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Intersection of Mental Illness, Addiction and Incarceration

November 8, 2018

by: Faryal Choudry – winner of the 2018 Judith Holm Memorial Scholarship Award

I am a native of Peshawar, Pakistan, completing my final year at A University Graduate School of Social Work. I intern at XYZ Behavioral health agency, where I provide individual and group therapy to dual-diagnosis clients with severe mental illness. XYZ, offering psychiatric hospitalization and residential programs, day programs, and outpatient services, is a non-profit and serves those (of all ages) who suffer from trauma, depression, addiction, anxiety, and co-occurring disorders. In my field placement at XYZ, I followed the Assertive Community Treatment (ACT) model, focused on formerly incarcerated clients who need help overcoming mental illnesses in order to reintegrate into the community.

Use of Self
My family has influenced my values. My open-minded, intellectual parents often reminded me that every story has two sides and stressed the importance of finding out the facts on both sides. As I reflect on my use-of-self, I realize that my beliefs help me, in this intervention, to empathize with my client JR*, and to adopt a strengths-based approach. Personally, I connect with JR as I have family members who struggle with addiction. I provided individual therapy to JR once a week for ten weeks.

The Client
The client of concern in this report is JR, a 45-year-old African-American who identifies himself as a heterosexual male and comes from a lower-middle-class background. He has a prior diagnosis of schizoaffective disorder and cocaine dependency. This dual-diagnosis client is a frequent recidivist in jail and prison. Following his discharge from prison, he was referred to XYZ for community reintegration services.

JR’s presenting problems included his frequent alcoholism and substance use, which included mixing cocaine with his medications. In addition to feeling “stressed” and “unmotivated”, he reported a history of mania/hypomania/psychosis with symptoms such as irritable mood, grandiosity, exaggeratedly high-self-esteem, increases in goal-directed activities, and high energy levels with a decreased need for sleep.

JR described his life as “unmanageable” and claimed a real desire to improve himself through rehabilitative treatment. He also reported that he heard voices and claimed he was “chosen by God.” His cocaine use adversely affected his functioning in the community, to the extent that he was hospitalized in an XYZ access center 19 times over the last year.

Therapeutic Alliance
Initially, JR was reserved in therapy sessions, made little eye contact, and gave brief responses that lacked essential details. He appeared to be in pre-contemplation stage. Concerned that I saw my own reflection in him, I was anxious about experiencing countertransference. However, I maintained active listening skills throughout the sessions: appropriate eye contact, attentive body language, receptive vocal tone, etc. I put JR at ease by rephrasing and empathically responding. I used both open-ended and closed-ended questions and withheld judgement, which encouraged him to disclose. I provided psychoeducation about the mental, physical, and spiritual health consequences of drug use, that can limit behavior-change possibilities and inhibit recovery. In addressing his substance-use problems, I assured him that if he were not satisfied with the treatment he could discontinue it. He decided to continue it.

In retrospect, I regret that I did not use two useful techniques for empowering clients to share their thoughts and feelings: humor and self-disclosure. I feared humor would make JR think I was making light of his critical issues and problems and would cause him not to work with me anymore. Regarding self-disclosure, Dewane (2006) cautions that it should be used only to benefit the client. I feared that it might harm our client-therapist relationship by focusing on my issues and not his.

Bio-Psycho-Social Assessment
Demographics
JR, a 45-year-old lower middle-class African-American, is a heterosexual male with four brothers and two sisters. His mother raised him in rural Florida; from childhood he has had little contact with a largely absent father.

Presenting Problems
JR reported frequent use of alcohol and substances, including mixing marijuana with his medications. He often feels “stressed” and “unmotivated”, and says he has a history of mania/hypomania/psychosis. His symptoms have included irritability, grandiosity, high self-esteem, increased in goal-directed activities, and high energy levels with a decreased need for sleep.

Medical and developmental issues
JR has a history of HIV and diabetes; he has met all of his developmental milestones.

Family relationship
JR was raised by his mother; his father left the home when JR was two.

Social/recreational issues
JR reported that he has very few friends.

Education/employment issues
Per JRs sister, he was an above-average student in high school and completed the eleventh grade. Financial difficulties due to underemployment are a source of stress for JR.

Legal/military
JR did not serve in the military. He has been incarcerated. In 2003, he was acquitted by reason of insanity on charges of cocaine sale and possession. In 2016 he was convicted of burglary and theft and served almost two years in state prison. A possible factor in his incarceration is the disproportionate punishment of African Americans under current drug policy (Mauer & King, 2007).

Substance abuse
JR first smoked marijuana at age 11. He later used cocaine with his father and increased his cocaine use during his high school years. He was first treated inpatient for substance use a decade ago.

