Psychiatric Illness with Substance Misuse - Essay Example

 Psychiatric Illness with Substance Misuse For this assignment, I chose to work closely with a 31 year old female client diagnosed with dual diagnosis (psychiatric illness with substance misuse) to discuss her journey from her perspective and link it to the appropriate theory. My client care is currently being coordinated by community mental health team in London where she is being regularly seen for ongoing support, monitoring and administration of medication. For the purpose of this essay and to maintain confidentiality, I am going to call her Jenny. I chose her for this assignment after reading her case notes and discussing it with my mentor who recommended her to me as someone who likes to talk about her experience and is willing to share her story to students and other professionals for educational purposes. Jenny is well known in psychiatric services, has a long history of substance misuse and 3 hospital admissions –the last being in October 2010. In this essay, I am going to focus on the last few years of my client journey and the period from her last admission to hospital to where she is now. I will explore how she came to this point from her perspective and analyse the information gathered in interviews. Due to illicit substance misuse and non compliance with her treatment, Jenny's mental state deteriorated leading to a hospital admission. When discussing her drug addiction problem, Jenny talked about various stressors in her life prior to admission to hospital and using drugs to escape from problems and not being able to break the cycle of dependence. Jenny talked about her drug habit and how it affected her mental state and behaviour. She acknowledged prior to her admission to hospital that she started to feel negative about herself, neglect her personal hygiene and increasingly feel agitated and angry. At that time, she continued to drink alcohol and use crack cocaine and cannabis as she found it difficult to overcome her cravings and was not compliant with her treatment. She reported feeling threatened by fellow female occupants at her supported accommodation and felt they were trying to harm her. Her record showed that on admission she was aroused, agitated, talking to self, trying to kill some insect on her shoes and responding to unknown stimuli saying that there were spiders around her body. Substance misuse affects people’s mental health in relation to how they see themselves, their mood and behaviour. Although drug use can give short-lived pleasure, long term use can have very harmful effects and can cause mental health problems (Mind, 2011). There is a growing body of evidence which suggests that drug use particularly cannabionids, hallucinogens and stimulants such as amphetamines can trigger psychotic symptoms in people with mental health problems, cause a relapse in mental state (Jackson-Koku, 2001) and increase their violent behaviour (Phillips, 2000). In addition, poor adherence to medication plan can cause reduced effectiveness of the medication and can lead to relapse and subsequent re hospitalisation. People who use substances can experience adverse effects such as non compliance with medication, disengagement, distorted perception and cognition, suicidal ideations and homelessness (Dickey et al. 2000, Cleary et al. 2008, Kendal 2004). Reasons why people use substances vary and are influenced by socio cultural factors and purpose of their use. The reasons why people continue to take drugs depend on combination of factors including psychological, biological and social (Rassool, 2006). According to Bettinardi-Angres et al. (2010), although there seems to be a biogenetic predisposition to addictive behaviour, often this is not enough to cause chemical dependency and people are often influenced by their personality problems such as impulsivity and poor coping skills as well as environment and social pressure. Prior to her admission Jenny was living in supported accommodation where many of the residents have mental health problems, drug and alcohol misuse. Jenny reported that this environment and relationship with residents made her more likely to take drugs as a result of how they socialised. After a month on admission and compliance with treatment, Jenny's presentation and mental state slowly improved and was discharged from hospital on a CTO to ensure her continued concordance with treatment and engagement with services outside of hospital. This has worked for her. She stated that she has been compliant with conditions of her discharge as she did not want to go back to hospital again. She felt that her good rapport and relationship with her care coordinator has helped and that her engagement and cooperation was due to her wanting to work with the team and remain well, not because of a CTO. Although CTOs are commonly used by clinicians for patients that have been detained in hospital, "no robust evidence" was found in research about their effects on outcomes such as hospital readmission or patients' quality of life (Community Care article, 2007). It appears that good therapeutic relationship with her care coordinator played important role in her engagement with services. This is in line with research which suggests that good relationship between nurse and patient can result in positive outcome, prevent relapse and increase compliance with treatment (Norman and Ryrie, 2009). Jenny reported that close working with her care coordinator who provided support and encouragement helped her to comply with her medication and to remain mentally well. According to O'Connell et al. (2002), adherence with medication and patients following treatment plan are associated with improvement of specific symptoms of disorder as well as their physiological, psychological and social functioning and quality of life. Although her mental state remained relatively settled and she was compliant with medication, Jenny continued to use drugs and this affected her behaviour. She lived in various places (mainly supported accommodation) which resulted in evictions due to her antisocial behaviour and concerns about her prostituting and using drugs in their premises. She was also physically and verbally abusive towards staff and other residents. She reported not feeling happy about staff at her supported accommodation who tried to control her behaviour and put boundaries in place, stating that she felt they did not like her. Jenny accepted to be referred to drugs and alcohol service and in meantime to