Concurrent Disorders Case Study

CONCURRENT DISORDERS GROUP ASSIGNMENT
SWRK 2053, SOCIAL SERVICE WORKER PROGRAM
GEORGE BROWN COLLEGE, TORONTO

Group Members: Jena McTavish –––  100948041
(All Section I) Marcus Cahuas –––  100945009
Martin Otárola –––  100933908

Due and Submitted: February 18, 2016   ( Week 6 )

1.      Describe how you would assess the severity of his Substance Use. Indicate the severity
            (Mild, Moderate, Severe) and explain the reasons for your answer (1 Page).

We would say that Jamal makes high‐moderate use of opioids. We say “high‐moderate” because he
difinitively satisfies 2 (and partially satisfies an additional 4) of the 11‐Symptom Criteria provided in
Week 2 and 3 slides. The 2 definitive criteria are:
1. Use continues despite knowledge of adverse consequences: He continues to use Oxycontin
despite medical professionals’ warnings about dependency (CS, Pars. 7 and 14).

2. Craving/Intense urge for substance: While the case study does not indicate that he “craves”
Oxycontin in a physiological sense, he becomes anxious when he does not have steady access
to it and will seek out alternatives like opium and heroin if Oxycontin is not available (CS, Par.
8).

The 4 partial criteria are:

1. Characteristic withdrawal symptoms (but no substances taken to relieve withdrawal): He
became “quite sick for several days” when he tried to cut down on his Oxycontin use just
before leaving for Canada (CS, Par. 10).

2. Much time/activity to obtain (but not to use or recover): He makes use of the criminalized
market to get access to painkillers whenever medical professionals have barred him further
access to Oxycontin (CS, Pars. 7 and 14)

3. For longer period than intended (but not necessarily larger amounts): His use of Oxycontin
went down from 5‐6 pills to 2 pills a day since leaving the military (that is: his dosage seems to
be directly related to the severity of his mental health symptoms). He uses Oxycontin for
longer periods than intended –– against doctors’ recommendations –– and is aware of the
dosage he is taking. (CS, Par. 8)

4. Persistent desire or repeated unsuccessful attempt to quit:  While he does not have a
“persistent” desire to quit nor even a history of “repeatedly” trying to quit, Jamal does
understand that he needs to quit and did try to wean himself off of Oxycontin once in the
past, before leaving for Canada (CS, Pars. 10)

The one criteria we would add that is not part of the 11‐Symptom is “use or efforts to obtain have
resulted in conflicts with the law”, which we feel is significant. And while this may be the result of his
unfamiliarity the Canadian drug regulation system (given that there seemed to be no such system in
Afghanistan where he was freely able to obtain opiates) (CS, Par. 8), we still feel it is something that
needs to be explored and addressed.

J. McTavish, M. Cahuas, M. Otárola –– Page 1 of 9

Other Considerations:
It is worth noting that Jamal is at the Preparation stage of change, given that he acknowledges
that has to “quit using drugs to manage his problems” and has attempted to wean himself off of
painkillers in the past (CS, Par. 10). This will greatly facilitate his shift toward Action (treatment).
We do not feel he satisfies the performance‐related criteria of the 11‐Symptom because his
functional‐social impacts are the result of his mental health symptoms, his immigration, the makeup
of his community, and the discrimination he has had to face in Canada. It appears to us that he only
uses drugs to manage his mental health symptoms. His self‐medication is a concern, though, since he
is not professionally familiar with the long‐term effects of painkillers, and of Oxycontin in particular.

   2.      Describe how you would assess the severity of his Mental Health. Indicate the severity
            (Mild, Moderate, Severe) and explain the reasons for your answer. Also indicate a
            possible diagnosis (1 Page)

Based on personal/familial experiences and our previous work with both Regehr & Glancy’s
Mental Health Social Work Practice in Canada and the DSM‐5 (at placement and Mental Health class
last semester), we would say not only that Jamal is experiencing symptoms of severe Post‐Traumatic
Stress Disorder (PTSD), but also that he is at risk for Major Depressive Disorder (MDD).
We suspect Jamal is experiencing PTSD because he is exhibiting telltale symptoms, such as:
nightmares (DSM‐5 PTSD Criterion B2), flashbacks (DSM‐5 PTSD Criterion B1), panic attacks (DSM‐5
PTSD Criterion B5), interrupted sleep (DSM‐5 PTSD Criterion D6), and a powerful fear of dying (DSM‐5
PTSD Criterion D4). Moreover, these symptoms are the result of witnessing and experiencing
traumatic events (DSM‐5 PTSD Criteria A1 and A2, differentiating it from Adjustment Disorder); they
are not the results of substance use or another medical condition (DSM‐T PTSD Criterion H); and they
have persisted for more than 1 month (DMS‐5 PTSD Criterion F, to differentiate it from Acute Stress
Disorder).
We would say Jamal’s PTSD is severe because: (a) not only does he satisfy the DSM’s
generalized severity measure for “Severe” (DSM‐5, 188); but (b) the symptoms are severe enough
that he feels the need to self‐medicate in order to manage them; (c) he becomes anxious about his
ability to manage his symptoms when he is at risk of running out of painkillers (perhaps because they


