Unwavering tough love

By Jen Arbis
Clinical Head

Tristan is a 25 year old substance abuser who entered SELF on March 17, 2012. At the time of his admission, he claimed he had hit “rock bottom”. He was living alone in an apartment, drowning in misery, with no signs of hope or purpose in life. At this point, his family intervened and brought him to SELF.

Background

Tristan was born out of wedlock in Olongapo City. Prior to his birth, his biological parents Leslie and Joseph cohabited for a couple of months before Leslie discovered that Joseph was previously married. As a result, she left him and gave birth to Tristan.

Leslie tried to raise the child on her own but ran into difficulties as she was living in a convent. It was at this time that she gave custody of the child to Joseph. But Joseph refused to take care of the child. His eldest brother Jun and his wife, however, agreed to raise the child.

Even as they had three other kids, Tristan was raised as their own and given equal opportunities. Despite this, Tristan was not able to form a close relationship with his parents and siblings. As he grew older, he became more and more distant from them.

As a child, Tristan was a loner and very quiet at home. In school, he misbehaved and got into a lot of trouble. His parents were busy managing their growing business and Tristan was often left in the care of maids and drivers. Jun was temperamental and was verbally abusive. This frightened Tristan, ultimately affecting his self-esteem.

At age 12, Tristan began to take Valium, marijuana and alcohol. At 13, he learned about his adoption. He was told that his Uncle Joseph, whom he knew as an irresponsible and reckless person who had been to rehab for substance abuse, was his real father.

Tristan became more rebellious and unruly. He developed the “black sheep” image, leaving the house to stay with his girlfriend or friends every time there was a conflict. At age 14, he tested positive for drugs and got kicked out of school in the 8th grade.

At one point, his family gave up and turned him over to his biological father who, at that time, was still an irresponsible person. Predictably, their relationship did not work out.

After eight months, Tristan decided to return to his adoptive family and was eventually transferred from home tutoring to regular school. Tristan, however, was too laid back and had to attend summer classes in order to finish high school.

As he entered college, drinking alcohol became a regular routine along with the occasional drug taking.

At age 20, Tristan had gone deeper into substance abuse and his adoptive family threw him out of the house again. He subsequently started to search for his mother whom he later found living a hand-to-mouth existence with her new family in the province of Rizal. He lived with them but, unable to accept the poverty, Tristan often fought with his mother and would leave the house regularly. In order to support his vices, he resorted to prostitution.

After two years, he decided to make amends and come home to his adoptive family. Upon his return, they took on the responsibility of taking him to a rehab facility. From 2008 to 2009 Tristan went along with the program and made it to Reentry. But he remained angry and eventually absconded from the program during one of his days-off. Despite his family’s wish for him to return to the program, Tristan convinced them that he was okay.

Months later, Tristan was allowed to work in the family business. He managed to be sober from drugs for two years but continued his drinking habit, causing him to be disruptive and uncontrollable.

One day, he had an argument with his adoptive father who accused him of taking drugs. Frustrated by the lack of trust he had so hoped to regain, Tristan decided to use drugs again. It was just a matter of time before he was back to his old habit of substance abuse. This time, however, his use led to severe paranoia and depression.

Initial Treatment Process

Tristan was picked up from his apartment and brought directly to SELF. He stayed in the Evaluation and Motivation Unit (EMU) for one month. During his stay there, Tristan constantly shared that he was hearing voices but insisted that he did not have a drug problem.

The initial diagnosis of the facility psychiatrist was Substance Induced Psychosis. This was later confirmed by a psychological test.

Initially, Tristan was prescribed Vitamin C (1000 mg) and Vitamin B (500 mg) daily, to help in his detoxification process.

When Tristan joined the TC Primary Program, his problematic attitudes came out early on. He was arrogant and defied the rules and regulations. Aside from being sneaky, he was lazy and non-caring in his work. Due to his disrespectful and vindictive behaviors, he always ran into conflict with other residents.

His mood was so erratic that he became disruptive, almost getting into a physical fight with a resident. This led him to be placed back in the Prospect Chair. After a couple of weeks, the TC family reaccepted Tristan.

His general behavior improved and he was able to move up to the assistant level before he began to misbehave again. After failing to respond to sanctions, Tristan refused to undergo any TC process and was thus placed back in the Prospect Chair, this time in the EMU.

Breakthroughs

At the EMU, Tristan vented his anger at the program, claiming he did not need treatment. As his form of protest, he sat for months in defiance of the program to prove his point.

It took several weeks before Tristan finally calmed down and agreed to a Mental Status Examination. He was diagnosed to be suffering from Paranoid Schizophrenia. It was also then that he admitted to feeling paranoid about the people around him.