cut down on drugs and alcohol use whilst contemplating of stopping her drug and alcohol habit. According to Rao et al. (2007), substance misuse is associated with high risk of assaultive behaviours and aggression. This is related to the findings of Scott et al (1998) who states that people with dual diagnosis are more likely to present with violence and hostile behaviour than individuals with less complicated mental illness. It is likely that her increased aggression and irritability were due to her withdrawal symptoms from her substance use. Phillips (2000) stated that most withdrawal features are often unpleasant to individuals and accompanied with feelings of extreme craving. Especially the withdrawal from crack cocaine accompanied with overwhelming experience of craving can lead to violent and impulsive offending. In addition, George (2010) suggests that people who are trying to reduce their substance use are more likely to present with anxiety, restlessness, tiredness and insomnia. Jenny is the mother of four and a half years old child who is being looked after by Jenny`s mother. Jenny`s mum holds custody over her daughter and is willing to encourage contact with her and the little one, provided that Jenny starts working on her substance misuse and does not display any disruptive behaviour as this might influence her. Although she speaks highly of her daughter and the relationship she has with her, Jenny’s record showed that due to her continued drug use and chaotic behaviour, she has not been playing her role in terms of the commitment she promised to keep, visiting and providing for her daughter. According to Griffiths (2005), continual choosing of short term pleasure and relief from their addictive behaviour results in adverse consequences and long term damage as often individuals compromise their relationship with family and friends. Her continued drug use and the effects drugs had on her behaviour caused many anxieties to her family who were very concerned about her wellbeing and wanted her to get well, move on from services and look after her daughter. Jenny reported often feeling pressured by family to stop alcohol and drug use and to get back to university and complete her degree which often resulted in getting into arguments with her family members. This is in line with research which suggests that much of the family conflicts can be a result of substance abuse. However, in some instances, dependence exacerbates existing conflicts such as failure to live up to your parent expectations (Sullivan, 2001). Recently, she has been engaging with drugs and alcohol services by attending their drop in sessions and claims she has found this helpful in cutting down but unable to stay off drugs. Jenny claims she does not have the willpower to stop at the moment but will consider it in the future. According to Drug Scope/Adfam report (2009), too few people complete drug treatment and emerge from it ‘drug free’ and argued that abstinence is hard for many people with serious drug problems. New recovery based approach in field of substance misuse acknowledges that individuals with these problem will need different kinds of services and support at different times, and shifts the focus to achieving the outcomes that matter to people and their families and friends – such as improved health, a place at college or a job, somewhere decent to live, leisure activities and positive relationships with others. A range of different approaches can facilitate these outcomes for different people and at different points in their journey out of drug dependency. Hansen et al. (2008) state that abstinence from substance use is not recovery. They state that “Abstinence begins when an alcoholic/addict quits consuming alcohol and drugs. It occurs at a point in time, as an event. Recovery on the other hand, begins when an abstinent alcoholic/addict starts growing and changing in positive ways. It occurs over a period of time, as a process. Abstinence requires a decision; recovery requires time and effort”. Prochaska et al. (1982) developed the stages of change model which describes process involved in eliciting and maintaining change. According to this model, people move through different stages in order to change their behaviour and maintain it: pre contemplation: not intending to make any change, contemplation: considering a change, preparation: making small changes, action: actively engaging in a new behaviour and maintenance: sustaining the change over time. When an individual has reached maintenance stage they may slip back and relapse. However relapse is part of recovery when people return to an earlier phase. According to Cleary et al (2008), people rarely change their behaviour over night, rather this change occurs over time and perhaps after several admissions. It appears that Jenny is in contemplation stage as she is aware of consequences of her drug habit. She is considering change but is ambivalent about it. The fact that she is attending drop in session implies that she is taking some steps in addressing this issue which is affecting her life and relationship with others. Getting support from services and attending self help groups have been identified as important when recovering from their dual diagnosis as well being honest to self and others (Edward et al, 2012). Recently, she moved in with her boyfriend who has been physically violent towards her due to her drug use and since then, there has been some improvement in her mood and behaviour. Jenny reported feeling generally happier and more “with it”. She confirmed not taking crack cocaine or drinking alcohol but continues to smoke cannabis. She sees her boyfriends as protective as he makes her stay off drugs. Research suggests that the support women receive from their intimate partners is significantly associated with their motivation to successfully complete drug treatment (Lewandowski et al. 2009). In addition, living with a partner can be a protective factor for African American women who use drugs (Lam et al. 2004). Social networks and social support are associated with a variety of positive outcomes among women addicts who are in and out of drug treatment. Social support has been shown to be predictive of drug treatment completion (Knight et al. 2001), abstinence (Kaskutas et al. 2002; Loudenburg et al. 2003), less frequent marijuana use and drinking to intoxication (Tucker et al., 2005), and better drug treatment outcomes for women in both outpatient (Comfort et al. 2003) and residential treatment (Alemi et al., 2003). Department of Health (2004) suggest that dual diagnosis is one of the most challenging clinical problem mental health services face as it focuses on two problem areas (mental health and substance misuse) as the relationship between the two is complex and often controversial and many individuals with this diagnosis have other needs that would need to be addressed when trying to understand and help them. Clients with dual diagnosis, as in Jenny’s case have a lot of additional difficulties apart from medical and psychological, relating to social, housing and lifestyle matters. That is why it is important to apply a more holistic approach when meeting needs of such individuals. Integrated care is important when addressing clients’ mental health and substance misuse problems. In particular, the use of care programme approach on regular basis would ensure identifying such needs and facilitate better liaison between mental health and drugs and alcohol service. Staff working with dual diagnosis clients apart from addressing their mental health needs are also responsible for addressing other needs their clients might have, focussing specifically to empower clients to increase their personal responsibility for their own recovery from drug/alcohol use and mental illness. As a result of experience of working with this client I was able to gain good understanding of how mental illness and substance use can impact on individual, their recovery and how it can affect their level of functioning. By acquiring good understanding of Jenny's unique circumstances and requirement, we were able to ensure that the level of service and support she received was tailored accordingly and that her personal views and opinions were taken into consideration within programme of treatment. Since I worked closely with this client with mental health and substance related issues, I have developed an excellent working knowledge of issues faced by clients in this field and how their care and treatment is being coordinated as a way of supporting them in their recovery. I have also realized that there are many factors that can lead to the success of treatment of a person affected by the problem of substance use. It is important to closely follow all the steps they are told by their physicians so that they can fully recover from the problem. The other thing that I have discovered is that people taking medication for substance abuse need to be closely monitored by a health care professional. This helps to ensure that they do not skip the period they should be taking their medication. Health care professionals also have experience in diagnosing the causes of abusing substances by different people. It can also be seen that the medical professionals can make recommendations to the physicians about the patient progress in terms of their recovery path. Whenever the medication seems to be ineffective, they can recommend that the client stops using it. This positively helps in addressing the problem faced by the person affected. Apart from taking medication, I also think that counselling is very important since it helps the person involved to recover from the problem of substance abuse. Some people often see themselves as outcasts in their respective societies and this is the reason why they take drugs. However, proper counselling may be good to these people since they often lack good advice. Through counselling, the clients can gain self confidence and this will help them to realize that they are just like other people and capable of performing various tasks that can uplift their welfare. It is important for the counsellors or caregivers to people with drug related problems to talk about the benefits and other positive aspects related from quitting drugs. It is not good to use threats or speak negatively about people who use substances since they may view themselves as condemned and social outcasts. This aggravates the situation than solving it. I have also realized that full recovery from substance abuse problem is a gradual process that goes through different stages. Indeed, the addicted person can take drugs while on a recovery path but what is important is to cut on the volume consumed. This is commonly referred to as withdrawal symptoms and they affect progress in terms of recovery from drug abuse problems. I have noted that if a client follows all steps in taking the medication for substance abuse problems, there are chances that they will fully recover. References Bettinardi-Angres, K. and Angres D. H. (2010) Understanding the disease of addiction. The Journal of Nursing Regulation, 6 (2), 6-8. Cleary, M. , Hunt G. E., Matheson, S. and Walter G. (2008) Psychosocial treatment for people with co-occurring severe mental illness and substance misuse: systematic review. Journal of Advanced Nursing, 65 (2), 238-258. Drug Scope/Adfam (2009). Recovery and Drug Dependancy: a new deal for families is available online on http://www.adfam.org.uk/docs/recovery_dependency.pdf (accessed 15 March 20014). Great Britain. Mind - National Association for Mental Health (2011) Understanding the psychological effects of street drugs. London Griffiths, M. (2005) A 'Components' model of addiction within a biopsychosocial framework. Journal of Substance Use, 10 (4), p191-197. Hansen, M., Ganley, B. and Carlucci, C. (2008) Journey from Addiction to Recovery. Research and Theory for Nursing Practice: An International Journal, 22 (4), p256-272. Jackson-Koku, G. (2001) Mental illness and substance misuse : a nursing challenge. British Journal of Nursing, 10 (4), p242-146. Lewandowski, C. A. and Hill, T. J., (2009). The Impact of Emotional and Material Social Support on Women’s Drug Treatment Completion. Health and Social Work, 34 (3), p213-220. Phillips, P. (2000). Substance Misuse, offending and mental illness: a review. Journal of Psychiatric and Mental Health Nursing, 7, p483-489. Prochaska, J. O., and DiClemente, C. C. (1982). The Transtheoretical therapy: toward a more integrative model of change. Psychotherapy: Theory, Research and Practice, 19, 276-288. Rao, H., Luty, J. and Trathen, B. (2007) Characteristics of patients who are violent to staff and towards other people from a community mental health service in South East England. Journal of Psychiatric and Mental Health Nursing, 14, p754-757. Rassool, G. H. (2006) Dual Diagnosis Nursing. London: Blackwell. Sullivan, E. (2001) Dual Diagnosis: Counselling the Mentally Ill Substance Abuser second edition. New York: The Guildford Press. Read More