quality of life (Zygmunt, Olfson, Boyer, & Mechanic). Much research has been conducted on individual types of therapy and how they may be implemented by ACT, but no single researcher has compared the major types of therapy and found a perfect solution as to which, if any, to implement into the ACT model.
One important component to increased quality of life lies in medication adherence, because clients who refuse medications experience distressing symptoms. Zygmunt et al. reviewed literature about the necessity of medication adherence for clients with schizophrenia, stating that 50% of those diagnosed with schizophrenia will stop taking medications within a year after first discharge (2002). Once clients have stopped taking medications, they will experience increased risk of relapse (3.7% greater than compliant clients), and symptoms can negatively impact quality of life. Researchers then researched psychosocial techniques and therapies for improving medication compliance. Zygmunt el al. did find that programs such as ACT were more effective, as was motivational interviewing, because each focused on behavioral training. Findings suggest that clients will be more compliant when given concrete instructions and problem-solving strategies. Behavioral training was effective because clients were provided direct feedback for compliance.
Based on the results of the study, it seems evident that evidence-based practices such as CBT and DBT might be paired with the ACT model to increase quality of life and reduce symptoms because both types of therapy are rooted in behavior. Pinninti et al. (2010) have researched the benefits and difficulties of utilizing CBT in an ACT program. First and foremost researchers maintain that medication compliance is critical for ACT clients, but that CBT and training can improve client’s functioning and reduce symptoms because it provides skills training and helps clients improve coping skills for dealing with their mental illness. Pinninti et al. believes that “the improvement in functioning included interventions, such as helping clients make appropriate life decisions, improving social and leisure skills, and dealing with barriers to employment”. However, data suggests that CBT in an ACT setting does not seem to be beneficial for clients who are being treated for substance use. Contrary to Zygmunt et al. (2002), Pinninti et al. (2010) found that there was no correlation between CBT and medication compliance. They also did not find a correlation between CBT and hospitalizations, but this may be due to already reduced rate of hospitalizations because of the ACT model.
Another potential behavioral model that might be beneficial in an ACT program is DBT. While DBT is primarily utilized for clients with Borderline Personality Disorder (BPD), any clients who suffer from emotional dysregulation may also benefit from this type of therapy. While ACT focuses primarily on Axis I conditions, in recent years, data suggests that 26% of clients have a co-morbid personality disorder (Burroughs et al. 2012). Furthermore, “ACT programs appear to lack a theoretical framework for addressing the behavioral concerns typically associated with clients who are diagnosed with personality disorders”. Although Burroughs et al. discuss the lack of framework for clients with personality disorders; it also reflects the more general lack of framework which is associated with ACT in regard to symptom reduction and quality of life. Researchers suggest that using DBT in an ACT program can be beneficial to clients because this type of therapy helps clients regulate emotions, impulsivity, and parasuicidal behavior. It also would be easy to implement into the structure of the program because staff are available 24/7 as is also required by DBT training. Also, staff is already used to seeing clients with increased needs, and would be able to reinforce the client’s skills training when they are providing services to the client in the community. Not only that, but “ACT has the staffing infrastructure necessary to implement DBT with an average ration of staff to clients of 10:1”.
Although it seems as though there are many benefits to implementing the DBT model, there are some serious considerations as well. Problems include the cost and time commitment of becoming certified to practice DBT. For ACT to implement DBT, all staff would need to be trained, and the training is quite expensive at $2400 per person for a 7-day training seminar (Burroughs 2012). Another concern is that there is a high rate of turnover for ACT employees, so the county would need to pay to certify every new employee. Overall, the cost-benefit ratio makes agencies second guess implementing this type of intervention.
The final type of therapy suggested by Zygmunt et al. is motivational interviewing (MI). While this was originally created for clients who use substances, the techniques can be adapted to other Axis I diagnoses as well (Miller 2012). The theory behind motivational interviewing is that clients are stuck in a pattern in which change is difficult and they often do not see a need to change. Clients may also not view themselves as having a problem, which is quite common among schizophrenics, and is often the reason that clients stop taking medications. Based on this, the premise of motivational interviewing is for the client to recognize the reasons for and importance of change. An importance difference between this type of therapy and others is that there is no certification required to use MI. Also, the resources are free on the website, and there are online training modules that staff can use to become proficient. The only potential pitfall of MI is that because there is no certification, staff may be practicing the technique without proficiency.
It is also worth mentioning, that similar to MI, small scale efforts to improve client’s quality of life and symptom reduction can also be implemented. For example, Lang et al. (1999) found that the more engaged clients were involved in creating their treatment plan, and had higher quality of life. The reason for this is that clients sometimes values differed from that of the psychiatrist in the surveys. Clients found pride in smaller scale improvements that clinicians did not notice as much.
In research conducted by Zygmunt et al., researchers found that behavioral therapies and motivational interviewing proved to be effective ways of reducing client’s symptoms and improving quality of life. Within behavioral therapies are DBT and CBT. It seems thus reasonable that if ACT were to implement an evidence-based therapy model, it be CBT, DBT, or MI, as these are also considered in some circles to be three of the five most utilized forms of treatment (Adlaf 2012). Due to the exceedingly high cost and the large amount of training in DBT, this can be ruled out as a formal treatment method.
