Behavioural integrated treatment - Case Study Example

Intervention-cognitive-behavioural integrated treatment. Intervention-cognitive-behavioural integrated treatment (C-BIT) is a type of multi-purpose tool, designed for the psychological treatment of patients suffering from both mental illness and problematic substance misuse. It has add-on attachments for every circumstance, whether the identified problems lie with anger control or personal finances (Graham 2004). Substance abuse is a common and devastating disorder among persons with severe mental illness (SMI). According to Regier et al (1990), dual disorders, which denotes the co-occurrence of substance use disorder and SMI, occured in about 50% of individuals with SMI and was associated with a variety of negative outcomes, including higher rates of relapse, violence, hospitalization, homelessness, and incarceration (Drake et al., 2001). Reports published in the Journal of the American Medical Association, had shown that roughly 50 percent of individuals with severe mental disorders were affected by substance abuse, 37 percent of alcohol abusers and 53 percent of drug abusers also have at least one serious mental illness and among the mentally ill patients, 29 percent abuse either alcohol or drugs (National Alliance on mental illness 2007). Cognitive-behavioural therapy is a relatively short-term, focused psychotherapy for a wide range of psychological problems including depression, anxiety, anger, marital conflict, loneliness, panic, fears, eating disorders, substance abuse, alcohol abuse and dependenceand personality problems. The focus of therapy is on how you are thinking, behaving, and communicating today rather than on your early childhood experiences (The American Institute of cognitive therapy 2007). Models of Care 2002 (National Treatment Agency for Substance Misuse 2002) outlined the four-tiered framework for commissioning drug treatment. This was intended to provide a conceptual framework and be applied to local areas with flexibility. Implementation of the four-tiered framework has contributed in a large part to ending the wide variation in access to different types of treatment, so that each local area now has a broadly similar basic range of drug treatment interventions (National Treatment Agency for Substance Misuse 2006). Integrated dual disorder treatment (IDDT) is an evidence-based practice that has been found to be effective in the recovery process for clients with DD. In IDDT, the same clinicians or teams of clinicians, working in one setting, provide mental health and substance abuse interventions in a coordinated fashion. As an evidence-based psychiatric rehabilitation practice, IDDT aims to help the client learn to manage both illnesses so that he/she can pursue meaningful life goals. The critical ingredients of IDDT include assertive outreach, motivational interventions, and a comprehensive, long-term, staged and individualized approach to recovery (Substance Abuse and Mental Health Services Administration's and Center for Mental Health Services 2007). The various staging of CBIT includes, assessment followed by engagement and building motivation to change, negotiating some behavioural change, early relapse prevention for substance use problem and integrated relapse prevention and management of psychosis and substance use problem. Building adaptation coping skills and working with family and network members are additional therapeutic options available. A fundamental problem is a lack of clear operational definitions of "dual diagnosis". In many areas a significant proportion of people with severe mental health problems misuse substances, whether as "selfmedication", episodically or continuously. Equally, many people who require help with substance misuse suffer from a common mental health problem such as depression or anxiety (Department of health 2000). Chadwick et al (1994), conducted a study among 12 people with delusions. Ten people in the cohort took part in two investigations that used between-subject multiple-baseline designs; the remaining two, each of whom held three distinct delusions, took part in a study using an across-beliefs multiple-baseline design. Cognitive therapy was found to be useful in these patients and was considered as a treatment option. According to Alford et al (1994, p.369-80), "cognitive therapy directly targets specific delusional beliefs which theoretically give rise to the disordered verbal behaviour". According to Enright (1994, p.1811), "Once a person is depressed a set of cognitive distortions known as the cognitive triad (negative view of oneself, current experience, and the future) exert a general influence over the person's day to day functioning, and negative automatic thoughts become increasingly pervasive. Other biases in information processing also act to consolidate the depression, whereby patients exaggerate and over generalise from minor problems and selectively attend to events that