Student: Jenny Downing

Student Number: 11295803

Assessment item 2

Case Study

Word Length: 3500

Due date: 11-Oct-2010

c











 Working as a mental health nurse is always going to be challenging, frustrating and
stressful, but in spite of this, there will be times of exhilaration when positive outcomes are
achieved. The following case study is about Joe a 28 year old man who came into the service
in 2001. After this first admission Joe states his life spiralled out of control and as his drug
addiction increased his noncompliance with prescribed psychiatric medications became
worse. There are three core beliefs to drug addiction. These are the need to use the drug, a
chronic medical illness and a disease of the brain (Mack, Harrington, & Frances, 2010). Non-
compliance of medications is not uncommon in chronic disorders. Failure to take medications
and continuing with substance abuse is the cause of many relapses and readmissions to
hospital (Elders, Evans & Nizette, 2005). Joe reports spending much of his time homeless
and in and out of inpatient units, with very limited social connections. Kemp, Hayward &
David (1997), refer to this as the µrevolving door phenomena¶.

Marijuana is a commonly abused illicit drug. Its affects on the brain cause distorted
thoughts, problems with thinking and daily functioning skills and a decrease in cognitive
abilities (National Institute on Drug Abuse, 2009). Joe commenced his marijuana use at the
age of 14 when it was introduced to him by his mother. Alcohol is another issue for Joe. It
has long been known that alcohol and other substances go hand in hand. It is well
documented that people using marijuana tend to move onto other illicit drugs and often
alcohol and cigarettes are associated with the use of marijuana (Ghodse, 2010).

Joe¶s personal beliefs and declarations cause cognitive dissonance. Joe would like to
find a girlfriend and one day buy a house but his drug use interferes with these thoughts.
Discussing this with Joe will assist him in identifying the positives of ceasing substance
abuse and the negatives of continuing. This however is currently unrealistic as Joe has a
learnt behaviour and behavioural change is a slow process (Sim, Khong & Hulse, 2004).

Joe has never worked. Since coming into the authors care Joe has continued to be
non-compliant with treatments, difficult to engage and very reliant on his mother. His mother
has been provided with carer supports and counselling. The case manager is aware of the
positive benefits of working with family carers and family members and has already built a
good relationship with Joe¶s mother (Elders, Evans & Nizettes, 2005). This case study will
outline strategies utilised in treatments while working with Joe.

The author¶s first meeting with Joe was while he was an inpatient of the acute care
facility. He had become unwell after not taking medications he had been prescribed on his

c











recent unsuccessful discharge from a rehabilitation centre. He had arrived back into the
regional area where he was homeless except for support by his mother who assisted him in
finding emergency accommodation. Joe does not believe he has a mental health illness. Joe
has a lack of insight into his disease and therefore a poor outlook (Corrigan, 2002).

On discharge from hospital Joe was on fortnightly depot injections. He was at first
compliant due to his mothers continued involvement and care. An assessment was organised
with the case worker and Joe. The phases of medication concordance consist of engagement,
assessment, therapeutic and evaluation.

×




1. Rractical considerations consisting of what medications, suppliers, other

medicines, homeopathic remedies, and alcohol and substance abuse.
2. Side effects from medications
3. Readiness ± importance and confidence
4. Common beliefs about medications.

G





1. Rractical issues surrounding non-compliance of medication

2. Reflecting on past experiences
3. Exploration of ambivalence
4. Discussions around medication concerning beliefs and side effects.
5. Benefits for the future

Joe arrived by himself for this first appointment. The first appointment consisted of a
thorough assessment. This assessment is a standard tool utilised within New South Wales.

G
  




  

: Voluntary after hospital admission



  : Joe, his mother and previous notes.

   

 
: Joe recently absconded from a drug and alcohol
rehabilitation centre and arrived back in town to be near his mother. He has spent 2 weeks in
the inpatient unit and has now been referred for follow up case management with the

c











Community Mental Health team. Joe has been non-compliant with medication and continues
to smoke marijuana and consume alcohol.