are so distressing); and (d) his symptoms physically disable him to the point where he is “laying on the
floor, curled up and crying” (CS, Par. 6).
We say he is at risk for Major Depressive Disorder because he satisfies a number of telltale
risk factors, such as: child/youth trauma, young (adolescent) age, a struggle with a chronic condition,
unstable employment, loss (especially of his military friends upon settling), an isolating social
environment, living alone, being of lower socioeconomic status, having few social supports, and
having “no education” (Regehr & Glancy, 178). What’s more, we are seeing Jamal in January, whereby
months of low light (November to March) are associated with the development or worsening of
depressive symptoms (Ibid). Opiate use is also associated with major depressive disorder at a rate of
49.3% (Wild et al., 2005 in Regehr & Glancy, 179).

While Jamal acknowledges that his symptoms are a “problem” (CS, Par. 10) there is no
indication that he has a concept of “trauma”, nor even that his symptoms are the result of his past
traumatic experiences. This may partly be the result of his (and most people’s) unfamiliarity with
mental health conditions. It may also be the result of his upbringing in Afghanistan, where warfare,
terrorism, and the deaths and mental distresses associated with them are so common and so
normalized that the concept of “trauma” or “disorder” no longer has social or cultural significance.
Moreover, it should be noted that Jamal falls under Terr’s (1994) Type II trauma (repeated
traumatization) and Rothschild’s (2000) Sub‐Classification II (never having developed a wide range of
effective coping skills) (Gitberg & van Wyk, 420). These are important to note because they give us (a)
a better understanding of the nature of Jamal’s trauma, and (b) more information to work with to
develop a more effective treatment plan.


3.      Indicate the appropriate type of treatment for concurrently disordered client
             such as Jamal, as per the Week 2 and 3 slides (1‐2 pages?)

Based on a dogmatic use of the Severity Model, the most appropriate type of treatment for
Jamal would be “Collaborative Care mainly in Mental Health System”. However, we feel he would
actually be best suited in a single‐setting program that offers Integrated Severe PTSD and
High‐Moderate Opiate Use care. We argue this because his opiate use is directly linked to the severity
of his symptoms, so it would be beneficial for him to tackle both at the same location. Moreover, as
mentioned in our assessment: Opiate use has been associated with major depressive disorder at a
rate of 49.3% (Regehr & Glancy, 179), so it would be great to have concurrently‐trained professionals
monitor him throughout his treatment to ensure that depressive symptoms do not develop or
worsen.

Elaboration:
The integrated program should help Jamal reduce (if not altogether eliminate) PTSD
symptoms with pharmacotherapy and specialized individual and group psychosocial therapy. Our
hope is that this would help him move through Herman’s (1992) three stages of trauma recovery
(safety/stabilization, remembrance/mourning, and reconnection/integration) (Gitberg & van Wyk,
423) . It should also, at the same time, help him wean off of Oxycontin and other opioids as his
primary means of managing symptoms, so that the pharmacotherapy and his newly‐acquired coping
and self‐soothing skills do the bulk of the symptom‐management work. Ideally, he would also be
weaned off of the pharmacotherapy after being ‘stabilized’, so that his coping and self‐soothing skills
alone become the main means through which he manages his symptoms. But this may not always be
possible for everyone.
Given the intense and negative withdrawal effects of Oxycontin and other opiates, this
Oxycontin/opiate weaning process will likely involve concurrent pharmacotherapy to help de‐intensify
(if not altogether eliminate) these negative withdrawal symptoms. Care should also be taken to
ensure that Jamal does not become physiologically or psychologically dependent on the
pharmaceuticals used to


treat his PTSD symptoms or his Oxycontin/opiate withdrawal symptoms (Gitberg & van Wyk, 422).