confirm their negative view of themselves". The behavioural elements in therapy may include: Setting up behavioural experiments to test irrational thoughts against reality Graded exposure to feared situations in reality or the imagination Target setting and activity scheduling A programme of reinforcement and reward Teaching specific skills such as relaxation Role playing, behavioural rehearsal, therapist modelling coping behaviours According to Bradshaw (1998), there was a growing commitment to the design of psychotherapeutic treatments that are grounded in knowledge of the psychopathology of specific diagnostic groups and tailored to the unique needs of the population (Hogarty et al 1995, Liberman, 1993 cited in Bradshaw 1998). John (name changed) is an unemployed graduated aged 32 years. He is single and belonged to lower middle class family. He is the fifth and the last child of his family. He is an easy going and carefree kind of person. John was a normal person till his high-school graduation. He was an average student and was not very interested in studies. He had a group of friends who were addicted to use of drugs and alcohol. By the end of graduation, John had taken up the habit of drinking and using drugs. As his addiction increased, he began to experience auditory hallucinations and delusions. He had developed negative feelings and emotions. He was socially withdrawn. Fearing that anti-social behaviour would develop in him, his mother had admitted him in the psychiatric department of the health care centre. John was taken into the C-BIT programme, where he was treated by a team of skilled psychiatric personnel. The staffs of the service and support team are adequately trained. According to Department of Health (2000),t training for assertive outreach staff in the delivery of a manualised integrated treatment approach (Cognitive-Behavioural Integrated Treatment), followed by on-going regular weekly support and joint-working to aid the delivery of the intervention from the COMPASS Programme team. The rationale of Cognitive Therapy holds that substance abuse is learned, and, therefore, it can be "unlearned" and stopped through the use of cognitive-behavioural techniques. Understandably, a person with a substance misuse disorder faces many challenges, and, potentially, many serious consequences. By engaging in Cognitive Therapy, such an individual can take part in an effective, flexible, and evidence based therapy. Assessment The diagnosis of mental health problem was taken into account using ICD-10 and problem with alcohol and drug use was measured using alcohol/drug use rating scale. The following outcome variables were used in this study 1. Psychiatric symptoms using Hopkins Psychiatric Rating Scale (Derogatis, 1974 cited in Bradshaw 1998). 2. The engagement measurement toll using substance abuse treatment scales. 3. Units of alcohol taken over 30 days 4. Amount of drug used over 30 days 5. Substance related behaviour. The cognitive methods in therapy included: detailed explanation and discussion of the cognitive model , keeping a diary monitoring situations, thoughts, and feelings to develop awareness about these, identifying connections between thoughts, affect, and behaviour , examining evidence "for" and "against" the thoughts, coaching patients in challenging negative thoughts by question and rationalising techniques, learning to identify dysfunctional assumptions underpinning distortions and cognitive rehearsal of coping with difficult situations or use of imagery . According to Department of health (2000), substance misuse among individuals with psychiatric disorders has been associated with significantly poorer outcomes including: - Worsening psychiatric symptoms - Increased use of institutional services - Poor medication adherence - Homelessness - Increased risk of HIV infection - Poor social outcomes including impact on carers and family - Contact with the criminal justice system. Substance misuse is also associated with increased rates of violence and suicidal behaviour The ABC model (Ellis, 1970) was used to teach the cognitive view and process of treatment. Issues from the client's daily life were used to highlight the cognitive components of feeling and behavior. The therapist and client would label the A (activating event) and C (the emotional consequence) of an emotional episode and the therapist would help the client figure out possible self- statements (B) that could have led to the emotional consequence or that would lead to other emotional responses. The treatment of John was aimed at the following, 1. Treating the Psychiatric disorder 2. Maintaining a good physical health 3. Developing psychosocial adjustment (family & social relationships, leisure, work, education, finances, legal problems, spirituality) The psychiatric team was a very friendly and enthusiastic group of personnel who were interested in John to pursue his normal way of living. They initially started with the