A Critique Analysis of an Assessment of a Dual Diagnosis Client - Case Study Example

A Critique Review of an Assessment of a Dual Diagnosis Client that was Participated in 3300 Introduction: Substance misuse and addictive behaviour are very common and are regarded as a major public health problem in the United Kingdom. In this critical review, the author, a mental health value stream worker critically reviews the assessment and engagement processes of a client with dual diagnosis. This is designed to demonstrate the scientific rationale and clinical efficacy of an assessment tool and the engagement process that would have been used while assessing a client of this kind. The primary diagnosis of this client was paranoid schizophrenia with a subsequent secondary diagnosis of a substance-related disorder, drugs and alcohol dependence. The patient has been with Early Intervention Services since July 2007. The client has a recent exacerbation of symptoms with deterioration of mental health, and the paranoiac component of schizophrenia has increased recently in that he developed evident persecutory delusions. He believes neighbours are tracing him with electronic devices. He was verbally abusive and threatening to the attending community team, and the mother reported threatening behaviour. He had also assaulted mother in the recent past. He is on psychotropic medications, and despite being on those, he continues to abuse illicit drugs and alcohol. Clients with a dual diagnosis are difficult to assess because they are not a homogenous group. In addition, these clients often are poor historians and are noncompliant during the assessment process (O'Connell DF, 1998). Individuals with dual diagnosis often have complex and multiple needs that are difficult to assess in a comprehensive manner. The key process is engaging with the client that can lead to a successful interview to extract information from the client. This interview process also would need to be a medium of developing a therapeutic relationship with the client. When this interviewer approaches the client, the client may appear isolated and lost in thought. This interviewer needs to introduce him/herself and explain the reasons of the interview to the client. The lack of knowledge and skills in assessing mental health or taking a drug and alcohol history and exploring the attitude towards substance misuse is difficult. Often during the first encounter, the client would not respond. The assessor must ensure that the place of interview is private, secluded from outside, and ascertain that all the client's conversations remain confidential. With this, most of the clients would ease a little bit, opening up would demand more. During this process, it is important to face the patient with an open mind taking care to exclude social prejudice, negative attitudes, and stereotyped perceptions about the substance misusers. When the patient needs utmost care, these factors in the mental health workers may lead to inappropriate assessment and consequently inadequate care, and the patients may end up receiving minimal care. Due to the basic mental condition and social stigma associated with substance abuse, the patients would normally be very reluctant to answer questions. Most clients would verbalize after the initial screening period is over, provided the assessor persists to develop an empathic attitude. When the client starts verbalizing, this opportunity needs to be taken to facilitate both verbal and nonverbal communication, taking care to ensure empathic statements. During the conversation, the content must be summarized and recapitulated frequently, gradually advancing from points of dissent to negotiation. As things would start falling in place, the nature of questions needs to be changed from open to closed questions. The interviewer must remain guarded in terms of normalizing statements, making premature reassurance, false reassurance, switching topics, and asking leading questions. In his psychiatric history, his presenting complaint was that neighbours are following him with electronic gadgets, and his mother is following him closely. The presenting history was not elicited from him. On presentation, the patient was hostile, and there were verbal and nonverbal expressions of anger and resentment. Therefore, the interpersonal behaviour needs to be observed during the interview and to be corroborated from other reports. Very frequently it could be observed that the patient may be sarcastic with demonstration of passive-aggressive behaviour, verbal abuse, and assultiveness. It is essential to revise the initial assessment by observation of the client in the clinical setting, because full assessment of underlying psychiatric problems may not be possible until abstinence has occurred. It must also involve assessment of client's motivation to seek treatment, desire to change behavior, and understanding of diagnosis (O'Connell, D. and