However, some of the skills associated with it, such as validation and emotional regulation, can be used. Also, because the data on CBT suggests that it does not help as consistently when paired with ACT, and also because it has not proven to be helpful with substance users, it should be ruled out as well.Overall, motivational interviewing appears to be the best approach to working with clients in ACT settings. Both substance users and clients with other axis I diagnosis can benefit from the skills training in MI. MI is also a better option because it is easier for clinicians to become proficient in MI than for other therapies, and also it has no costs nor special certification.
ACTA (2012). ACT model. Assertive Community Treatment Association. http://www.actassociation.org/. Retrieved March 1, 2012.
Adlaf, A. (2012). Syllabus. Interpersonal Practice with Adults.
Burroughs, T., & Somerville, J. (2012). Utilization of evidence based dialectical behavioral therapy in assertive community treatment: Examining feasibility and challenges. Community Mental Health.
Horiuchi, K., Nisihio, M., Oshima, I., Ito, J., Matsuoka, H., & Tsukada, K. (2006). The quality of life among persons with severe mental illness enrolled in an assertive community treatment program in Japan: 1-year follow-up and analyses. Clinical Practice Epidemiology Mental Health, 2, 18.
Lang, M. A., Davidson, L., Bailey, P., Levine, M. S. (1999). Clinicians’ and clients’ perspectives on the impact of assertive community treatment. Psychiatry Services, 50, 10: 1331-40.
Mechanic, D. (2008). In mental health and social policy: Beyond managed care. Pearson Education, Inc: pp.xi-xvi.
Miller, B. (2011). MI basics. Motivational Interviewing. www.motivationalinterview.org. Retrieved March 10, 2012.
Pinninti, N.R., Fisher, J., Thompson, K., & Steer, R. (2010). Feasibility and usefulness of training assertive community treatment team in cognitive behavioral therapy. Community Mental Health., 46, 4, 337-41.
Powell, Garrow, Woodford & Perron: Policy Making Opportunities for Direct Practitioners in Mental Health and Addiction Services. Mental Health Policy. Retrieved March 1, 2012.
Zygmunt, A., Olfon, M., Boyer C., & Mechanic, D.(2002) Interventions to improve medication adherence in schizophrenia. Am J Psychiatry, 159, 10. 1653-64.
“The Eden Express”: An Inside Look at Schizophrenia
When reviewing novels to read for the memoir project, I hoped to find a first person account of a serious and persistent mental illness. Working at Assertive Community Treatment (ACT) for my field placement, I am engaged with this client population daily. However, understanding the diagnostics of a disorder is quite different from understanding the actual client’s experience and thought processes. By reading a memoir that features a first person narrative of mental illness, I hoped to become more aware and empathetic to the experiences of my clients. After perusing the list, I chose to read “The Eden Express” by Mark Vonnegut.
“The Eden Express” chronicles Vonnegut’s post-collegial journey (moving to British Columbia, creating a commune, and trying to be a “good hippie”) during the late 1960s and early 1970s. Throughout this journey, Vonnegut becomes symptomatic and is hospitalized twice and diagnosed with schizophrenia. In the afterward, Vonnegut describes the changes in DSM criteria and states that if diagnosed today, he would be diagnosed with “manic depressive” disorder. However, the symptoms that Vonnegut describes appear to be more closely related to schizophreniform disorder due to his extreme yet short-lived psychosis. For example, Vonnegut’s psychotic episode lasts less than six months and much more positive symptoms are described than negative symptoms. After his recovery, friends and family believe that he has returned to baseline; this indicates that he has not decompensated nor retains negative symptoms.
Other prominent symptoms of schizophrenia spectrum disorders that Vonnegut experiences include visual hallucinations of a face, auditory command hallucinations, ideas of reference, paranoia about being poisoned, and grandiose delusions of being the messiah and of having killed his father and girlfriend (Virginia). Cognitively, he experiences difficulty inhibiting sensory stimuli, and difficulty with attention. Vonnegut also engages in clang associations, neglects hygiene and groom, has lack of sleep and lack of appetite, is catatonic at times, and is suicidal in regard to delusions of his death saving the world. While Vonnegut does exhibit some symptoms of depression, it is in response to the anxiety and grief that his delusions cause.
Vonnegut’s behaviors while psychotic are similar to the types of behavior that I see at ACT. Many of my clients do not maintain hygiene and groom and are often naked (just as Vonnegut runs through the neighborhood in the nude). Vonnegut made an insightful observation while hospitalized, stating that: “most of how you’re treated…is determined by how you are dressed. If you have on a suit and tie, there’s no such thing as a locked door. With nothing but a sheet, there’s no such thing as an open one” (195). When I visit a client, I conduct a mini mental status exam and hygiene and groom is the first aspect that I notice. Other similarities include difficulty paying attention to the conversation, staying on a specific topic, and processing multiple questions at once. Although, I have yet to experience a client who clangs, I do see clients who have grandiose delusions about living in a palace, being a king, a messiah, or a rock star. Many of my clients also endorse auditory hallucinations, most of which are persecutory like Vonnegut.
