Therapy-interfering behaviors

Having just terminated with my only individual client this year, I am reflecting back on our time together. One of the key parts of the DBT framework that we operated under was the idea of therapy-interfering behaviors. In addition to focusing on the client's behavior, DBT requires the counselor to look at their own behavior and see how it interferes with the therapeutic work. Within the setting of the hospital, I found that the structure of the setting also interfered with treatment. Her primary therapist would schedule appointments during her skills group, because she was on the civil side of the hospital and did not know the treatment schedule (or ignored it). My client would often be off of the ward during we had scheduled to meet because the ward had gone outside to enjoy the nice weather. Also, my schedule did not always allow for us to meet, especially on days where I was sick or had to leave work early. On these days, I violated Linehan's mandatory notification for cancelling appointments.

In reflecting back, I also feel a certain sense of loss I hadn't really felt before in working with other clients over the termination of the therapeutic relationship. Perhaps it was that I was more emotionally invested in this relationship because my role was to positively reinforce all of her efforts and to provide an enthusiastically supportive environment for her. I would psych myself up before each meeting, so that even though we were generally going over pretty boring material (interpersonal effectiveness is not the most interesting DBT module), I would present and engaging front for my client to work with. Perhaps it was that this case was the one on which I worked most closely with the administrators and other treatment staff. I was tasked with creating a behavior plan and received supervision from the clinical administrator. Perhaps it was that this was part of a unit-wide program of implementing DBT for the traumatized women on the ward. I guess it was a combination of those factors that left me with more sadness at the end of the therapeutic relationship.

Competency

Having led a legal competency group since my first week at St. Elizabeth's, I'm only now getting a clear picture of some of the intricacies involved in "competency." These issues came up today in placement in a number of different circumstances.

H. is a client who is highly intelligent (a former college professor) who has been diagnosed with schizophrenia. Her prominent symptoms include persecutory delusions, which cloud her judgment. Her case highlights the two different kinds of competency. Her legal competency evaluation hinged on her rationality, as her factual understanding was intact. She rightfully pointed out the subjectivity involved in an assessment of rationality. Indeed, her medical competency was evaluated by two different committees who arrived at two different conclusions. She learned that the second committee found that she was not medically competent to refuse medications. She reacted violently to this news and created a pretty intense situation on the ward.

The relevant point here is that a person can be legally incompetent to stand trial yet be medically competent to refuse medications. Oddly, a mentally ill person is usually assumed to be legally incompetent; whereas, they are assumed to be medically competent. Since legal competency usually implies psychiatric medication, H's legal competency was entangled to an even greater degree with her medical decisions.

The other patient L is an example of when competency cannot be restored. L's schizophrenia symptoms cause her thoughts to be disorganized and her cognition about her case to be impaired. Since she had been to court for hearings three times, she is going to be civilly committed if she does not pass this competency evaluation. Our hospital is now trying to give some empirical evidence of incompetency, so she will be the first patient I've had who will be completing a formal battery/assessment of competency (a written test). However, these tests are not able or less able (according to the administrators on my ward) to assess the rationality of a person. For many of the clients, the rational part of competency is the problem, as the thought disorder impairs a full-enough level of rational thought.

The happier part of today was learning that two of my clients had passed their competency assessments, and seeing the progress they had made over the past few months. Makes that whole self-efficacy piece for me that much more evident.

Medical Model and Traditional Treatment

One of the strange things about being a social worker in a medical setting is the difference between the professional cultures. Social workers have a different attitude and focus than psychologists, psychiatrist, physicians, and nurses. However, in observing and participating in groups with social workers who have worked in this setting for a long time, I have seen the creep of the medical model into social work practice and it's genuinely disturbing.

As an example, I attended a Discharge Planning group on the civil side of the hospital which was lead by a social worker. She spoke about CRF homes and how stepping down works. While I took issue with some of her interpersonal style, which lacked empathy and a skill-building approach, those seemed like more surface-level concerns. The clients, meanwhile, were venting their frustration over the lack of control over their discharge plan (as well as their life, in general) and the lack of autonomy they experience in the hospital. Instead of validating these concerns or showing them some skills on self-advocacy within the setting, she seemed focused solely on apologizing for the system and instilling in the patients the supreme need of medication compliance.

While I understand that medications do help those with severe mental disorders function better in the community, it is ultimately up to the client to make the decision to continue or discontinue medications. Although this is a radical viewpoint, if the client were to discontinue medications and make his reasons known to his care workers, it could be interpretted as a growing sign of independence from treatment staff and ownership of his mental health issues.

Substance Abuse

Most of the patients at St. Elizabeth's have a severe mental illness, homelessness, and substance abuse issues (most often crack or alcohol). Since I had done research on substance abuse for the majority of my time at GMU, I was interested in how substance abuse interacted with psychotic disorders. Specifically, I was interested in if the drugs reduced some symptoms of mental illness. If we were able to see what these drugs did for people, perhaps we could fill that void with something less damaging.

From the research I found, there is no clear picture. For some, cocaine can ameliorate some of the negative symptoms; however, it can also exacerbate the positive symptoms--especially at high doses. Unlike what I had been told in school, the only drug that was statistically shown to lead to greater instances of mental illness was marijuana, and that connection was fairly week. (This is excepting drug-induced psychosis).

Another research area I explored was the idea of using harm reduction with many of the patients. This concept, glossed over in the readings, is in dire need at the hospital. Our clients have often prostituted themselves to support their habit, use in unsafe locations, and are in abusive relationships (often with a pimp). However, there are no services on the ward for those who do not wish to give up this lifestyle immediately or completely. It is merely assumed that when a person is on the ward, their natural goal will be to completely abstain from all substances. (Fortunately, we do have a psychiatrist who emphasizes that if they do relapse, they should continue taking their medication and can still seek help at the hospital.) Formally, there is no education on safe sex practices or safer/reduced drug use.

I was in the process of deveoping a plan to implement a harm reduction group on our ward; however, I could not find materials on harm reduction and domestic abuse. Since our clients are often in exploitative, abusive relationships, this would have been key. Also, I feel that the gender dynamic may have been inhibiting in creating an open environment to share experiences. The hospital itself would have likely been the largest obstacle, in that harm reduction does not fit well into the medical model of treatment and can be construed as endorsing continued substance use or prostitution. It would have made a nice thesis topic, though.

DBT and behavior planning

In preparation for working with my client with Borderline Personality Disorder, I had read the book excerpted for this week's reading. The first thing the ward administrator--who is heading up the effort to engage the client in DBT-- and I did was to draft a list of the client's most high-risk behaviors. In the process, we were struck by how much progress she has really made while on the ward and how much she has begun to engage treatment, DBT in particular.

I was tasked with drafting a behavior plan for the client. From my years working with emotionally disordered kids and writing/implementing behavior plans, it is one of the few things I feel fully competent in doing. However, the behavior plans I had drafted in the past were grounded in a cognitive-behavioral methodology. While DBT is grounded in CBT, it has unique aspects that were interesting to explore in the process of writing the plan. Another confound was the influence of Trauma-Informed Care, another methodology being implemented across the hospital. This process eschewed the behaviorist interventions of a daily inventory (diary cards in DBT), a token economy, and ABC processing. Instead, TIC promotes understanding of self-soothing methods and bodily awareness during stress.

Integrating these plans was difficult for me and the other members of the treatment team. We ended up throwing out most of the behavior plan I had drafted because it was too CBT-oriented and instead favored a more TIC-centerd approach to behavior processing. However, the overall DBT structure within the forensic setting (there is an entire chapter on it in the book you excerpted for class) remains intact.