Patient ‘A’ was a 34-year-old male with a psychiatric diagnosis of schizophrenia and a was experiencing a dependency and misuse of opioid medication.
Patient A in the past 4-years had received two psychiatric treatments in the Canada for schizophrenia with minimal efficacy as symptoms remained. Patient ‘A’s condition deteriorated to a point where he was living on the streets, and a strong family intervention was needed to encourage patient ‘A’ to accept, albeit reluctantly another inpatient treatment. Patient ‘A’ was admitted under my care and he received 10-weeks of an inpatient treatment before his planned and voluntary discharge.
In general, although assessment and treatment are undertaken on a case by case basis, it is fair to say that for conditions such as schizophrenia spectrum disorders, including psychosis and delusions, in symptom infancy, treatment effectiveness appears greater with a combination therapy. Meaning that best practice is in the integration of psychotropic medication with specialist psychological therapy. In the treatment of patient ‘A’ the psychological therapy was fundamental to encourage his initial acceptance of a medication regime. Past treatments provided undesirable side effects and involuntary medication managements created a distrust of clinicians. Medication consumption is often the initial driver for the improvement of the psychosis, and this also appeared true in the case of patient ‘A’. In chronic and severe cases long term use of medication will be required to maintain improvements. However, for early episodes of psychosis or if the psychosis is of low to moderate severity, and also even in some severe cases, it is reasonable, symptoms dependent to schedule a tapering of the medication and an eventual cessation.
Patient ‘A’ during his early days of admission was resistant to taking anti-psychotic medication and therefore psychological therapy needed to focus on developing a strong psychologist-patient rapport and trust. Psychological therapy also provided patient ‘A’ with a working understanding to the experience of his psychosis providing a formulation for its inception and development, which logic substantiated a treatment methodology that would accordingly reduce symptoms. The psychological formulation related to his genetic susceptibility, attachment disorder, psychological trauma and prescription medication mismanagement as the main causative factors of his condition. After a five-week period patient ‘A’ accepted the combination treatment and within ten days there was noticeable and objective changes in his mental presentation. The change in cognition provided the opportunity to use an innovative psychological therapy, one specifically developed by Dr Gavin Jones to treat his psychosis. The rigid adherence to the prescribed psychological therapy supported the beginnings of symptom dissipation and a reduction in the distress that he was experiencing, a distress which was related to the disturbing content of his visual, auditory and olfactory hallucinations.
Patient ‘A’ remained reluctant to use medication as a means to treat his condition, and in working collaboratively we agreed that when the levels of symptoms reduced to a lesser afflicting severity, we would begin to decrease the anti-psychotic medication. Patient ‘A’ remained committed to the psychological therapy and after an 8-week period his family spoke of significant improvements in his psychological presentation and his personality. Importantly patient ‘A’ at this point had developed a strong insight into his psychosis and he had developed an awareness that his rigid delusions were in fact unusual beliefs to explain his hallucinations. As ‘the mental health of ‘A’ began to improve attention and encouragement was directed to the other important areas of life, which had been neglected due to his poor mental health and drug misuse. Increasing the enjoyment and pleasures in his life, refining interpersonal relationships, and gaining meaningful employment and occupational interests would be important stabilising factors, which would act as an antidote to a relapse in mental illness and opioid misuse. Patient ‘A’s schizophrenia remains in remission and he is continuing to lead a meaningful life without the use opioids.
Post-traumatic Stress Disorder, and Methamphetamine dependency
Patient ‘B’ is a 29-year-old female from Chicago, United States who was experiencing a high dependency to methamphetamine for about 5-years, and her lifestyle was becoming increasingly chaotic and unsafe. Patient ‘B’ had received 4 previous impatient admissions for drug dependency, which facilitated 12-step recovery-based treatment models. Patient ‘B’ had received 6-months abstinence, which was achieved within the inpatient facility.