Group Therapy: Following Gitberg & van Wyk’s recommendations, the group therapy should
match the client’s stage of recovery (430). That is: When clients are addressing issues of safety and
stabilization, the work done in group should be “time‐limited, structured, and supportive” (Ibid.). As
clients become better able to manage their reactions and start becoming more prepared to directly
confront their traumatic experiences, group work that “focuses on the development of insight and
trust” is recommended (Ibid.).
Recovery Model, including Life (Coping/Self‐Regulation) Skills and Employment Counselling:
Aside from the coping skills mentioned above, we also feel that employment counselling should be
provided to help Jamal (a) re‐explore his personal and career goals; (b) to see if there are any
government and community programs that may help him toward his goals; and (c) to help him
develop resume‐writing, job‐searching, and interviewing skills to help him increase his likelihood of
finding more stable work. If French pronunciation is an employment barrier for him, then “speech
coaching” classes might also be an option, although we would much rather seen an end to language
discrimination in Quebec. This could be something we or another organization can pursue, if there
isn’t already another organization doing this work.
Collaborative Treatment Planning and Roll‐Out: Of course, this is the treatment program we
would like Jamal to undergo; however, Jamal may have certain hesitations or discomforts around
pursuing any one of these treatment options. Therefore, we will be in constant conversation with him,
as recommended by Gitberg & van Wyk (429), to determine what he is interested, willing, and
comfortable pursuing. Our outlook is that any change process will be a positive step forward, and that
the exploration of initial treatment options will hopefully open him up to exploring and pursuing other
previously‐recommend (or even unexplored) options, as his comfort, confidence, and skills improve.


4. Draw the Severity Model graph in detail on one entire page. Mark on the graph where
Jamal fits based on your assessment.


5.      When you meet with Jamal. how would you conduct the counselling session in a
            trauma‐informed way? What approaches would you take and why? What are some of
            the key elements of his experience that you would want to focus on? (2 Pages)

(1) Before the session even begins: We will ensure that we greet Jamal in a warm, friendly, kind, and
gentle way, and that we try to create a safe, comfortable, and inviting space for him. This will include:
being extremely conscious of grand or rapid gestures ––– and of personal space ––– especially the
extension of a handshake, which may not be culturally appropriate. We will also offer him some water
and allow him to chose where and how he would like to sit (provided that there are various seating
options in the office). The subliminal messaging behind all this is that we are being considerate of his
desires and needs, and that he has a certain amount of agency and choice within the agency.
(2) For the introductory portion of the meeting: We will provide Jamal with an overview of:

(a) what brought us together today (his drug charges);
(b) what our role is in his sentencing process (Not to judge him; to assess him; to
      recommend him for a treatment program; and to review his care and progress);
(c) what each stage of the process will entail;
(d) what he can expect at each stage of the process (especially PTSD and use relapses!); and
(e) what the mandated purpose of this initial meeting will be (assessment)

We will also include:

(f) a vague overview of what we already know about him (“your past in Afghanistan”,
     “your current life in Canada”, and “your charges”), plus
(g) a quick mention of our six working approaches:
(i) Caring, (ii) Empathetic, (iii) Non‐Pathologizing, (iv) Client‐Centred,
(v) Empowerment‐Based (supportive, motivational, strengths‐focused), and
(vi) Anti‐Oppressive (relational, situational, structural, and power‐conscious).

Aside from the obvious education and familiarization purposes of this introduction, we are providing
Jamal with all this detail in order to:
(a) minimize ‘surprises’ and any strong reactions these ‘surprises’ may cause;
(b) show that we  are transparent in our work;
(c) show that we have nothing to hide from him;
(d) show that we are a safe and trustworthy person to speak to; and
(e) show that we are committed to working with him ––– and on helping him heal and grow.

Of course, we will do all this in a way that is easy for Jamal to understand, and in a way that will not
overwhelm him. We will also try our best to thoroughly address his questions and concerns.


(3) For the assessment portion of the meeting: Following Gitberg & van Wyk’s recommendations
(423‐424), we will let Jamal know:
(a) that there will be an exploration of a wide range of issues, which will include among
        them past traumatic experiences and past and current substance use;
(b) that some of the questions may be uncomfortable or difficult to answer;
(c) that he can choose to not answer a question (by asking us to move to the next one);
(d) that he can choose how much information to disclose; and
(e) that he can request that an exploration or line of questioning end at any time.