counselling regarding his delusions. The treatment options available and the means to combat the disorder were explained in detail. It was made clear to John that the fear instilled in him was not substantial. The delusion he was experiencing was a psychological one with no practical existence. The sessions were initially 15 minutes and gradually increased as compliance of John increased. He was initially motivated to increase his activity level. He was an athlete in his school days. He was motivated to take up athletic exercises to keep himself busy and active. John was given a calendar to record his activities in the morning, afternoon and evening. The activities recorded by him were reviewed at appropriate intervals and improved to increase his activity. John was also taught meditation (Bensen 1974 cited in Bradshaw 1998), practiced for short periods initially in each session. John was motivated to practice the meditation for relaxation and improve his psychosis. The pros and cons of alcohol and drug abuse were instigated into him. The first task given to John was to list out the advantages and disadvantages of using alcohol and drugs using the Payoff Matrix. The advantages and disadvantages from John's perspective were dealt positively. It was interesting to note the advantages and disadvantages listed by John. Peer group recognition was the main reason in the advantages group. He also mentioned that he was always in the "happy go state", after alcohol and drug use. This state relieved him of his mental tensions at home and in the society. Being unemployed were one of the major causes of his mental tension. The disadvantages included becoming tired and ill often and not having girl friends. The team then proposed a different view and listed the advantages and disadvantages related to drug and alcohol abuse. The advantages of quitting alcohol and drugs were stated to be a better social status, becoming employed, a healthy life style and having girl friends. The major disadvantage was summarized to be the loss the peer group, which inculcated the habit of alcohol and drug abuse in him. John was taught the skills of coping and resisting the urge to take alcohol or drug during his treatment period. His family members were also included in the process of treatment. His mother was the most supportive of all. She was determined to get her son cured of delusion and drug abuse. When questioned regarding his interests, John had mentioned about his interest in hardware designing. John was given an opportunity to take up an employment with a local hardware shop. After a series of sessions, John showed signs of improvement. He experienced improvements in psychosocial functioning. He had developed an aversion to alcohol and drug use. He was motivated to develop his career and had preset achievement goals. The post treatment analysis showed that his psychological and drug abuse scores had markedly improved over the last 3 months. He was more dedicated to his work and was socially well behaved. The use of alcohol and drug was nil in the last 30 days. He had not experienced delusion for quite a longtime now. His daily activity involved, exercises in the morning followed by a session of meditation, attending his workshop till evening. His attitude towards life had changed and was more positively motivated. C-BIT therapy was found to be very useful in this case of treating delusion and alcohol/drug abuse. When cognitive behaviour therapy was added to routine inpatient treatment 54% of patients remained well at the 12 month follow up compared with 18% in the routine treatment group (Miller et al 1989 cited in Enright 1994). Beneficial effects of cognitive behaviour therapy in improving compliance, insight, and functioning has been shown in a mixed group of patients with psychotic disorders. C-BIT training has been shown (in research reported elsewhere) as helpful to ordinary members of both mental health and substance misuse teams. None of the treatment methods are original in themselves, but this is an excellent guide to how they can be tied together in a coherent system, and how they can be matched to the various phases of treatment, which are themselves determined by the patient's current levels of motivation and readiness to change (Graham 2004). Consumers with co-occurring disorders are also much more likely to be homeless or jailed. An estimated 50 percent of homeless adults with serious mental illnesses have a co-occurring substance abuse disorder. Meanwhile, 16% of jail and prison inmates are estimated to have severe mental and substance abuse disorders. Among detainees with mental disorders, 72 percent also have a co-occurring substance abuse disorder (National Alliance on mental illness 2007). Integrated Dual Disorders Treatment occurs when a person receives combined treatment for mental illness and substance use from the same clinician or treatment team. It helps people develop hope, knowledge, skills, and the