He was treated with Lexapro (10 mg) and Solian (100 mg).

To help him with his thought process and to increase his motivation level, Motivational Interviews were conducted and psychological worksheets were administered.

Several weeks later, after observing that his impulse control had improved, Lexapro was discontinued. As he complained about not being able to sleep well, he was given Seroquel (300 mg).

However, after two months, Tristan suddenly had another episode of acting out; he challenged an EMU staff to a fight. During his regular Mental Status Examination, he admitted to experiencing hallucinations, which made it hard for him to focus and control his temper.

Hence his Solian was doubled to 200 mg and his Seroquel was raised by 100 mg to 400 mg.

Over the next month, Tristan slowly stabilized. After a series of panel assessments, he decided to give the program another try. He rejoined the Primary Program and complied with the rules and TC processes.

Although quiet and reserved, Tristan managed his duties responsibly. Even with minimal emotional investment, his behavior became more consistent.

Over the next few months, he was able to work his way up the Chain of Command and because of this Solian was discontinued.

On his 11th month, he had his first Encounter with his sister and brother-in-law, who were his guardians in the program. During this process, Tristan still displayed a lack of any accountability, blaming most of his failures in life and recent relapse to his adoption.

He was then confronted by his sister who claimed that his attitudes were there even prior to his relapse.

Except for his parents who were not willing to participate, numerous dialogues with other family members were also conducted.

Together, these dialogues helped Tristan open up and he became accountable for his own wrongdoings. He recognized that his substance use was not the main problem but rather his attitude toward his reality. He also became aware of his thinking error that no one cared for him.

Lapses and Relapses

In the next six months, Tristan experienced several lapses in his behavior. His tendencies to be lazy, sneaky, non-caring, and disrespectful started to surface again. In response, the program subjected him to numerous Behavior Shaping Tools. In addition, he was lined up for a few Peer Confrontation sessions where the community helped him to take accountability for his actions. His counseling sessions were also increased.

From a psychiatric standpoint, his inability to keep a consistent disposition was addressed by an adjustment in his medication. He was again prescribed Solian (100 mg) and Lexapro (10 mg) while Seroquel was reduced to 200 mg.

Turning Point

On his 18th month in the program, Tristan finally opened up about an anger toward himself he had suppressed for a long time. In recalling the times he resorted to prostitution, he was disgusted with all the hurt he had inflicted upon himself. It came to a point where he even doubted his sexuality.

Then, at the Head level, he had another dialogue with his family and once again asked to be pulled out from the program, to no avail. His family was determined to have him complete his program. This behavior got Tristan demoted to the crew level.

Two months into his demotion, Tristan shared a valuable lesson. It dawned upon him that in trying to run away from the program, he was actually running away from himself. When he saw that his TC family accepted him for who he is, he realized that he had to run no more. It was the defining moment that allowed him to forgive himself and embrace the program.

From that day on, Tristan worked hard and made it to the Rehabilitative Stage in the Upper House where he served the community as Housekeeping Crew. There, the frequency of his lapses was reduced significantly and his tolerance to correction and criticism was enhanced.

Tristan eventually started to have days-off at home during his Pre-reentry and Reentry phases. He observed that his family and the outside world had not changed much and that only he was changing.

It was now clear to him that if he really wanted a life of recovery, he should not be dependent on others. He decided to come to terms with his past, stop blaming his family and start taking accountability for his actions. “Count my blessings” became his new mantra.

After this accomplishment, Lexapro was reduced to 5 mg and eventually discontinued. Seroquel was also later replaced with Clozapine (50 mg).

In Aftercare, even as his family was not yet ready to accept him home yet, Tristan applied to work in SELF under the Supervised Practicum Internship Program (SPIP). In the end, Tristan finished two full terms of the SPIP during which he was able to complete two Vocational Courses: Basic Car Maintenance and Diesel Mechanics. Currently, Tristan is being trained as a staff of the Housekeeping Unit.

His maintenance medications are Topiramate (50 mg) and Clozapine (25 mg).

Conclusion

This is a case where the provision of a holistic treatment and rehabilitative approach to a client with a Co-Occurring Disorder (COD) was made successful with the unwavering and steadfast support of the guardians.

Had Tristan been humored and allowed to leave SELF during any one of his three attempts, the cycle of his psychiatric medications would not have been completed.

The TC program succeeded in guiding the client to not only acknowledge his disorder but also accept it and learn how to manage it responsibly.  But this process was made possible by a closely monitored regimen of medication.

Hence, the collaborative effort of the TC behavior modification program, the psychiatrist, the counselor and the supportive family member made for the success of this case.

By | 2018-04-02T11:42:02+00:00 April 2nd, 2018|Categories: Clinical Case Studies|0 Comments

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