We will discuss our roles and responsibilities around confidentiality and the duty to report. And we
would let Jamal know that it is alright to feel and express his emotions during the initial meeting, in
part because this may be the very first time he confides his problematic substance use and/or trauma
history to another person.
(4) Rather than jump straight into the formal assessment questions, we would start with a
casual conversation to get a sense of what Jamal feels about his summons to our agency, his charges,
and his relationship to OxyContin (the catalyst for his being at our office) via a question like “When did
your relationship with Oxycontin first start?”. Our hope is that this will lead into a discussion about his
symptoms and his use of Oxycontin to manage them and, with that, a discussion of when his
symptoms first appeared and why. Our hope is that this will in turn lead into a discussion of his
traumatic past (especially his parents’ assassination and the abuse he experienced at the hands of his
uncle). However, if he does not reveal any of this information –– or if he reveals only a selective
amount –– then we will know that he is not yet ready to tap into his traumatic experiences.
(5) At this point, Jamal may or may not have discussed his symptoms. It would be prudent to
go through a checklist of common PTSD symptoms (Gitberg & van Wyk, 425) and then ask him if he
has heard about Post‐Traumatic Stress (we would leave out “Disorder” since it may sound
pathologizing/stigmatizing and may close him off to the discussion). It is our hope that in hearing
about PTSD and its symptoms, he starts thinking about his own symptoms’ relationship to his
traumatic past (if he hasn’t already done so). Moreover, we will explain that there are particular
treatments available (including a pharmacotherapeutic component) to help people with PTSD manage


their symptoms and return to a less symptomatic (if not a symptom‐free!) life. Our hope is that he will
be open to this more formal assessment and treatment plan, given that one of his immediate goals is
to manage symptoms.
(6) Aside from trauma, symptoms, and opioid use, we would also ask him how other aspects
of his life are going and whether or not he would want support with any of them. We will include
these areas and possible solutions in our treatment plan, as they arise. Therefore, we will ask about:
(a) His family life, which would include asking him about: How life was like living with
       his parents; How he feels about what happened to them; and How life was like living
       with his uncle.

(b) Immigration and his life in Canada: Why/when he immigrated, how he is adjusting, and
       what his life‐goals are. This would include a discussion of his employment situation, his
       economic situation, and if he is at risk of losing access to necessities like food and housing.

(c) Community and Resources: His support circles, his access to healthcare, his access to
       ‘life‐giving’ activities, etc.; and

(d) Any other Mental Health or Substance Use Concerns: Especially the use of any other
      substances, depressive symptoms, and suicidality (for which the GAIN‐SS would be useful).

(e) Any other areas in need of support (according to Jamal): This would be our final question.

Resources Consulted

American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (5th Ed.). Washington,
DC: American Psychiatric Publishing.

Elliott, D.E., et al. (2005) 10 Principles of Being Trauma‐Informed [Adapted Handout]

Gitberg, M, & van Wyk, L. Trauma and Substance Use. In Alcohol & Drug Problems: A Practical Guide for Counsellors
(415‐432). In the SWRK 2053 Concurrent Disorders Reading Kit.

Harris & Fallot (2011) Principles and Philosophy of a Trauma‐Informed System [Adapted Handout]

Klinic Community Health Centre (2008) Trauma Informed Toolkit. [Guide]

Maisto, S.A. (2013) Drug Use and Abuse: First Canadian Edition. Toronto, ON: Nelson Education, Ltd.

Mead, S. & Copeland, M.E. (2000) What Recovery Means to Us: Consumers’ Perspectives. [Handout]

Health Canada (2002) Best Practices: Concurrent Mental Health and Substance Use Disorders. [Report]

Regehr, C, Glancy, G (2014) Mental Health Social Work Practice in Canada (2nd Ed.). Don Mills, ON:
Oxford University Press.

Spindel, P. (2008) Case Management from an Empowerment Perspective. Mississauga, ON: Nu‐Spin
Publications.


RUBRIC


Answer is written in clear sentences, word
processed, doublespaced, full names of group
members & sections listed, stapled, no
handwriting used, delivered on time with cover
page and rubric attached (professional
presentation)


/6_____

#1: Severity S. Abuse correctly identified

Detailed rationale for severity level given


/3_____

/6_____


#2: Severity of M Health issue correctly identified

Detailed rationale for severity level given

Correct Diagnosis Given

/3_____

/6_____

/3_____

#3: Correct choice of treatment given, using the
Model

/3_____

#4: Model clearly drawn as detailed graph, and
Jamal correctly placed on graph.

/4_____

#5: Concrete ideas given on how to work with
Jamal in a trauma informed way illustrated with
specific links to C Study

/6_____

Total:________/40__=_________


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