support they need to manage their problems and to pursue meaningful life goals (Substance Abuse and Mental Health Services Administration's and Center for Mental Health Services 2007).. In a study by Baker et al (2006), a short-term improvement in depression and a similar trend with regard to cannabis use was noted among participants who received the motivational interviewing/CBT intervention, together with effects on general functioning at 12 months. The motivational interviewing/CBT intervention was associated with modest improvements. According to National Alliance on mental illness, "Despite much research that supports its success; integrated treatment is still not made widely available to consumers. Those who struggle both with serious mental illness and substance abuse face problems of enormous proportions". This case study has shown the benefits of C-BIT in treatment of dual disorders. This intervention can be used in future treatment policies for treating dual disorders. References Alford, BA, Beck, AT., 1994. Cognitive therapy of delusional beliefs. Behav Res Ther, 32(3), pp.369-80. Baker, A , Bucci, S, Lewin, TJ et al., Bucci, S, Lewin, TJ et al., 2006. Cognitive-behavioural therapy for substance use disorders in people with psychotic disorders. The British Journal of Psychiatry, 188, pp. 439-448. Bensen, H, Beary, J, Carol, M., 1974. The relaxation response. Psychiatry, 37, pp. 37-46. Bradshaw, W., 1998. Cognitive-Behavioral Treatment of Schizophrenia: A Case Study. Journal of Cognitive Psychotherapy,12(1),pp.13-25. Chadwick, PD, Lowe, CF.,1994.A cognitive approach to measuring and modifying delusions. Behav Res Ther,32(3), pp.355-67. Derogatis, L.,1974. The Hopkins symptom inventory. Behavioral Science, 19,pp.1-15. Department of health., 2000. Mental health policy and implementation guide-Dual diagnosis good practice guide, London: DOH Drake, RE, Essock, SM, Shaner, A, Carey, KB, Minkoff, K, Kola, L, Lynde, D, Osher, FC,Clark, RE, Rickards, L., 2001. Implementing dual diagnosis services for clients with severe mental illness. Psychiatric Services, 52(4),pp. 469-476. Ellis, A., 1970. The essence of rational psychotherapy.. A comprehensive approach to treatment. New York: Institute for Rational Living. Enright, SJ., 1997. Fortnightly review: Cognitive behaviour therapy-clinical applications. BMJ , 314, pp.811. Graham, HL, Carnwath, T., 2004. Cognitive-Behavioural Integrated Treatment (C-BIT). Psychiatric Bulletin, 28, pp. 470-471 Hogarty, G, Korublith, D, Greenwald, A., Dibarry, A, Cooley, S, Flesher, S, Reiss, D, Carter, M, Ulrich, R.,1995. Personal therapy: A disorder-relevant psychotherapy for schizophrenia. Schizophrenia Bulletin, 21, pp. 379-393. Liberman, R.,1993. Designing new psychosocial treatments for serious psychiatric disorders. Psychiatry, 56,pp. 237-253. Miller, IW, Norman, WH, Keitner, GI., 1989. Cognitive-behavioural treatment of depressed in-patients: six and twelve month follow-up. Am J Psychiatry, 145, pp.1274-9. National Alliance on mental illness, Retrived May 22, 2007, from http://www.nami.org National Treatment Agency for Substance Misuse,2002. Models of Care for treatment of adult drug misusers, London: NTA/DOH. National Treatment Agency for Substance Misuse, 2006. Models of Care for treatment of adult drug misusers: Update 2006, London: NTA/DOH. Regier, DA, Farmer, ME, Rae, DS, Locke, BZ, Keith, SJ, Judd, LL,Goodwin, FK.,1990. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA,, 264(19), pp. 2511-2518. Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Mental Health Services (CMHS) Retrived May 22, 2007, from http://mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/cooccurring/ The American Institute of cognitive therapy. Retrived May 22, 2007, from http://www.cognitivetherapynyc.com/problems.aspsid=256 Please use this intervention-cognitive-behavioural integrated treatment (C-BIT). Talk about a fictional client who has paranoid delusions and drug misuse problem. Focus on the intervention and whether it worked and talk about the theory behind it and then contrast this intervention with other techniques. Please see below for more details. Essay Assessment Strategy-A 3000 word essay: Critically analyse and apply the theory underpinning one intervention with a dually diagnosed client. Contrasting this intervention with other techniques (critically reflect). Ensure it is a mental health professional who understands dual diagnosis and assessment tools and interventions. Harvard Referencing Include in references: Graham, H.L. (2004) cognitive-behavioural integrated treatment(C-BIT), John Wiley & Sons, Chichester. Hamilton,I. (2000) Dangerous drug interactions. Nursing times. 96 (46):41 National Treatment Agency for Substance Misuse (2006) Models of Care for treatment of adult drug misusers: Update 2006, London: NTA/DOH. Mueser, KT., Noordsy D.L., Drake, R.E., Fox, L. (2003) Integrated treatment for dual diagnosis, the Guildford press, London. 11111111111111111111 Read More