  

 : Since the age of 19 Joe has been in and out of
hospital units with many diagnoses. These include polysubstance abuse, schizophrenia,
antisocial personality disorder and drug induced psychosis. He has been admitted to several
rehabilitation units but these have all been unsuccessful.




: There are no current legal orders. Joe has been under the Guardianship Board
in the past.


× Joe is currently only smoking Marijuana and cigarettesHe has
in the past used all other illicit substances but due to costs cannot afford to continue. He has
also been binge drinking on week-ends and whenever he has the funds to purchase alcohol.




 : Joe¶s mother introduced Marijuana to him when
he was 14 and his brother 12. Both his parents smoked and used illicit drugs. He is unaware
of any other family health problems. His younger brother also uses many substances on a
regular basis and has just been incarcerated for two years.


 : Hepatitis C.

×






 : Largactil

!


  Olanzapine 20mg BD.

× : Over the years Joe has taken many different medications. He has
had side effects from some and he has been non-compliant with others.

"


 : Nil



 

  :

Joe and his brother were born in Sydney. They attended school there until Joe was 9 years
old. He then moved with his mother and brother to a regional area where he continued going
to school until year 11. At the age of 14 his mother introduced him to marijuana. He has
never been employed. He has nothing to do with his father and minimal contact with his
brother.

c











!



 Joe receives a disability pension. He is living in a one
bedroom bedsit in a large housing department building. He has a very good relationship with
his mother but no other friends or family contacts. (His step father does not have anything to
do with him or his brother.)



#$

×

Tall, medium built man wearing unclean, baggy clothes.

%
 


 
&: Difficult engaging in conversation. No eye contact.

×
: Flattened affect with no facial expression.

: Reports feeling low and very depressed.



: slow

G
 : Blocked. Repeated and abrupt halt to speech as a result
of losing one's train of thought.

G

 No current suicidal thoughts.


: No evidence
 '


Roor insight and judgement
 (

: Joe¶s overall level of risk was low.


 
Joe has an extensive history of substance abuse
and numerous psychiatric admissions. Diagnosis is unknown however Joe is currently
seeking help to become drug free and medication compliant.
    : Schizophrenia, antisocial personality disorder, substance abuse.


 
© Identify what Joe would like from the service.
© Measurement tools for baseline likelihood of compliance
© Organise a link with drug and alcohol services for educational strategies.
© Rrovide motivational interviewing and Cognitive behaviour therapy.
© Organise a full medical with community GR.
© Appointment with Rsychiatrist

c











Fortnightly appointments were organised in conjunction with depot injection. Joe however
turned up on the second appointment and refused his injection saying it was causing side
effects and he did not need medication. It was at this stage discussions with the clinical team
were organised and an appointment for the psychiatrist organised the following week. Joe
attended this appointment with his mother and it was decided to change medications. Joe was
given oral medications and a weekly pickup of packaged medications from the chemist
organised. It was now more difficult to engage Joe as he had no reason to attend the
community centre. After sending text messages to Joe and no response contact was made
with his mother who was happy with his progress.
Approximately six weeks later Joe¶s mother made contact to say he was in Intensive
Care after an overdose of Lithium a mood stabilising drug that Joe had not been prescribed of
recent time. He was in an induced coma and this is where Joe remained for ten days. He was
then transferred to the medical ward of the hospital. It was at this stage the psychiatric team
became involved once again. Soon after this Joe was transferred to the inpatient mental health
unit. On discharge weekly appointments were organised at the community health centre. The
case manager arranged transport and it was at this appointment Joe¶s expectations for future
case management were planned and developed.

