TRIADD
Teletraining Research and Information around Dual Diagnosis

 

TRIADD Case Studies

Case 1

A case of a mildly intellectually disabled man aged 33 years who was verbally and physically very violent and who had been in a psychiatric unit after leaving school and was considered so uncontrollable that he was unable to be cared for in the community. His family background and history are reported and a brief overview of the therapy process. The diagnosis was, according to ICD 10 (see key words under ICD DSM) mild cognitive disorder, dissocial personality disorder and personality disorder of the impulsive type.

Gerald

The first case is that of a young man aged 33 who has now lived in large village community for 14 years. I shall call him Gerald.

Part one: Background

Gerald is a mildly intellectually disabled man whose family background is not typical. He is the youngest child in a complex family structure with many brothers, sisters and half- brothers and sisters. He lived in a home environment full of violence and abuse. Many family members were involved in criminal activities. Alcohol abuse was prolific. Gerald attended a special school but was often violent and needed to be sedated. One of his positive achievements in school was that he learned to play the drums – for which he has great talent and this became important later. Not only was he aggressive at school but also at home. The crisis came when he almost killed his alcoholic father. The family were forced to take refuge and barricaded themselves in a room in the house. The police were summoned and Gerald was taken to the state psychiatric hospital where he was heavily sedated, restrained and placed in a closed ward. He remained there for 6 months. Due to the unusual and intense involvement of a social worker a discussion took place as to whether it would be possible to live in the institution. He was given a place but there was an initial time limit set of one year.

Part two: treatment

He came to a community setting diagnosed variously as mild cognitive disorder (ICD 06.7), dissocial personality disorder (ICD F60.2) or emotionally unstable personality disorder of the impulsive type (ICD 60.3). See key words here for an explanation of ICD descriptions.

I was not the first psychologist to work with Gerald, but when his previous psychologist left our foundation, he himself expressed a wish that I replace him. After a life of violence, extremely disturbed personal relationships with his mother, father and brothers and sisters, and many disappointments, the loss of his psychologist was just another serious blow. During the transition period, when he knew my colleague was about to leave, he would arrive in the department and smash the furniture and hurl the pictures hanging on the wall against the walls. These outbursts were accompanied with violent and abusive language. Similar scenes took place in his group home. He terrorised the other residents. It was unlikely he could remain in the village.

Part three: the beginning of the new therapy

My predecessor had attempted to undertake therapy with Gerald giving him the opportunity to talk through his problems and trying to find, mutually, some solutions. He also undertook activities with Gerald such as playing ‘kick football’ and visiting his mother’s grave. Gerald had responded positively to the therapy, but sometimes he did not turn up, or did so at the wrong time and then leaving behind him a trail of destruction.

My first objective was to offer him, through a relationship with me a „feeling of safety“ (Sandler and Joffe 1968). The question was how to achieve this first and critical stage. It was clear he did not want to sit with me for the designated hour. I believe, as do other clinicians that we must learn to work in unusual settings with such extreme people. So I asked what he would like to do in the session. After a few unsuccessful attempts doing something together (play kicker, make coffee, go for a stroll) he suggested we take a car ride around the neighbouring villages. While I was hesitant about this proposal I took it seriously, and booked the staff car.

For the past eight years we have driven around the villages and towns once a week for an hour. At first we did not say very much. Often he would sit beside me and sometimes suck his thumb. When I asked him how he was or what he had done in the last week, he would often reply with a loud and aggressive voice and say 'don’t disturb me – you get on my nerves'. I interpreted this as an effort to avoid building up a relationship with me; he was afraid of trusting me, afraid of experiencing yet another disappointment. I do not believe that he saw me as a good object during this phase of the therapy. For him reality was that everyone was his enemy and all were to be disdained. He was unable to believe I could help him with his violent outbreaks. When from time to time he acted as if he would strike me I tried to show him through my facial expression that not only that I was not afraid of him but also that I accepted that he was at these moments out of control. In spite of many violent experiences in the village at this time, he never once went further than to try to make me afraid. Somehow with me he was learning that aggression was not having an effect.