Beyer, E., 2004). For assessment of this patient, an assessment tool known as PANSS or positive and negative syndrome scale. The PANSS tool serves all the purposes. During the interview, the cognitive verbal process would need to be observed, and it was found that the client had a conceptual disorganization indicated by disorganized process of thinking characterized by disruption of goal-directed sequencing (Zimmerman, M. & Mattia, J.I., 2001). Assessment for circumstantialities, tangentiality, loose associations, gross illogicality, and evidence of thought block is a must, since these indicate the gravity of the psychiatric illness, and the gradation of these symptoms in the tool may serve as a baseline on which the future improvement can be assessed. Verbal report from the family members and the community mental health workers should be given due weightage to grade and characterize the behaviour, and these findings could be corroborated with the manifestation during the interview. The patient may be excited and hyperactive, and these may be reflected as accelerated motor behaviour (Schultz, J. M., & Videbeck, S. D., 2002). Along with these, the client may also demonstrate heightened responsivity to stimuli, hypervigilance, and unstable mood. The patient's thought content as expressed during the interview should be analyzed for grandiosity, suspiciousness or persecution expressed by guardedness, distrustful attitude, suspicious hypervigilance, and frank delusions or any combinations of these. It would be necessary to score the client's symptoms in both positive and negative scales. During the course of the interview, the physical manifestations of affective tone and emotional responsiveness during were to be observed (Zimmerman, M. & Sheeran, T., 2003). Diminished emotional responsiveness would be characterized by a reduction in facial expression, modulation of feelings, and communicative gesture. The reports of functioning from community mental health workers, family, and observations of interpersonal behaviour during the course of interview and the client's behaviour in the milieu would suggest emotional withdrawal manifested by lack of interest in, involvement with, and affective commitment with life events. The patient was hardly communicative (Zimmerman, M. & Mattia, J.I., 2001). This is a dependable scale; however, it fails to directly point to substance abuse disorder of the patient. The reliability of this instrument was shown by the stability of the measurement across time, that is, test-retest reliability and by internal consistency (Kay SR, Fiszbein A, Opler LA, (1987). The instrument had content validity since it measured all aspects of schizophrenia. The substance abuse disorder is better determined or assessed by tools such as CAGE or CAGE-AID. This tool screens for alcohol or other drug problems. The tool, GAIN-SS identifies people who are likely to have substance abuse or dependence disorder. This comparatively is a better tool since this also screens for mental health disorder simultaneously. GAIN-SUDS is an initial screening for substance abuse severity using DSM-IV substance abuse disorder and substance dependence disorder criteria and assesses for alcohol and other drugs. PDSQ or psychiatric diagnostic screening questionnaire and alcohol and drug subscales screen for substance abuse and substance dependence disorder. AUDIT is another tool that screens for harmful or hazardous alcohol consumption only. These tools are specific for substance abuse, but would be inadequate for mental health assessment. In the present situation, since schizophrenia symptoms are more prominent, the initial assessment can be made with the use of PANSS tool and with therapy, when the patient stabilizes, the AUDIT or CAGE tools may be applied to assess the patient and finally plan the management of chemical abuse disorder (Maisto, S.A., Carey, M.P., Carey, K.B., Gordon, C.M. & Gleason, J.R., 2000). ASI with psychiatric subscale can be used to have an overview of psychiatric status with 13 items completed by the client and 9 items completed by the interviewer. The DAST is the drug abuse screening test that asks questions directly or indirectly on presence, symptoms, and adverse effects and legal issues related to drug abuse, and a score of more than 6 indicates substance abuse, and this as expected cannot score the mental health problem. The DAST is only a method of identifying potential drug problems. The MAST is Michigan Alcoholism Screening Test that is aimed at identifying individuals with drinking problems and is a standard test that is used to determine if an individual is an addict (Saunders, J.B., Aasland, O.G., Babor, T.F., De La Fuente, J.R., & Grant, M., 1993). The Seltzer method is used for scoring in this scale, and there is a series of questions designed in such a manner that each question answered yes gets 1 point except questions 6, 10, and 11, that get 3 points for