u× 

A therapeutic collaboration had been established with Joe and his mother. His mother
had been asked to encourage Joe to attend these meetings without her. This meant Joe had to
contact the case manager for transport or ride his bike. Meetings were organised in the
afternoon seeing as Joe often had trouble getting out of bed early. Discussions focused on
Joe¶s feelings, thoughts and behaviours about his expectations from these meetings. Joe
however was very noncommittal and engagement difficult. It was important to identify
anxieties, expectations, and how Joe usually sought help. Rast experiences and difficulties
were also discussed. Reflection about the information was relayed back to Joe to ensure he
knew he was being heard and the case manager was listening seriously to his discussion.
Drawings were presented with Joe so he could visualise his life cycle and understand what he
had been doing and how changes could occur (Mulhern, Short, Grant & Mills, 2004).
A Liverpool University Neuroleptic side-effect rating scale (LUNSERS) was also
completed (Morrison, et al 2000). The LUNSERS score was 44 identifying low levels of
side-effects experienced. J

J
J      

 


c











 Following this a Drug Attitude Inventory (DAI-30) was attended which identifies the
clients beliefs about treatment and insight into addictions.
J

J
J      
    !" #

Joe scored -4 which is non-compliant.
A KGV symptom scale is a psychopathology measurement tool that allows the case
manager to identify what symptoms are being experienced by their client. This tool assesses
14 symptoms. Reople with psychiatric symptoms experience many symptoms so this
highlights what individual clients are experiencing to assist with treatments.
J

J
J      
$%& 


It was at this meeting discussions focused on Joe¶s expectations from the service. It
was important for Joe to take control of his medication so collaborative efforts could be
instigated. An appointment was organised for the following week and Joe was aware that
education on medication and the reasons he was prescribed them would be discussed along
with the introduction of motivational interviewing and cognitive behavioural therapies.
á× 


At the commencement of this meeting current medications prescribed for Joe were
discussed. Exploration of Joe¶s beliefs and concerns as to his non compliance was
determined. Joe was vague in his answer however it was obvious it was his lack of insight
and difficulty in remembering. Non effective and destructive strategies were avoided. It was
important not to use closed questions, labelling, be the expert, use confrontation or blaming.
Joe¶s readiness for change was also identified. The case manger feels Joe is at the
contemplation stage where he is seriously considering change so needs to elicit reasons for
change (Rubak, Sandbaek, Lauritzen & Christenson, 2005).

After this the four stages of motivational interviewing were utilised.

 
 
&

1. Reflective listening to express my understanding of Joe¶s belief¶s and cause of

reluctance, showing expressions of empathy and
2. Work out the conflicts of wanting to be good and unhealthy behaviours.
3. Avoid confrontation using empathy and understanding
4. Encourage confidence of self-efficacy to make changes that are possible.

c











Motivational interviewing can be successful in discovering the importance of changes and in
building confidence. The theory here understands Joe¶s personal values and what can be
expected from change. Rromotion of confidence will assist Joe in seeing he has the ability to
change. Motivational interviewing increases confidence for change (Treasure, 2004).

Rroviding information to Joe of his ambivalence to change was presented in a diagram.

À  )

Side effects of medications Sleep
Nausea No bad voices
Sleep all the time Good voices

!
%
 
G
 *!%G 

Cognition-thinking: Affect- feelings: Behaviour-doing

Cognitive behaviour therapy is a psychotherapeutic method being used to assist in addictive

behaviours. CBT is being used to assist in developing insight into the problem and control
over the problem (Mitcheson, Maslin & Meynen, 2010). Joe¶s addiction is a learnt behaviour
from when he was 14 years old. Joe requires positive reinforcement, and guidance in
changing his thinking and life. As Joe has difficulties with problem solving and unable to self
manage, CBT sessions need to be structured and focus on the current problems. This is also
needed due to Joe¶s ambivalence. This therapy is used to alter anyone¶s thinking pattern,
mood and behaviour (Mitcheson, Maslin & Meynen, 2010).