Being able to observe so many similarities between the behaviors of Vonnegut and my clients makes me wonder what their internal experiences are like. Some clients seem quite stable, but when asked more about their history, will speak at length about their views of the world, most of which are extremely disorganized, tangential, delusional, and paranoid. I really appreciated this memoir because I can see how difficult it might be to focus on a conversation with a care provider while there are so much internal stimuli and at the same time, there is a sensory overload. It was also interesting to read that Vonnegut felt as though everything in his mind was coming together to give him the knowledge of the world, and that it all made sense. It is easy to see how difficult it can be to do reality testing and challenge these strong ideas which are blossoming in the mind, while it is difficult to process what the clinician is saying.
When Vonnegut was finally hospitalized, his initial treatment was shocking because he was not informed about his treatment at all. He was given Thorazine three times a day but was not told what it was or why it was necessary. His illness was not described to him or even officially diagnosed. Also, he was released with no aftercare plans, medications, or even a prescription. It seems quite obvious that he would quickly relapse, and he was hospitalized again weeks later. This time, he was court ordered to receive treatment due to aggression and hostility. The same doctor (Dr. Dale) was his attending clinician, but was much better the second time around. He described schizophrenia as biochemical and described the effects of the Thorazine. After being stabilized in the hospital, Vonnegut had another episode, and after being isolated, a patient came to him and told him that he was freeing him from his power. Vonnegut states that this was the most helpful treatment that he ever received because he felt relaxed and released from his grandiose delusions of controlling the world. He was also given electroshock therapy and Thorazine.
I find it interesting that Vonnegut attributes his sustained recovery to his counseling sessions with Dr. Dale and the incident with the patient. Because of nature of the illness, a medication regiment is extremely important in maintaining mental health, but clients often choose not to see this because it strips them of power over themselves. I have often heard clients voice concern over lack of control of their body and mind and the need for medication to sustain this control, but Vonnegut either does not recognize this or he is an exception to what many clients experience.
Throughout the memoir, Vonnegut reflects on his cultural identity, stating “I am a white middle-class American heterosexual male… I am a down-under hippie revolutionary, alienated from the reins of power and persecuted by cops” (182-183). Although Vonnegut would be considered in the majority in all cultural categories, he often struggles with this because of his “hippie” status and desire to be one with others and one with the oppressed populations. After his first psychotic break, he even admits to being prideful because he feels that he has attained a heightened self-awareness by being a minority and oppressed in the realm of mental health.
As a member of the middle class, Vonnegut had used money from his parents to attend college, where he studied liberal arts and became quite political. He then purchased land and organized a commune to run the land and live and work together on the farm. When Vonnegut needs to be hospitalized, he does not have the burden of finances for the stay, the aftercare, or the medications because his parents are able to support him financially. Being a white male, he was also able to receive adequate care and was not discriminated against for his cultural identity. Throughout his psychotic episode, Vonnegut explores and agonizes about his “repressed sexuality” but he does not make this known to his friends or clinicians, so he is not stigmatized for straying from the norm (by having group sex or sex with an animal). Because of living in a commune, the client has surrounded himself with open and accepting friends who are able to support him through his illness.
As a part of greater society, Vonnegut would likely have had a very different experience and be stigmatized, but since he was living on his self-made commune with other hippies, he had a very different experience. Vonnegut’s culture is deeply tied to the hippie movement in the United States. He describes the hippie movement and the commune as all being one and aiding each other. Because of this, he believed that his friends would take care of him. He says, “There are lots of pressures in the hip community that make that sort of decision even harder to come to than normally. Doctors don’t know anything, mental hospitals are repressive, fascist, etc. Hippies are supposed to be able to take care of their own” (164). The cultural norms of the historical time period and the type of environment in which they lived made a strong support network but made treatment difficult. Vonnegut’s friends believed that his psychological distress was not negative but that he was enlightened. At many times, Vonnegut’s symptoms were even further exasperated by marijuana use on the commune. It is because of the hippie community’s societal norms that Vonnegut was untreated for such a great length of time; his friends did not believe in mental hospitals until he was too ill to function.
Seeing Vonnegut in a full blown psychotic episode made his friends question their beliefs regarding mental illness. While they originally believed that “ ‘schizophrenia is a sane response to an insane world’. ‘Mental illness is myth’. [and] The Sanskrit word for crazy means touched by the gods” (164). They later reflected that, “this whole thing is really giving me a whole new outlook on mental illness” (156). The hippie community that Vonnegut was a part of believed that it was ideal to try to achieve a higher level of awareness. Many experimented with drugs to try to become more self-aware, and many of Vonnegut’s early symptoms demonstrated some of these unusual and philosophical ideas. The early symptoms were then positively reinforced by both self and friends because it was desirable to learn to think differently and see the world in a new way. Thus, the time period, life experiences, and social network made a huge impact on Vonnegut’s course of illness and treatment.