each yes answer. A score of 1 or less points indicates not alcoholic, a score of 2 points indicates possibly alcoholic, and a score of 3 points or more indicates alcoholic. ASI-X is based on the expanded female version of the addiction severity index, ASI instrument. ASI-X is adapted to comparability with the EuropASI (Fiellin, D.A., Reid, M.C. & O'Connor, P.G., 2000). This is basically an interviewer severity rating that estimates the patients' need for additional treatment in each area. The scale ranges from 0, where no treatment is necessary to 9, where treatment is considered to be needed to intervene in life-threatening situation. Each rating is based upon the patient's history of problem symptoms, present conditions, and subjective assessment of treatment needs in a given area, current problems, and the perception of treatment needs within each area. Therefore, this tool again is meant for chemical abuse problems and does not view the psychiatric problems. To measure and assess the severity of alcohol dependence, the severity of alcohol dependence questionnaire (SADQ-C) has been developed. It is a 20-item questionnaire designed to measure the severity of dependence of alcohol. It is divided into 5 subscales, physical withdrawal symptoms, affective withdrawal symptoms, craving and withdrawal relief drinking, and consumption and reinstatement (Kosta, K., 2002). It is a widely used measure of severity of dependence and has demonstrated reliability and validity. It is relatively quick to complete and is easy to score. It is probably most useful as an assessment tool for use with problem drinkers rather than a screening instrument. SADD or short alcohol dependence data questionnaire that is used to measure the severity of alcohol dependence. It has many similarities with SADQ, but it is less focused on the experience of withdrawal symptoms and includes behavioural and subjective aspects of alcohol dependence. It has a good test-retest reliability and construct validity and correlates highly with the SADQ. It has been argued that it is relatively independent of sociocultural influences. This test is based upon the Edwards and Gross formulation of the alcohol dependence syndrome. It is a 15-item self-report questionnaire, aimed to provide a measure of the severity of dependence on alcohol based upon a continuum of mild problem drinking to severe alcohol dependence. The subjective and behavioural indices impart greater sensitivity in identifying those drinkers not yet experiencing alcohol withdrawal phenomena. In this case, as per recommendations, this subject was also screened for co-occurring substance use. The tools that were used were already highlighted, and these tools were brief, valid and reliable, and had good sensitivity and specificity. The possibility of chemical abuse was also screened by asking the client a few questions on the basis of staff rating about the probability of the client having a co-occurring disorder (Schultz, J. M., & Videbeck, S. D. 2002). All the available information was reviewed including records from previous admission, treatment history, referral notes, and test results. An informal check list of behavioural, clinical, and social indicators along with a formal screening tool such as PANSS revealed that the patient to be schizophrenic. The other indicators favouring such dual diagnosis were evident by difficulty budgeting funds, symptom relapses apparently unrelated to life stressors, treatment noncompliance, social isolation, violent behaviour, pervasive and repeated social difficulties, and cognitive impairments (Prochaska, J.J. et al., 2005). The person's appearance, alertness, affect, anxiety; movements, organization, purpose, and speech; orientation, calculation, reasoning, and coherence all suggested problems. During the process of interview and assessment, it was important to keep in mind that assessment process is not only an opportunity on the part of the interviewer to understand the clients situation, it was also a process to allow the client understand his clinical situation that will enable him to cope up better and cooperate better with the intervention (Allen, J.P., Litter, R.Z., Fettig, J.B. & Babor, T., 1997). Clients with a dual diagnosis often are dissatisfied with life circumstances, have inadequate or ineffective support systems, live in a nontherapeutic home environment, and have a history of self-medication. The frequent use of drugs and alcohol interferes with the action of any psychiatric medications the client may be taking. Substance-related disorders often exacerbate clinical symptoms of an existing disorder or precipitate additional symptoms (Mueser, K.T., Noordsy, D.L., Drake, R.E. and Fox, L., 2003). As indicated in the previous section, the process of assessment had to be multidimensional with skills of interview demonstrated at its maximum to assess all the spheres of biopsychosocial facets of the disorder that the