Patient ‘B’ was under the care of Dr Jones for a 4-week period. The short period for treatment means that there is particular value and importance based upon a thorough psychological assessment, formulation and aftercare treatment recommendations. Patient ‘B’ provided Dr Jones with a synopsis of her life story and treatment exposure, which at the surface value appeared to adequately explain her current presentation. Similarly, to many people who experience an overwhelming dependency to a substance or unhealthy compulsive behaviours there is the experience of psychological trauma. Psychological trauma is a term often discussed within mental health and drug and alcohol and the meaning can be poorly understood. In essence the meaning of psychological trauma can be taken from a medical or psychiatric classification, which requires the meeting of certain perquisites in cognitive, affective and behavioural presentations; and from a psychological perspective which can understand trauma as a subjective experience in the rupturing of two separate narratives. The first narrative is the expectation of your reality, which collides with the experience of an unusual event, which shatters and ruptures your psyche creating a nonlinearly experience of time where unpleasant memories and feelings from the past can intertwine their way into the present.
Patient ‘B’ in using a psychiatric understanding of her presentation was enduring a post-traumatic stress disorder (PTSD), which was classifiable from her experience of several life-threatening episodes of violence. The PTSD symptoms were severe anxiety, depression, severe mood fluctuations, insomnia, irritability and anger. Patient ‘B’ also spoke of unwanted feelings of guilt, shame, disgust, and a psychological and emotional numbness, which can be described as a disassociation. In terms of behaviour, ‘B’ due to her past experiences lived in fear, and quite often acted in a suspicious anticipatory manner almost expecting to be further victimised. The constant fear led her to use alcohol and significantly methamphetamine to numb her psychological and emotional pains. ‘B’s occasional misuse of opioids and tranquilisers was to encourage a sleep onset, which could more accurately be described as an unconscious sedation rather than a sleep. While, patient ‘B’s behaviour while using methamphetamine became chaotic and harmful to her mental and physical health. The stress that ‘B’ was placing on her family as they watched her suffering was enormous and heart breaking, causing fractions within a family that was traditionally harmonious.
PTSD and psychological trauma are a complex biopsychological condition and simplistically speaking the trauma symptomatology that ‘B’ experienced occurred after her violent victimisation, which caused a dysfunction to her stress axis, medically known as the hypothalamic pituitary adrenal axis. The complexities involved in the dysfunction to the stress axis meant that rational decisional making became prejudiced with irrational and impulsive thinking and behaviours. The impulsivity became significant within interpersonal relationships where ‘B’ would frequently misperceive situations, and she became intolerant, hostile and aggressive of family opinions or support. ‘B’s self-worth continued to decline, and her esteem was sought in frequent sexual partners, which of course further degraded her self-worth. Symptoms of restlessness, irritability, anxiety and depression exacerbated, as did overwhelming feelings of hopelessness and loss, which resulted in her severe dependency to methamphetamine to somehow numb her torment and pain.
Past inpatient treatments for ‘B’s difficulties were accessed from within 12-step facilities, which within the general population are often regarded as the correct means to treat people with a dependency issue, which is most likely derived from the media’s attention to celebrities who (inaccurately) proclaim treatment successes at such inefficacious rehabs. Even though ‘B’ had received significant treatment time, no single healthcare professional provided her with the correct and necessary psychological interventions that would have provided her with improvements in her mental health and dependency issues. The persistence of ‘B’s difficulties can in part be explained in the medical mismanagement of her trauma symptomatology, which was persisting and prejudicing her ability to lead a normal life. ‘B’ assumed that her ‘trauma’ had been appropriately treated because past 12-step rehabs prided their patient management in using qualified ‘trauma therapists’. A clearly made up and unlicensed profession that oozes with quackery, and charlatanism that is endemic throughout the wider rehab world.