One of the most positive aspects of commune living was that Vonnegut had many social supports. Vonnegut’s main social supports were his girlfriend (Virginia), dog (Zeke), and core commune companions (Simon, Mary, Joe, Sarah, Kathy, and Jack). Also, although Vonnegut did not see his family often, they were supportive in visiting him at the hospital, assisting with aftercare, and wrote him letters while he was living at the commune. Because of the many social supports, Vonnegut was able to receive great monitoring by his friends. There were times when he refused to eat, and they would sneak protein and vitamins in his beverages to help sustain him. They also took turns watching him 24/7 when he became suicidal before his hospitalization. After he was hospitalized, they all assisted with aftercare in reminding him to take medications and helping him get to and from his biweekly psychiatrist appointments. While these same supports had not been helpful in recognizing a need for more serious care, they did provide quality care to Vonnegut throughout the course of his illness.
Throughout the memoir, Vonnegut described a feeling of disconnectedness when it came to his girlfriend and their sexual relationship. While Vonnegut does explore some same-sex feelings while psychotic, he later denies them and believes that Virginia has difficulty with intimacy. Maintaining intimate relationships can be quite difficult for clients with schizophrenia because of repeated episodes, retained negative symptoms, and a general decompensation of the mind. However, although Vonnegut and Virginia do eventually go in separate directions, Vonnegut writes in the afterward that he is happily married with two children. As Vonnegut is most likely wrongly diagnosed and actually has schizophreniform disorder, it would be easier to have an intimate relationship, especially once he is stable.
Although Vonnegut’s friends faced many challenges in caring for him, especially when he was suicidal, they were able to work together and provide 24/7 support. They were also able to support one another and relieve each other of care taking responsibilities due to their living arrangement. This is not the case for many care givers. Many clients with schizophrenia live isolated lives because their care givers become exhausted and frustrated and eventually leave their loved one. This is harmful for both parties, and it is the reason that family group therapy was created, to support the care giver and client.
The memoir is also a historical piece in that it reflects the culture of mental illness during the late 1960s and early 1970s. The DSM II would have been the clinician’s main tool (Castillo 1997). The DSM II was similar to the DSM I except that it took a more biomedical approach, where the DSM I integrated biopsychosocial. This change was due to the new advances in medications, primarily the discovery of lithium and neuroleptic medications. The DSM II also was more disease-centered and the paradigm shifted even more towards this approach in the 1970s. The view of schizophrenia as a brain disease and a chemical imbalance is certainly seen in the memoir as Dr. Dale describes the illness as “biochemical” and treats Vonnegut primarily with Thorazine. It is, however, quite progressive that Dr. Dale also utilized therapy sessions, which is more client-centered, and was not as utilized during this cultural period.
Overall, Vonnegut allows readers to enter the mind of a client with schizophrenia and to understand psychiatry in its early stages. Vonnegut’s experiences are also unique as his social network is rather unusual and demonstrates that there are both positive and negative aspects to any culture.
Castillo, R. J. (1997).Why culture? Culture & Mental Illness, 1-22.
Vonnegut, M. (1975). The Eden Express: A Memoir of Insanity.
Simulated Group for Females with Alcohol Dependence
Simulated Groups: Adult Women with Substance Abuse or Dependence
Alissa, Corina, Allison, & Kate
i. The purpose of this group is to encourage abstinence from alcohol, build alternative coping skills, and motivate change towards positive behavior. The group is offered to adult gender-identified females who express motivation to make a change in their drinking behavior. This is not a dual diagnosis group.
ii. The problem is that the women have an alcohol use or dependence diagnosis and are attending group to make a positive change in their drinking behavior.
iii. The group leaders will use the stages of change model with motivational interviewing and cognitive behavioral techniques.
iv. The leaders will incorporate psycho-education and will model communication and problem-solving skills. Leaders will create a safe and empathetic environment for clients. Leaders will encourage motivation for change and facilitate group dialogue.
v. A short paper of 1-2 pages about the peer-reviewed, evidence-based practices
There are several different therapeutic group models that are being used in substance abuse treatment. These include psychoeducation, skills development, cognitive-behavioral, support, and interpersonal process groups. All of these models share some characteristics with other models. For example, most skills development groups operate from a cognitive-behavioral orientation (Flores 2005). The current group will use cognitive-behavioral therapy (CBT) as our primary model. The group will employ aspects of psychoeducation, specifically by teaching group members about the stages of change. Additionally, the group will use motivational interviewing (MI) techniques to help group members to increase their intrinsic motivation for change. There are four main principles of MI: express empathy, support self-efficacy, roll with resistance (explore client’s views), and develop discrepancy between client’s behaviors and what they wish for.
According to an analysis conducted by McHugh and colleagues, many large-scale trials and quantitative reviews support the efficacy of cognitive-behavioral therapy in treating alcohol use and dependence (2010). Researchers examined various CBT interventions, including motivational interventions, contingency management (using a nondrug reinforcer, such as a gift card), relapse prevention (identifying and preventing high-risk situations), community reinforcement approach (altering environment to reward sober behavior), and behavioral couples therapy. Researchers concluded that all of these interventions have shown efficacy and that, if combined, these interventions could yield even more positive outcomes.