Mental/physical status
JR was disheveled at our last session, though he had erect posture. He seems alert, vigilant, calm, and well-oriented to time and place, but he talks with a flat affect and sometimes sounds loud and pressured. He denies having hallucinations, delusions, or suicidal and homicidal ideation. In the session he was logical and displayed good judgement, but he demonstrated little insight into his problems.

Recommended treatment
JR should have more individual weekly therapy and group therapy, AA meetings, medication management, and case management.

Differential Diagnosis
JR’s differential diagnosis is 295.70 (25.0) schizoaffective disorder, bipolar type. He experiences multiple manic and psychotic symptoms and his sister said he “has been acting strange for more than a week.” He reported inability to sleep, a flight of ideas, and a high sex drive.

He met the following Criteria for his schizoaffective disorder diagnosis:

Criteria A
The client met the following criteria for schizophrenia: (1) delusions (“I am the New Jesus”); (2) hallucinations, claiming he had “conversations with God” and was “chosen by God’; (3) disorganized speech, rapid and hard to understand; and (4) grossly disorganized behavior, e.g. refusal to sit down, sudden unexplained laughter, bounding his leg up and down.

Criteria B
The client met the following criteria for mania: decreased need for sleep, pressured speech, flight of ideas, psychomotor agitation, and high sex drive.

Criteria C
The client’s mood disturbance has caused severe social malfunction with his family and the police, and he has been hospitalized for this condition.

Diagnosis rejected: JR does not suffer from the major depressive episodes that would indicate a diagnosis of bipolar I or bipolar II disorder. Nor is he schizophrenic, for he exhibits too many manic symptoms.

Other Diagnosis: JR is in remission from a severe cocaine use disorder (DSM 5 304.20 F12.20): diagnostic criteria were: (1) use of cocaine in larger amounts than originally intended over a 12-month period; (2) heavy engagement in activities necessary to obtain cocaine; (3) strong desire to use cocaine and inability to quit; (4) inability to fulfill his major obligations at home; (5) use of cocaine despite his previous incarceration; (6) neglect of important social and recreational activities because of his cocaine use.

Selection of Theory
To guide my intervention, I used the Social Learning Theory (SLT): addiction is rooted in how we observe and learn from our peers and role models. Bandura (1977) stated that individuals living in areas with high rates of crime are more likely to act violently than those living in areas with lower rates of crime. Treatment based on this theory can help clients break out of negative mental and behavioral patterns (Horvath et al., 2018).

I used a bio-psycho-social approach (Engel, 1980) to issues of addiction and mental disorders, in which they are conceptualized as resulting from maladaptive behaviors, causing distortion of the neural pathways and of executive function and amplification of motivational processes. This can lead to a lifetime of drug addiction (Volkow et al., 2016).

To understand the contextual factors that affected JR’s trajectory, I also utilized Systems Theory, which conceptualizes behavior as influenced by various factors that work together as a system (Villadsen, 2007). Each system has its own subsystems, e.g. JR’s family, who he characterized as “in denial” and “keeping his sickness a secret.” JR’s incarceration can also be analyzed through Systems Theory and tools like Sequential Intercept Mapping (SIM) 1, which relate policy to client’s difficulty in functioning socially and occupationally (Groffin, 2015). JR faced barriers due to his limited job skills, poor education, and felony background (easily discoverable by prospective employers).

With these theories and approaches in mind, I used Cognitive Behavioral Therapy (CBT), a solution-based therapeutic approach that encourages clients to face and alter their distorted mindsets, thus changing their behaviors from detrimental to productive (Leahy, 2011). Within CBT, I used Motivational Interviewing (MI) to address JR’s symptoms of schizoaffective disorder: by exploring his ambivalence about changing his behavior, I hoped to stimulate his motivation to adopt healthier behaviors (Keung, 2018).

I also employed a developmental life course (DLC) perspective that mapped out JR’s psychosocial life journeys as he experienced social, emotional, and behavioral vicissitudes. His life trajectory suggests that he transitioned from a relatively carefree childhood to an adulthood fraught with mental illness. Yet the concept of human agency, the idea that people can make their own choices, is evident in his life, as he chooses not to take his prescribed medications, and sometimes chooses to combine them with cocaine.

Regarding developmental risk and protection, the developmental impact of life events depends upon the period in a person’s life in which they occur (Hutchinson, 2014). JR started to use cocaine in his early teens, hence his brain chemistry was altered at a young age. He was also hospitalized for many years for his cocaine addiction. The DLC perspective highlights the importance of interdependent and linked lives (Burton-Jeangros et al., 2015). I thereby concluded that this client appears to have limited linked lives, which included estranged relationships with his family.

