(6-12-08)
George
George M. was a 47 year old, biracial male. He had been raised by his grandmother. His mother had been Hispanic, a prostitute, and died of an accidental drug overdose when George was “young.” His grandmother’s family had not accepted George because his father was unknown but obviously black. George reportedly had significant learning and behavior problems in school, and eventually dropped out at age 16. He had never earned his GED.
George had been arrested a number of times, usually for vagrancy, public drunkenness, shop lifting, or other minor offenses. He had served several sentences in county jails is several areas, and one brief prison sentence for armed robbery (George did not carry a weapon but the organizer of the event did, no one was injured but they were rapidly apprehended, and George’s partner quickly negotiated a deal: George served 18 months of a 5 year sentence.
George had intermittently abused alcohol and a number of other drugs. He had been through detox programs in two states, and “almost” completed one drug treatment program.
George had received a variety of mental health diagnoses over his life: Conduct Disorder as a youth, Schizophrenia and substance abuse diagnoses as a young man, and most recently diagnoses of depression, Bipolar Disorder. and substance abuse.
George had a very poor work history and had seldom been able to sustain employment. He had often worked in restaurants and through temporary employment agencies.
Amazingly enough, George showed average tested intelligence (WAIS-III FSIQ 93) and was literate (reading comprehension about 6.5 grade, standard score 88).
George was currently homeless. He had applied for Social Security and been denied due to possible malingering in the evaluation. He had been terminated from the local mental health center for noncompliance and missing appointments. He was receiving medication through the local free clinic: a low dose of a neuroleptic (Geodon), a mood stabilizer/anticonvulsant (Depakote), and an antidepressant (Zoloft). George reported he took his medication regularly. He had had clean drug screens for the past several months through his probation office. He was seen for services through the state vocational rehabilitation office.
Problems at initial contact
- temper control & aggressive behavior
- inappropriate language: “Fuck them”, “dirty Spicks”,
- “cock suckers”, “kiss my ass”, “coons”, “racist
- bastards”, “retards”, “Jesus freaks”, “breaking my
- balls”
- ruminative thinking
- mistreated, discriminated against, accused unjustly
- social anxiety
- poor personal hygiene: dirty, body odor, scratching self
- unemployment
- social isolation
- disorganization and psychotic thinking under stress
- paranoia, treat sensitivity, hostile attributions
- homeless
- unemployed
- history of alcohol and drug abuse
- smoking 2 to 3 packages of cigarettes per day
Treatments
- wk 1 individual session medication
- rapport building & planning
- referral to community shelter
- wk 2 indiv. session medication shelter
- social skill training
- wk 3 indiv. session med shelter
- social skill training
- referral to AA and to MH support group
- wk 4 biweekly indiv ses med shelter support groups
- social skill training
- wk 5 biweekly indiv ses med shelter groups
- social skill training
- volunteer work at shelter
- wk 6 biweekly indiv ses med shelter groups volunteer
- social skill training
- wk 7 weekly indiv session med shelter groups vol
- social skill training
- job interviews
- wk 8 weekly indiv session med shelter groups vol
- social skill training
- job interviews
- wk 9 weekly indiv session shelter groups vol
- social skill training
- employment
- unscheduled crisis session
- wk 10 weekly indiv session med shelter groups
- social skill training
- job interviews
- wk 11 weekly indiv session med shelter groups vol
- social skill training
- job interviews
- wk 12 weekly indiv session med shelter groups vol
- social skill training
- employment
- wk 13 weekly indiv session med shelter groups vol
- social skill training
- employment
- wk 14 weekly indiv session med shelter groups
- social skill training
- employment
- wk 15 weekly indiv session med shelter groups
- social skill training
- employment
- wk 16 weekly indiv session med shelter groups
- social skill training
- employment
- seeking housing
- wk 17 weekly indiv session med groups
- social skill training
- employment
- apartment
- wk 18 weekly indiv session med groups
- social skill training
- employment
- apartment
- wk 19 weekly indiv session med groups
- social skill training
- employment
- apartment
- wk 21 indiv session med groups
- social skill training
- employment
- apartment
- wk 23 indiv session med groups
- social skill training
- employment
- apartment
- wk 24 indiv session med groups
- social skill training
- employment
- apartment
- referral community agency
- wk 25 indiv session med groups
- social skill training
- employment
- apartment
- transition to community agency
- wk 27 indiv session med groups
- employment
- apartment
- termination
Course of treatment
27 weeks, 31 sessions, augmented by psychotropic medication, support groups, and community resources
Follow-up: two years
Outcome: employment, independent residence, participation in social activities of support groups, maintenance with group therapy in social service agency, successful maintenance of parole status
Possible factors contributing to success
- Relationship with therapist
- Successful management of medications
- Normal cognitive abilities
- Success with accessing community resources
- Social skill training
- Avoidance of substance use
George’s social skill training goals
- Eye contact and attention to other
- Bathing and clean clothes
- Voice loudness and clarity
- Posture
- Listen and restatement
- Deep breath for stress control
- Greetings
- Withdrawal if stressed
- Self-monitoring of feelings
- Appropriate replies
- Turn taking
- Judgments regarding appropriate topics
- Job interviewing
- Refusing requests
- Making requests
- Responding to compliments
- Aanaging difficulties
- Eye contact
- Paraphrase
- Monitoring conversation
- Anger control
- Expressing gratitude
- Sharing interests
- Dealing with offers of drugs
- Negotiating
- Compromise
- Expressing positive feelings
- Casual conversation
Treatment techniques
- interviewing skills; contracting & planning (empathy, honesty, clear expectations)
- behavioral rehearsal
- direct instructions
- modeling
- feedback
- videotape feedback
- stress management & treatment compliance monitoring