A meta-analysis conducted by Magill and Ray (2009) found a small but statistically significant treatment effect of CBT for adults diagnosed with alcohol- or illicit-drug-use disorders. Effects were strongest when CBT was compared with no treatment, and the results suggest that the effects may be larger with women than with men and when delivered in a brief format, under 20 sessions. Their findings also showed that the CBT effects diminished around six to nine months and was significantly diminished after 12 months. They found no difference in efficacy due to format (group or individual).
Motivational Interviewing, an approach commonly used and discussed with alcohol abuse treatment, seems to be effective, though further research is needed. A meta-analysis conducted by Smedslund and colleagues (2011) looked at motivational interviewing (MI) in one-on-one individual interventions in comparison to no treatment, to assessment and/or feedback about substance use, and to other active treatment approaches. Researchers found that outcomes were significantly different between the groups. However, the analysis showed that other active treatments could be as effective as MI. At a medium follow-up period (defined as 6 months post-intervention up to, but not including, 12 months) MI proved more effective than for a group that only received assessment and/or feedback regarding substance use. Researchers of the analysis warn that the evidence they gathered is mostly “low quality” and should lead to caution when making use of their results.
vi. The Women’s Center of Ann Arbor will sponsor the group.
vii. The Women’s Center has space for the group to be held and staff to facilitate the group. The Center will provide water, tea, fresh fruit, and vegetables; 8AM-4PM phone support, and links to other resources in the community.
viii. Members are adult, gender-identified females with alcohol abuse or dependent diagnoses.
ix. The agency will recruit members through referrals of existing clients and will also accept referrals from outside agencies.
x. The group will screen clients based on gender, age (18+), and type of substance. The group is strictly alcohol use/dependence and not dual diagnosis.
xi. The group will be strictly adult (18+) and female. People from all identities according to race, ethnicity, ability, sexual orientation, and size will be accepted.
xii. It will be a closed and structured group. The group will meet for 12 sessions once a week for 1 hour.
xiii. Give a description of the types of activities planned for the group:
We will begin the first session by introducing ourselves and stating the goals and objectives of the group. We will then facilitate introductions through a round robin where members will be asked to state their name and one of their strengths or talents. The group leaders will describe a strength or talent of their own first; they will model an example that sets a positive and light tone for opening the session (ie “I’m Allison and I am good at gardening.”)
Next the leaders will facilitate the development of group guidelines with input from all members in a round robin style. Individuals will have the opportunity to “pass” if they don’t want to speak. If not mentioned by group members, the leaders will address the following: Confidentiality (including limits – mandated reporting), Respect (including “step up, step back” guideline), Attendance (“Please try to attend all groups and let us know 24 hours prior if you cannot make it; after three absences, you will be asked to leave the group”), and Promptness.
One of the leaders will also introduce the concept of “check-ins” and explain that in future sessions check-ins will relate to substance abuse and any challenges that have happened during the week. However, given that the group is still getting to know each other, the first “check-in” will be to answer the question, “what do I want to get out of group?” This activity will help us to understand members’ goals, gain a sense of where they might be at according to the Stages of Change, and help us to structure appropriate activities for future sessions. It will also help the group members begin to learn about each other.
Finally, the last activity of the first session will be a psychoeducational segment on the Stages of Change. The leader will explain the stages and then read a vignette. Members will then be asked to analyze where the person in the vignette is on the Stages of Change wheel. For homework the members will be asked to think about where they are on in the Stages of Change. They will be given a hand-out that will help them to identify where they are at on the wheel.
xiv. Agenda for Session I
1. Rationale for group – opening statement: stating the objectives of group, short history of the group and effectiveness of approaches used (hint: evidence-based) 5 min
2. Intro of members – name, ice-breaker: share one of your strengths -10 min
3. Present the agenda – 2 min
4. Discuss group guidelines – 10 to 15 min- offer the chance to brainstorm rules together, and then summarize:
Respect: step up, step back rule
Attendance: Please try to attend all groups and let us know 24 hours prior if you cannot make it, and you can only have two absences
5. Member check-in: 15 min
Introduce the concept of check-in: usually the check-in will be about each person’s substance use over the past week (report of using-keep nonjudgmental but explore what led to the episode, identify internal emotional cues during and after, and consequences), but for today check-in with each person’s goals for self in the group:
What are your goals for yourself in this group?
Psyched: stages of change, handout – the wheel (depicting stages of change), discuss the vignettes (identify where person in case study is at on stages of change) - 15min
7. Homework – Where are you at on Stages of Change? – take home additional hand-out that assists in identifying where you are at
Summarize session – thank participants for attending and for participating in group activities
Session I Group Note
6/18/2012 2:45 PM-3:35 PM SSWB 3816
7 group members and 4 staff attended the weekly alcohol group for gender-identified women. In this initial session, two staff members facilitated introductions of staff and members, stated the rationale for the group, presented the agenda, and discussed group guidelines. Members participated in a go-around to discuss possible guidelines. Guidelines included confidentiality, respect, attendance, and promptness. At this point, two other staff members facilitated a check-in (pertaining to reason for joining the group and goal while in the group) and a psycho-educational discussion about stages of change. Staff provided group members with a handout about the stages of change, and the group discussed these stages pertaining to a case example and then to their own lives. Members are to think about barriers and triggers for the next session.