Treatment Plan
The plan is inclusive of mental health, vocational, and substance use goals for JR’s improvement. This is based on both mental health diagnoses and evaluation of behavior/risk factors of reintegration. The plan was developed in collaboration with other staff members and JR. The treatment plan for JR addressed mental health, vocational, and substance-use goals. I also sought supervisor feedback. My supervisor encouraged me to incorporate motivational interviewing with cognitive behavior therapy during individual therapy sessions with JR. JR had an important role in setting his goals. He wanted to have his medications reevaluated and also wanted to learn vocational skills to help him reintegrate into the community.

The comorbidity of JR’s physical health, mental health, substance use, and reintegration issues created problems for JR and for me as a clinician in setting a treatment. JR wanted to get a driver’s license as a priority, but it was clear sobriety would be the goal. I provided psychoeducation on how long it would take. Initially, he appeared to be in denial. He expressed ambivalence throughout the interview. I provided him with psychoeducation about how drug use can affect mental, physical, and spiritual health and how drugs were restricting the potential scope of behavior-change possibilities for JR and his recovery. Agreeing to work on his sobriety, JR committed to attending Narcotics Anonymous (NA) meetings twice a week and relapse-prevention group therapy three times a week.

JR’s progress was collected from multiple sources. I kept in contact with his case manager, psychiatrist, and other staff members once a week. Client maintained a lifestyle of abstinence from drug/alcohol use/abuse: he tested negative on urine drug screen tests every week for two and a half months. He submitted signed Alcoholics Anonymous and Narcotics Anonymous attendance sheets every week. Client also completed 12 steps of Alcoholics Anonymous as evidenced by 12 steps worksheets that he submitted every week during group therapy sessions. His trauma symptoms have decreased based on his self-report and weekly participation in group therapy. My observation of the client indicates that he has made progress, as he has regularly attended his individual therapy, group therapy, and family sessions; and he shared regularly and openly during group and family discussions. The client has also completed all of his required assignments in a timely manner.

Intervention
Clinical Social Work Values
Clients like JR with comorbid disorders face many barriers: social injustice, stigma, segregation, discrimination, social exclusion, low-self-esteem, limited job-skills, and limited access to high -quality mental health treatments. I assured him of confidentiality: whatever he shared with me would remain private unless it harmed him or other people. By providing psychoeducation about available treatment options, I incorporated the social work value of informed consent into our sessions. I practiced cultural competence and stayed aware of my biases, beliefs, practices, and racial identity. When client identified himself as atheist, I (a Muslim) made sure our religious difference did not interfere; and I respected his dignity and worth by acknowledging how biases and cultural differences can affect client relationships.

African Americans who use drugs are more likely to be arrested than any other ethnic group. Aware of this fact, I displayed empathy by valuing (per the NASW Code of Ethics) the client’s inherent dignity and worth, while increasing my professional knowledge necessary to aid the client in the best way (Wright, 2017) through MSW studies, internship activities, and other channels.

Clinical Social Work Methods
In the face of XYZ’s opposition, I successfully advocated that JR’s substance-use issues must be addressed while determining the appropriate treatment for him, and that he not be sent to the state hospital but be placed at a substance-abuse treatment center for clients with severe mental illness and substance-use diagnoses. As intervention strategies, I used Motivational Interviewing (MI) and Cognitive Behavioral Therapy (CBT). Using MI, I explored JR’s substance use and addiction and proceeded to form a therapeutic bond that helped him to change his perspective and behavior. Similarly, I used CBT-related methods to: (1) explain his dysfunctional thoughts, (2) help him identify his thinking errors, and (3) provide him with more rational thoughts. As a part of CBT, I taught JR meditation skills and mindfulness techniques, which helped him to explore, process, and resolve feelings related to trauma. Initially he hesitated to complete his homework assignments, so I presented homework as an experiment for better understanding of the self rather than as a task to be completed.

Throughout my sessions with JR I used active listening techniques, including appropriate eye contact, receptive body language, and a responsive vocal tone. I affirmed his narrative and reassured him by citing statements he had made before. I also used MI techniques: open-ended questions, affirmations, reflections, summaries of his statements, etc. I thereby instilled hope in him through coping techniques such as stress management skills.

Client Feedback, Outcomes Evaluation
To determine the baseline at the outset of the intervention, JR was measured on the Illness Management and Recovery Scale (IMRS) and he was measured at intervals during and after to monitor progress.

Mid-way into treatment, JR mentioned that he had anger issues and frequently fought with his peers. He associated his anger with racial slurs, which made me wonder about his experience of racism through micro-aggression or overreaction. I incorporated anger-management into my use of CBT and encouraged JR to deal with his anger by means of coping skills and mindfulness techniques such as meditation, conscious breathing, and positive affirmations. I was remiss in not using an anger-management scale to measure his progress in that regard.