Part four: the treatment continues

Gradually, after four or five years, he would come to me more often and explain some situation to me. He frequently had genuine complaints but had reacted inappropriately. He was beginning to be more realistic (reality testing) although his frustration tolerance and anticipation skills were still weak. Soon both he and I were able to confront the staff or resident together with the problematic situation and talk it through. At the beginning he would come with me to a meeting then leave immediately with a loud abusive comment. But now he is able deal with interpersonal problems alone.

One important theme in Gerald’s life in the community concerned living in a group home. There, the re-enactment of living in his own family was simply too stressful for him. The care workers through the transfer processes were often in the role of the harsh parent; the other residents in the role of his brothers and sisters. The slightest word or action would trigger off his violent reaction.

One day in the role of a 'hilf ich' – an ego helper, we wrote a letter together to the director of the Foundation requesting that he be allocated an independent apartment in the village. After more than a year (frustration tolerance, anticipation), one became vacant and he has lived there now, trouble free and independently for over two years. He also has a permanent job in the sheltered workshop.

Part five: conclusion

We are currently working on the future – especially when I retire. He has informed me that he will not require a psychologist when I have retired but would like me to visit him from time to time. Most interestingly, he has formed his own 'volksmusik band' and plays regularly in the village and in community at large. Last year we visited his previous special school where there were many teachers who remembered him (as a matter of interest he was at this time allowed to visit only when accompanied by me – now he can visit whenever he wishes). The visit was so successful that it resulted in an invitation for him and his band to play at the end of year school festival. This he did with pride. Not only had Gerald learned to control his violent impulses, but he had genuinely learned to gain pleasure from pleasing others.

Comment:
An example of good team work over a ten year period with a very difficult and challenging young man with very positive results.

Some questions for your reflection:

1. How do you feel about the childhood of Gerald?
2. What do you think the effect of living in such a violent world had on him?
3. How do you feel about the loss of his first psychologist?
4. Would you consider removing Gerald from the village?
5. What form of therapy is being offered to Gerald as part of his treatment?
6. What has the team achieved here?

Some possible responses to the above questions:

1. Gerald’s childhood was especially violent and he seemed to be deprived of a normal loving relationship with his mother and father. His ‘object relations’ – that is, his relationship with his mother especially, were probably very disturbed from early infancy. Very disturbed relationships in early childhood may have a long lasting effect upon how an individual forms relationships in later life.

2. When someone lives in a world of violence it is often the case that they themselves become violent. In Gerald’s case not only was he abused violently but also he was able to see his brothers and sisters be abused and also abuse (see later in the case). It is no wonder that he had learned to abuse too.

3. Yet another disappointment. He had developed a relationship with someone and as is often the case, also with front line staff, they do not remain. A disappointment often results in a strong reaction, so it was no surprise that he reacted more violently.

4. As with many very difficult cases there is always a question of removal to another service. This was certainly discussed at the time and also later. Of course there is a point when nothing more is possible in a service and an alternative must be found. When that point is reached is often difficult to establish. In this case all parties agreed to work with him further and the new psychologist was accepted into the team.

5. The psychologist was following a form of psychodynamic therapy (see key words). This is based on forming a relationship with the person so that he or she feels able to communicate with the therapist. When Gerald had a problem he found it possible to talk to me about it. He would often not come at the appointment time. Sometimes he would ask me to accompany him to his workshop or residential group where he would attempt to explain some problem or event to the relevant staff. I was working on the assumption that with help and support Gerald could eventually solve his own problems. I always worked at the emotional level - asking Gerald how he felt about situations and how he could have dealt with them positively rather than with an outburst of aggression. Eventually these positive approaches would hopefully transfer to others (e.g. other residents, frontline staff, staff and co-workers in the workshop).

6. The team – all concerned with Gerald – had achieved a good understanding of Gerald’s history, an understanding of his negative and challenging behaviour (see key words) and had helped him to control his emotions better and form a realistic plan for the future. Staff in the residence, the workshop, the administration (to the level of director) and the psychologists had all played their various roles.

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December 2003