Center for Substance Abuse Treatment. Substance Abuse Treatment: Group Therapy. Treatment Improvement Protocol (TIP) Series 41. DHHS Publication No. (SMA) 05-3991. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005.
Hallgren, K.A., Moyers, T.B. (2011). Does readiness to change predict in-session motivational language? Correspondence between two conceptualizations of client motivation. Addiction, 106, 1261-1269.
Le Berre, A. P., Vabret, F., Cauvin, C., Pinon, K., Allain, P., Pitel, A.L., Eustache, F., & Beaunieu, H. (2012). Cognitive barriers to readiness to change in alcohol-dependent patients. Alcoholism, Clinical and Experimental Research.
Magill, M, Ray, LA. (2009). Cognitive-behavioral treatment with adult alcohol and illicit drug users: a meta-analysis of randomized controlled trials. J Stud Alcohol Drugs;70:516–27
McHugh, K.R., Hearon, B.A., Otto, M.W. (2010). Cognitive behavioral therapy for substance use disorders. Psychiatric Clinics of North America, 33, 3.
Muesser, K. T., Noordsy, D. L., Drake, R. E., & Fox, L. (2003). Persuasion groups. Integrated Treatment for Dual Disorders: A Guide to Effective Practice.
Smedslund, G., Berg, R.C., Hammerstrom K.T., Steiro A., Leiknes, K.A., Dahl, H.M., Karlsen, K. (2011). Motivational interviewing for substance abuse (review). Cochrane Database of Systematic Reviews 2011, Issue 5.
Through my fieldwork at ACT, I have been able to observe how the power dynamic between client and helper affects the client’s recovery. I have also been able to do my own research about power to learn more about power dynamics and the best ways to work with clients. One of the best evidence-based practices for improving relationships between case workers and clients during home visits is for the social worker to act as a guest and allow the client to act as the host (Muir-Cochrane 2000). By acting as a guest, the social worker relinquishes power and gives it to the client, creating a more balanced relationship. This can be especially helpful for clients who have an alternative treatment order (ATO), and do not want treatment, and who find having a social worker at their home to be invasive. In a study of nurses who conducted home visits, Muir-Cochrane (2000) found that acting as guest in a client’s home made a profound impact on the client’s mental health because it shifted the power dynamic and empowered the client. The client felt that s/he had control over his/her home and life. However, acting as a guest also involves sitting down when invited to by the client. Similarly, clients could choose not to ask workers to sit down, and by having control over this decision, there was a more evenly balanced power dynamic between the worker and client. Other research has also discussed the importance of being at the same eye level as a client. Lawrence-Weiss (2010) has found that regardless of the client’s age, one of the most effective ways to assist a client in building self-esteem is to speak to them at eye level. Lawrence-Weiss suggests that if a client stands, then stand; if a client sits, then sit, kneel, or bend over because this allows a client to feel validated. Furthermore, speaking to a client when not at eye level can induce frustration at not being truly heard or understood. It creates an unbalanced power relationship in which the social worker is superior to the client.
I truly appreciate the feedback that my team leader, supervisor, and team provide to me. Although I am completely comfortable at my field placement and feel well trained, I still have much to learn. I often find myself asking for feedback about how I handled different situations, so I can continue to improve my skills.
Due to the classes that I am taking, I have been provided with many opportunities to integrate my class work, research, evidence-based knowledge, and field experiences. On the first day of class, I look through all of the assignments and find ways to connect the assignments to field, so that I can do more investigative research that will be meaningful to my field placement. Integrating my learning is important to me because I find that I remember it for longer and have a deeper connection to it. It is a more authentic type of learning. This semester, I was able to take a course about group work and then apply the concepts from class and research to the groups that I lead at CSTS. In Mental Health Practice, I was able to learn better ways to write progress notes, assessments, and individual plans of service (IPOS), which I have also utilized at field.
When I first started at the University of Michigan: School of Social Work, I had clear goals in mind. My primary goal was to help improve the lives of others and lessen the suffering of oppressed populations. A second goal was to secure an internship at an inpatient or intensive outpatient setting. As for learning, I hoped to learn to provide effective psychological treatment, to diagnose mental illness based on the criteria in the DSM IV-TR, to evaluate patients and write discharge plans, to provide individual, group, and family therapy, and to record notes on patients and patient progress. I am proud to say that I have already accomplished many of these goals at my field placement. I was able to secure at internship working with serious and persistent mental illness clients who have acute and chronic mental illness. I have learned in classes and field about evidence-based practices, like Assertive Community Treatment, and other treatment modalities (CBT, DBT, and Motivational Interviewing) which I utilize daily. While I have taken courses pertaining to diagnosis, the social workers at ACT do not have the role of diagnosing clients, but I am pleased to have learned the skills necessary to perform this role. I evaluate clients daily through Mental Status Exams, and write progress notes for every client that I see. I have not been involved in transfers (discharges), but I hope to be more involved next semester.