client is suffering from. As evident from this discussion, the assessment must lead to a management plan that would promote the patient to change his life. In this stage, this assessment serves the purposes of building a therapeutic relationship, understanding the client on the backdrop of community and family, designing an intervention that can match the condition and the problems, repeatedly clarifying the process by planning of care, and identifying the goals of recovery for the patient and involving him in that process. For this reason, it was necessary for this interviewer to closely observe and interview the client to mainly assess his needs and diagnose his problems. Since records are important sources of information, all observations and findings needed to be recorded (Department of Health, 2002). The interview was designed in such as way that it could motivate the client. Although not possible in a single session, this assessment was an opportunity for this client to review the effects of his alcohol (Crome, I., Ghodse, H., Gilvarry, E. and McArdle, P., 2005, p. 56-84) and drug abuse on his life and the toll it takes on others. Through this assessment, he was motivated for a change that he can bring in to his life (Faltz, B. G., & Callahan, P., 2002). Outcomes: Outcomes focus on the client's willingness to participate in treatment, including compliance with the plan of care and his readiness to change (Kosta, K., 2002). The development of positive coping skills, verbalization of feelings of increased self-worth, development of appropriate social skills, desire to establish and maintain contact or relationship with a professional in the community (Sinclair, J.M.A., Latifi, A.H., and Latifi, A.W., 2008), and desire to socialize in drug- and alcohol-free environments are examples of appropriate outcomes. Clients enter treatment at various stages of their disorders. Therefore, flexible treatment programs that can meet the individual needs of each client are considered the most effective. The acute stabilization was attained with psychotropic drugs (Minkoff, K., 2000). From the behavioural aspects the patient agreed for a timeline of 2 months to abstain from both drugs and alcohol with a promise to comply with psychotropic medications. Engagement involves four steps: establishing a treatment relationship with the client; educating the client about the illnesses; active treatment when the nurse provides various interventions to enable the client to maintain stabilization by complying with treatment; and relapse prevention in which the nurse helps the client overcome denial and other resistances to treatment. Establishing a treatment relationship with a client may require many contacts by the mental health worker. Clients often struggle with issues of authority and control and feel threatened (Miller, W. R. & Rollnick, S. 2002). During the attempt to interview, the client presented with a flat affect, avoidant eye contact but hypervigilance regarding his environment, and appeared to be selectively mute. He became somewhat restless and was easily distracted during the interview, but denied being afraid, suspicious, or unhappy. The client was able to follow directions, but could not be engaged in any detailed conversation (Wade, D. et al., 2006). Substance misuse is not addressed directly until the end of the engagement process when a working alliance has developed (Barnett, J.H. et al., 2007). Cognitive-Behavioural Therapy: The patient was subjected to cognitive behavioural therapy when he was actively engaged in the care and the treatment process with neuroleptics clozapine. This mode of therapy has been a potent therapeutic tool for a range of mental health problems. A skillful use of analysis, disputing cognitions, combined with tasks to enhance skills to promote abstinence. A functional analysis was undertaken with the client examining positive and negative consequences of using and not using substances. It was discussed with him that positive consequences of using may include the alleviations of symptoms and boredom, socialization, pleasure and recreation (Graham, H. L., 2004). Negative consequences would include conflicts, legal, financial problems, risks of contracting HIV or hepatitis, as well as symptoms of exacerbation or relapse. Drug therapy with neuroleptics has been the cornerstone for pharmacological management of schizophrenia, and in the clinical settings it usually happens under the supervision of the psychiatrist, and drugs like clozapine or olanzapine are devoid of side effects that neuroleptics usually have. The mental health worker holds the responsibility of educating the client about the importance of drug therapy, its compliance, and maintenance (Rassool, G. H, 2006). To conclude, it might is summarized that the therapeutic work must be based on individualized assessment and treatment of each client. 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