Miller & Rollnick (2002), outline three essential ingredients for change. These consist
of ready, willing and able. Joe is not yet ready, willing or able to change. He is starting to be
more responsive and engaging with his case manger so there is hope. Compliance therapy
focuses on manualised interventions, motivational interviewing and cognitive behaviour
therapy. The main principles consist of working together, highlighting responsibility and
personal choices and concentrating on the concerns of Joe about treatment (Kemp, et al.
1996). Joe does not take responsibility for his life. He relies on his mother who always abides
by his requests. Another activity will be identifying the benefits of adhering to medication
and the life changes that are being discussed. A Careplan formulated to outline all strategies
that are discussed and being implemented with the expected gaols will be provided to Joe so
he has a documented plan for future appointments.

c











 A thorough assessment and a therapeutic relationship are the core elements required
to work collaboratively with clients in mental health with substance abuse and non
compliance of medication to provide effective case management. An understanding as to why
someone starts using certain drugs, identification of the effects of the drug on the person and
the long term side effects will guide case management in organising a plan for change
(Ghodse, 2010).

Utilisation of measurement tools in the early stages of assessment assist in guiding the
likelihood of compliance in psychiatric patients. The LUNSERS, Hogan drug attitude
inventory and the KGV psychopathology assessments will be redone once medication
interventions have been accomplished.

Joe has been abusing substances for 14 years. It has been very difficult working with
him and engaging him in therapies. His mother is very supportive but becomes very
overwhelmed with his behaviour. Family focused interventions have already been activated
with psychoeducational and behavioural strategies to assist in better outcomes for Joe
(Bosworth, Oddone & Weinberger, 2006). These have been with counselling and carer
support workers involvement for his mother. Liaison with drug and alcohol has been
organised for the next appointment so Joe and his mother can both receive education on the
long term effects of marijuana.

For future solutions the case manager intends to continue to work with Joe and his
mother. There are times when the case manager feels things are progressing. As cognitive
behaviour therapies and motivational interviewing therapies are developed by the case
manager, it is anticipated Joe will eventually become compliant with medication. It is then
recovery focused programs will be beneficial and Joe will hopefully become an active
participant in some of these programs that are offered by non government organisations
within the community.

Concordance of medication will increase acceptance of illness, provide positive

therapeutic alliance, increase stability within the family, provide increased support networks,
and increase perception of the severity of susceptibility (Kichener & Short, 2004).

c











 References

Bosworth, H., Oddone, E., & Weinberger, M. (2006). R




  





 

  Lawrence, Erlbaum Associates, London

Corrigan, R. (2002). Adherence to anti-psychotic medications and health behaviour theories.

 
 
, 11 (3), 243-254.

Ghodse, H. (2010). Ghodse¶s drug and addictive behaviour: A guide to treatment.

4th edn., Cambridge university press, Cambridge.

Kemp, R., Hayward, R., Applewhaite, G., Everitt, B., & Anthony, D. (1996). Compliance

therapy in psychotic patients: randomised controlled trial. , 312-345.

Kitchiner, N. & Short, N. (2004). Working with people who have psychological
problems because of a physical illness. (Ch 12. pp.161 -181) in Grant, A.,
Mills, J., Mulhern, R., & Short, N. (2004). 
 
  

  

 London: Sage Rublications Ltd.

Mack, A., Harrington, A., & Frances, R., (2010) 

  



 
  

 1st edition, American Rsychiatric Rublishing, America.

Mitcheson, l., Maslin, J., & Meynen, T. (2010).  


   
 






 

  





. John Wiley & Sons,

Singapore.

Morrison, R., Gaskill, D., Meehan, T., Lunney, R., Lawrence, G., & Collings, R., (2000)

The use of the Liverpool university neuroleptic side-effect rating scale, (LUNSERS)

In clinical practice, 
       
 


!166±176.

c











Mulhern, R., Short, N., Grant, A. & Mills, J. (2004). Key skills of assessment. In

Rubak, S., Sandbaek, A., Lauritzen, T., & Christensen, B., (2005). Motivational
interviewing: a systematic review and analysis. 
  " R


,
Review Article, 305-312.

Sim, M., Khong, E., & Hulse, G. (2004). Cannibis and psychosis. 
  # 

R 
 , 33(4) 229-332.

Treasure, J. (2004). Motivational interviewing.  

 





,

10, 331-337

J

J
J  

c