I am a 23 year old Caucasian female intern at Assertive Community Treatment and am currently completing my Master’s Degree in Social Work from the University of Michigan. I was raised in the Northwest Suburbs of Chicago and lived in a diverse community that consisted of many Mexicans and Eastern European immigrants. While in High School, I studied Spanish language and culture and primarily spoke Spanish at my part time job. Although I am white, I was raised in a diverse family and have cousins who are African American, Puerto Rican, Mexican, and Chinese.
Later in my education, I pursued a teaching degree from Albion College and chose to work in failing schools such as Albion High School and Jackson High School. I hoped to make a difference in the lives of students who may not believe in themselves or have enough support at home. While teaching at these schools, I saw the horrific impact that white flight had on these communities and became even more impassioned to make social change and work with minority populations.
As a treatment provider, I use a client-centered approach and attempt to learn about my clients as whole people rather than simply an illness or a person with an illness. I engage clients by learning about who they are and what makes them unique. I use active and reflective listening to show that I am interested in what they have to say. By viewing the client as an equal and creating a more balanced power dynamic, clients may be empowered and trust me as their clinician. With this trust, clients can openly discuss their struggles, and I am better able to assist them. This is especially important for me when working with minority populations because of the Caucasian and Middle Class status in which I was born. It is because of my own cultural background that I strive to alter power dynamics and empower clients.
Nina: A Case Study of Schizophrenia
Nina: A Case Study of Schizophrenia
The following is a case study of a client being treated for schizophrenia by an Assertive Community Treatment team in Michigan. This client will be given the pseudonym, Nina, for purposes of privacy and confidentiality.
According to the DSM IV-TR (2000), schizophrenia is a psychotic disorder characterized by at least two of the following five symptoms: hallucinations, delusions, disorganized speech, disorganized behavior, and negative symptoms (anhedonia, avolition, alogia, and flat affect). Symptoms also must impair social or occupational functioning, last longer than six months, must not be due to substance use or a general medical condition, and there must not have been any mood episodes (manic, depressive, or mixed). Schizophrenia is prevalent in roughly 1% of the population and can be one of the most costly disorders due to need of repeated hospitalizations because of suicidal or homicidal behavior. Schizophrenia is also one of the most deteriorative disorders, and once there has been one episode, clients most often do not return to baseline and decompensate more and more as the disorder progresses.
Nina, who is a 45 year old African American female, exhibits many of DSM IV-TR criteria for Schizophrenia. Nina experiences tactile hallucinations, as she believes that snakes are in her stomach and she can feel them crawl up her throat, and “they eat the medicine”. The feeling of snakes inside her is greatly distressing to her and causes her to vomit most evenings. Nina also has persistent delusions that she has “spirit babies” that live both inside of her and in Highland Park. Nina often desires to return to Highland Park to find her “spirit babies” and “the spirit man who [she] fornicated with”. Nina reports having up to 20 children but says she does not know their names. She reports that some of them “be crackin” and try to convince her to consume drugs for them to eat. Nina currently takes Vicodin and Klonopin for arthritis in her knees, but says she rarely feels relief because the spirits will steal these substances.
Nina also has delusional beliefs that she has psychic abilities and knows when a crime is about to take place. Nina reports that she often calls the police to warn them of future crimes. However, she says they do not listen to her, and when she watches the news and sees that the crime occurred, she feels guilty. When speaking with Nina about her psychosis, she is often tangential and loosely associated with time. For example, Nina will begin talking about her appointment with the psychiatrist last week, and a sentence later say that she was talking to him about being pushed into the street by the spirits. When asked when the event occurred, she reported that it occurred in 2004, but the meeting with the psychiatrist occurred in 2012. Nina will also perseverate on certain topics such as “fornicating with the spirit man”, having an alien baby at age 5, and how “Jesus breathed life back into [her] when [she] died of lung cancer”. Nina does not however, display disorganized behavior and she always appears with good hygiene and groom. She also does not currently appear to have any negative symptoms. Nina presents with a good mood and appropriate affect.
Multi-Axial Assessment for Nina
III. Arthritis in both knees; Type II Diabetes
IV. Unable to work; Problems with Social Network
Nina is currently an Assertive Community Treatment (ACT) client, and this treatment modality is the best fit for Nina and for clients like Nina who have experienced multiple hospitalizations for psychosis. Assertive Community Treatment is an evidence-based practice which provides a much different and progressive type of service than an inpatient facility; it offers community-based, at home care for clients with severe and persistent mental illness (ACTA 2012). Through ACT, a multidisciplinary team of social workers, a nurse, psychiatrist, peer-support, and mental health practitioner provide mental health care to clients both in the office and in the community. In the morning, ACT teams travel to the homes of 7-12 clients each day to provide at home care. During this visit, social worker observes clients take AM medications and observes the client set-up his/her medication in a med box up to the next time s/he will be visited. The social worker also conducts a mental status exam and inquires about whether the client needs any resources or assistance; the whole visit lasts approximately 10-15 minutes. In the afternoon, staff involves clients in different support groups such as co-occurring groups, shopping, art, nutrition, and walking groups. Staff also use afternoons to see clients in the office and assist clients with miscellaneous appointments and needs.