By affirming the client in his eagerness for rehabilitation, I offered well-channeled feedback that bolstered our mutual understanding. When I introduced distress-tolerance skills to help him regulate his emotions, I noticed his strength as he politely responded to requests by the staff and me. An example of change-talk was my discussing the efficacy of AA, which lead him to switch from his pre-contemplation stage to an action stage and attend AA meetings.

Per the IMRS ratings, JR showed significant progress at the end of ten weeks of sessions.

Use of Supervision
My supervisor mentored me and provided weekly supervision throughout my internship. He has good communication skills and supports my social work education. His constructive approach to criticism has inspired me to accept both positive and negative feedback as building blocks toward my professional development. I have also drawn upon his expertise to inform my choices of theory and my approach to interaction with clients, which made me a more empathetic listener, more compassionate, and less liable to engage in countertransference. This has been essential in my successful efforts to help JR and other clients reintegrate into their communities.

Adapting Theory
Learning about the medical and social models of disability through my selection and application of SLT and Systems Theory, I was able to see more clearly the impacts of a particular home-, work-, social-, or penal environments on a person’s life.

SLT and Systems Theory also provoked me to examine the relatively privileged, substance-free family and community in which I grew up. I realize that my background has sometimes limited me in empathizing with clients from less privileged backgrounds. I will continue to apply SLT so that I can better understand my clients and help them to overcome problems. I can progress in this way by using my own racial identity to empathize with their racial, ethnic, and cultural backgrounds.

Conclusion
I strengthened my advocacy skills while working with JR. I learned that advocacy, whether on a micro-, mezzo-, or macro-level, requires needs assessment, strategic planning, identifying sources of the client’s power to change (and one’s own power to assist the client), and finding solutions to the client’s predicament. Working with JR, I was able to alter my tendency toward submissiveness; I became more assertive and engaged successfully in negotiating and collaborating with the system in which we worked. I realized that the client and clinician, while never quite reaching the goals they set out to achieve, might plant seeds toward doing so, have meaningful conversations, develop alliances, spark changes in one another, and make incremental movements toward their target goals.

As a clinical social worker, I am learning how to dismantle social inequalities in policy and to empower those around me. I’ve been inspired by the success of JR and other clients in reintegrating into their communities; this has strengthened by belief in the potential of the human spirit to overcome barriers and to thrive. Regardless of legal status and co-occurring disorders, all people have problems and all struggle to make life better for themselves and their loved ones.

JR now runs his own graphic design business and works as a peer specialist in a mental health organization. His story shows that a person with resiliency, direction, guidance, and motivation can overcome a great deal and turn many negatives into positives.

(*details have been altered to protect privacy)

References
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Griffin, P., Heilbrun, K., Mulvey, E. P., DeMatteo, D., & Schubert, C. A. (2015). The sequential intercept model and criminal justice: Promoting community alternatives for individuals with serious mental illness. Oxford, UK, and New York, NY: Oxford University Press.

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Hutchison, E. D. (2014). A life course perspective. In E. D. Hutchison (Ed.), Dimensions of human behavior: Person and environment (5th ed.) (pp. 1-38). Thousand Oaks, CA: SAGE Publications. Retrieved May 9, 2018 from https://www.sagepub.com/sites/default/files/upm-binaries/36521_CLC_Chapter1.pdf

Hutchison, E. D., & Charlesworth, L. W. (2014). Theoretical perspectives on human behavior. In E. D. Hutchison (Ed.), Dimensions of human behavior: Person and environment (5th ed.) (pp. 34-69). Thousand Oaks, CA: SAGE Publications. Retrieved from May 9, 2018 https://pdfs.semanticscholar.org/151a/6303c857c1c691c8db4ff95eea9e375aa411.pdf

Keung, N. (2018). What is motivational interviewing (MI)? CBT Associates. Retrieved May 9, 2018 from http://www.cbtassociates.com/about-cbt/what-is-motivational-interviewing/

Leahy, R. L. (2011). Cognitive-behavioral therapy: Proven effectiveness. Psychology Today. Retrieved May 9, 2018 from https://www.psychologytoday.com/us/blog/anxiety-files/201111/cognitive-behavioral-therapy-proven-effectiveness

Mauer, M., & King, R. (2007). A 25-year quagmire: The war on drugs and its impact on American society. The Sentencing Project. Retrieved May 9, 2018 from http://www.sentencingproject.org/publications/a-25-year-quagmire-the-war-on-drugs-and-its-impact-on-american-society

Reamer, F. G. (2013). Social work values and ethics. New York, NY: Columbia University Press.
Volkow, N. D., Koob, G. F., & McLellan, A. T. (2016). Neurobiological advances from the brain disease model of addiction. New England Journal of Medicine, 374: 363-371. doi:10.1056/NEJMra1511480

Wright, G. (2017). Code of ethics. National Association of Social Workers. Retrieved May 9, 2018 from https://www.socialworkers.org/About/Ethics/Code-of-Ethics


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