That said and in fairness, patient ‘B’ did receive some outpatient work with a purportedly qualified psychologist, a profession, which can at times can be clumsy in the management of trauma and mental health. A recent survey indicated that over ninety percent of psychologists hold an anxiety about undertaking appropriate trauma work with their clients, which was founded upon (an incorrect) a belief about the risks of ‘retraumatisation’, and (false and unrealistic) beliefs that a client should not become upset during a psychology session. Wide held beliefs, which are therefore preventing patients from receiving appropriate and necessary treatment. Accordingly, patient ‘B’s distress after all her ‘trauma-therapy’ persisted and the emotional reactivity to her trauma memories continued to intertwine their way into everyday life and her chaos continued.
Under the care of Dr Jones, patient ‘B’ received her first full and thorough psychological assessment, formulation and evidence-based treatment plan. The first treatment objective in the short period that Dr Jones had to work with patient ‘B’ was to allow her to receive a restorative sleep, as good sleep is pivotal for good mental health. Patient ‘B’ was also prescribed a specialised type of psychological therapy that is evidenced to be the most effective treatment for trauma symptomatology’s. Dr Jones has an extensive clinical history of individualising the trauma focused therapy for a plethora of his former patient’s, and every patient who has undertaken the work has experienced improvements in their mental health.
The therapy can at times be emotionally challenging, but every patient who has participated in a trauma-focused therapy has stated that they greatly appreciated the intervention and would recommend it to others. In the therapy, patient ‘B’ was amazed at how she was able to talk about personal matters and experiences in a way that she has never communicated before. Even though the topics she spoke about were distressing, ‘B’ paradoxically at times said that she would leave the psychology session feeling slightly elated and looking forward to the next session. Such feelings of elation are not uncommon, and in her case, we discussed that the feelings could relate to relief and thoughts about hope. After all it is cathartic to talk in confidence, in an honest and open manner about suppressed memories and feelings, and the relief is the newfound hope knowing that past pains and sufferings will not be an eternal burden in the days and years to come.
Patient ‘B’ is currently living in Chicago and finalising her last year of university. Patient ‘B’ is in good mental health, and abstinent from alcohol and illicit substances. ‘B’ regularly undertakes the support of a psychologist who provides her with weekly honest and objective feedback, importantly ‘B’ has increased her social support, regularly meeting with friends, attending yoga and boxing classes, and spending meaningful time during her weekends with loved ones.
Executive Burnout, and Alcohol and Drug Misuse
Patient ‘C’ is a 47-year-old male, hedge fund manager who was originally from Australia but was working in the United States, and he sought inpatient treatment for an executive burnout. Patient ‘C’ was exhibiting severe anxiety, depression, fatigue, poor sleep, he was eating poorly, and unhealthily using alcohol and cocaine to cope with his distress.
Executive burnout is an umbrella term to describe an excessive amount of difficulties related to work, which relate to mental health, emotions and behaviours, and patient ‘C’ could be viewed as a classic case. Executive burnout is synonymous with employees being overwhelmed and overburden at work, which affects job performances, which adds to the individual’s stress and this further impairs occupational performances. Many people experience strains, pressures and unrealistic workloads but not all succumb to the mental pressures of the work environment, and some people even appear to revel in such hostile conditions. Patient ‘C’ was a gentleman who struggled to cope at work, and the psychological assessment appeared to indicate that perhaps what outwardly is described as an executive burnout, was a much longer endurance of a mental health problem, which only became obvious to others when performances related to work began to be affected. Meaning that the easy and obvious explanation that people came to be a work-related stress or an executive burnout, but then again people used to believe that the sun only rises because the roosters crow.