Programs like ACT are beneficial to clients who have many needs, who have difficulty with medication adherence, or who have chronic symptoms and who wish to continue to live independently (ACTA 2012). A program like ACT can benefit Nina because she has chronic symptoms; every day she feels the snakes inside of her stomach or talks about the spirits weighing her down. While Nina does report that she has a mental illness called schizophrenia, her definition of her illness is far different than most. Nina believes she was cursed and that is her illness. She does not think that she hallucinates or has delusions but that the spirits are real. Nina’s little insight into her illness would make it difficult for her to live independently without ongoing mental status assessments and medication management. Nina has stated that she would probably take more medication if she did not have ACT because “the spirits eat the pills” so she would take more to compensate. Nina states that she appreciates ACT “observing” her and assessing her mental health.
Research also supports the benefits of ACT programs in regard to decreased rates of hospitalization, higher rates of medication adherence, and improved quality of life. Zygmunt et al. reviewed literature about the necessity of medication adherence for clients with schizophrenia, stating that 50% of those diagnosed with schizophrenia will stop taking medications within a year after first discharge (2002). Once clients have stopped taking medications, they will experience increased risk of relapse (3.7% greater than compliant clients), and symptoms can negatively impact quality of life. Researchers then studied psychosocial techniques and therapies for improving medication compliance. Zygmunt el al. did find that programs such as ACT were more effective, as was motivational interviewing, because each focused on behavioral training. Findings suggest that clients will be more compliant when given concrete instructions and problem-solving strategies. Behavioral training was effective because clients were provided direct feedback for compliance.
Other alternative behavioral treatments include Cognitive Behavioral Therapy. First and foremost researchers maintain that medication compliance is critical for ACT clients, but that CBT and training can improve client’s functioning and reduce symptoms because it provides skills training and helps clients improve coping skills for dealing with their mental illness. Pinninti et al. (2010) believes that “the improvement in functioning included interventions, such as helping clients make appropriate life decisions, improving social and leisure skills, and dealing with barriers to employment”. However, behavioral training can be difficult for clients who have little insight into their illness. For Nina, attempting CBT on its own is quite a challenge, and one that I have actually attempted. When I first started doing wellness visits at Nina’s, she was always cooperative, calm, euthymic, and conversational. She had spoken to me about interpersonal problems with a friend, and I asked if she would like to try CBT. Nina was eager to try, but I quickly learned that she was not as stable nor had as much insight as I had thought. During the first session she perseverated about the spirits and snakes the entire session. Following sessions were similar. Thus CBT may not be the best option for all clients, but if clients are stable on the medications, it can be more helpful, and it can also complement ACT programs.
As an African American female raised in Highland Park (Detroit), Nina has a specific set of cultural values which affects the way she views her illness and recovery (Castillo 1997). In Nina’s specific culture, witchcraft is a real and accepted norm, and she believes that at the age of 18, a neighbor cast a spell on her. Nina believes this was the moment when she first experienced a spirit of a dead woman entering her body. Ever since then, she believes that spirits have entered her and stayed with her because she was cursed to be a vessel for the spirits. When discussing Nina’s illness with clinical jargon, such as calling the spirits “hallucinations”, Nina becomes angry and says she is misunderstood and that no one believes her.
Thus, in discussing Nina’s illness, it is much more helpful to her and client-centered to refer to her manifestations in her own terminology, “spirits”, and to explore the implications of these manifestations along with ways to cope with them. At first, this was difficult for me to approach due to my diagnostic ethnocentrism revolving around traditional western cultural schemas. However, after reminding myself to take a client-centered approach and use Nina’s own language and reflective listening, I became better able to build rapport and connect with Nina. For example, instead of discussing what the spirits are, Nina and I discuss how the spirits effect her life. Nina feels much guilt because she believes she has many children who she cannot spend time with, so instead of continuously conducting and failing with reality testing, we discuss how this guilt affects Nina, how she can cope, and how she can move forward.
ACTA (2012). ACT model. Assertive Community Treatment Association. http://www.actassociation.org/. Retrieved March 1, 2012.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th Ed.). Washington, DC: Author.
Castillo, R. J. (1997). Cultural assessment. Culture & Mental Illness, 55-75.
Pinninti, N.R., Fisher, J., Thompson, K., & Steer, R. (2010). Feasibility and usefulness of training assertive community treatment team in cognitive behavioral therapy. Community Mental Health., 46, 4, 337-41.
Sadock, B. J., & Sadock, V. A. (2007). Kaplan and Sadock's Synopsis of Psychiatry (10th ed.). Philadelphia: Wolters Kluwer.
Zygmunt, A., Olfon, M., Boyer C., & Mechanic, D.(2002) Interventions to improve medication adherence in schizophrenia. Am J Psychiatry, 159, 10. 1653-64.