Executive burnout is a condition classified with a chronic fatigue, pessimism, and a growing disregard to their company and occupation. Patient ‘C’ certainly experienced these symptoms, and he had no intention of returning to work. Patient ‘C’ as with other people with executive burnout was experiencing a sense of detachment from work, loved ones and friends; depressive symptoms such as a lowered libido and a reduced attention to personal care. Anxiety was persistent and severe, with frequent episodes of panic that included a depersonalisation and derealisation (i.e. a nonpsychotic experience of disreality within himself and the world around him); sleep disturbances where he was experiencing an issue with sleep onset, waking too early and an unrefreshing and nonrestorative quality of sleep. Patient ‘C’ complained of frequent illnesses often experiencing headaches, irritable bowel syndrome, lower back pain, respiratory infections, which are all likely the somatisation of his stress. Patient ‘C’ was also overweight, participated in no physical exercise, a heavy smoker, regular drinker, and he could use cocaine 3 to 4 times per week; ‘C’ was also a borderline type 2 diabetes and his lifestyle behaviours a serious risk for coronary heart disease.
The causative factors of occupational or executive burnout that were applied for ‘C’ can relate to most people who experience burnout, and the factors can simply be divided into the two areas of situational and individual demands. The situational demands are commonly perceived to be the factors of the occupational role that require a sustained effort. ‘C’ experienced a constant stress often over many years, which was related to high working demands and expectations. There was an ambiguity over his occupational role, where he was expected to take on managerial work; he endured pressures of differing personalities within the workplace; he also had at times a lack of autonomy, which was frustrating for a man with his extensive experiences. Patient ‘C’ would often only receive negative feedback and no encouraging or motivational support from management; there was an expectation to work over his agreed hours and to be receptive to work at home outside of office hours (e.g. to answer emails, phone calls or text messages).
The individual demands related to his personality and the mismatch of this to the working environment, which contributed to additional stress. ‘C’ had an introverted personality and was particularly agreeable, yet he worked within a high paced and open plan office, which required multiple interactions with differing people, and often others would seek his help and he felt obliged to be supportive. People with a gregarious and assertive personality would think little about challenging the behaviours of others within the office environment, they would be able to decline added workloads and would even find such working environments’ energising. Adding to ‘C’s strain was his perfectionism, a quality valued by the company but an unhelpful behaviour, which meant that he was spending a greater amount of time than necessary to produce outcomes, a personality trait that was adding to his inefficiency and contributing to his individual distress. However, that said ‘C’ was aware that other people can have similar personality types and characteristics to him, but they do not suffer with executive burnout. Therefore, the understanding and meaning of his executive burnout needed to be viewed from a more psychologically driven understanding, one which examined the predisposing and maintaining factors of his mental health.
In providing ‘C’ with an extensive psychological assessment, Dr Jones was then able to provide him with a detailed formulation, which allowed him to better understand the reasoning for his recent mental state. The formulation provided strategies to support ‘C’ to return to work and become more efficient in the working environment. Patient ‘C’ was a highly valued member of the company because he was charismatic and likable, but also his work was exceptionally profitable. The company understandably was amenable to provide as many resources as feasible to ensure that he could return to work. The solution focused strategies that were agreed were a private office space, an agreed reduced caseload with management, increased communication with management, a supporting member of staff, and regular psychological therapy. However, the psychological assessment, which also examined ‘C’s life chronicles, uncovered a distressing story about the loss of two young siblings during his teenage years. ‘C’ was filled with unresolved and unspoken grief from emotional encumbrance that had persisted with him for over three decades. Therefore, it was necessary for the psychological treatment to allow him to be able to resolve the grief and guilt associated to his survival, the processing of these memories and the new understanding of his personal trauma allowed a lifelong weight to be lifted. A weight which would mean that the stressors of his work and day to day life would appear somewhat less burdening and more manageable.
Today, ‘C’ remained true to his want to leave the company, which he had been employed with for over 7 years, and he has alternatively taken on an advisory and consultancy role in the financial sector. Since his inpatient treatment ‘C’ speaks about the change’s treatment have had for his mental and physical wellbeing, and the improvements that he has experienced in relationships with friends, and family, and the pleasure and enjoyment that he is now gaining from work. ‘C’ has stated that since undertaking grief-based therapy, he feels generally brighter in mood and more optimistic about life and work. He still drinks alcohol, but only occasionally and with restraint, he rarely uses cocaine, he has lost weight and is slowly rekindling his old love for cycling.