PS440 Unit 10 Integrative Case Conceptualization Example

Eleven Arrests and One Case Manager: A PS440 Unit 10 Integrative Case Conceptualization

[Student Name]

Purdue University Global

PS440: Psychopathology

Unit 10 Integrative Case Conceptualization

[Instructor Name]

[Date]

The guest, her family, the crisis center and its partners are composite; the studies and manual cited are real.

Identifying Information and Presenting Problem

Darla is a 48-year-old white woman who grew up on a ranch in western South Dakota and has lived in Rapid City for most of her adult life. She has had schizophrenia since she was 24. Over the past six years she has slept outside or in shelters for long stretches, and the arrests, eleven of them for offenses tied to having nowhere to go, have added up to about fourteen months behind bars. The center has known her since an officer chose a crisis bed over a jail cell for her last spring. She has since returned four times.

At her most recent stay, Darla heard voices telling her that the shelter staff were poisoning the food, had not eaten in two days and had been sleeping in a stairwell in January. She was frightened, angry and suspicious of staff, but she accepted food and a bed. Her presenting problem, in her own words, was that she needed somewhere safe to sleep.

Diagnosis

Darla meets DSM-5-TR criteria for schizophrenia, multiple episodes, currently in acute episode (American Psychiatric Association, 2022). She has persistent persecutory delusions and auditory hallucinations, along with negative symptoms, including flat affect and low motivation, that persist between acute episodes. Her course has lasted more than two decades. She also uses alcohol when she can get it, which the counselor noted as an alcohol use disorder, mild.

Predisposing Factors

Biologically, Darla's paternal grandmother spent years in a state hospital, which suggests a family vulnerability. Howes and Kapur (2009) proposed that many such risk factors converge on dysregulated dopamine in the striatum, which gives ordinary events false significance; Darla's belief that staff are poisoning her food fits that account of how delusions form. Psychologically, she describes a childhood in which her father's moods were unpredictable and sometimes violent, which may have contributed to a lasting expectation that others intend harm. Socially, the isolation of ranch life meant that her early symptoms in her twenties went untreated for more than a year.

Precipitating Factors

The current cycle of homelessness began six years ago, when her mother, with whom she lived, died. Darla could not manage the rent alone, lost the apartment and entered the shelter system. Her first arrest followed within months. Her most recent crisis followed another precipitant: she was released from jail in December without the long-acting injectable medication she had been receiving, because the prescription had not been transferred.

Almost every one of Darla's crises began with the loss of something that had been holding her steady: her mother, her housing or her medication.

Perpetuating Factors

Several factors keep the cycle going. Biologically, interruptions in medication allow symptoms to return, and each return brings behavior that leads to arrest. Psychologically, her suspicion of institutions makes her reluctant to accept help and leads her to leave programs early, a reasonable response given her experiences that nonetheless closes doors. Socially, each jail stay has suspended her disability benefits and cost her a place on the housing waiting list, and stigma has led shelters to bar her after incidents. Her alcohol use, which she says helps her sleep outdoors, worsens her symptoms and her contact with police.

Culturally, Darla holds the self-reliant values of the ranch community she grew up in. She describes accepting help as weakness, and she is most willing to engage when she can frame it as her own choice.

Protective Factors

Darla has real strengths. Her sister, who lives in Sturgis, has stayed in contact and keeps her belongings. She attends a Lutheran church downtown when she can, and the pastor knows her by name. She draws remarkably well and has sold a few sketches. Most importantly, she trusts one person in the system: a case manager at the county mental health center who has known her for three years and visits her wherever she is staying.

Integrating the Levels

Each level of explanation leads to a different part of treatment. The biological level points to consistent medication, which means a long-acting injectable that does not depend on daily pills and a system that keeps it going through jail stays. The psychological level points to a trusting relationship, built through the case manager, and to approaches that respect her preference for choice. The social level points to housing and benefits, without which no other treatment can hold. The cultural level points to framing help as her own decision, consistent with her values.

Treatment Plan

The evidence supports two core interventions. Coldwell and Bender (2007) pooled trials that offered assertive community treatment to people who were both homeless and seriously mentally ill. Compared with standard case management, assertive community treatment, a team-based model that provides services in the community around the clock, produced greater reductions in homelessness and greater improvement in psychiatric symptoms. Tsemberis et al. (2004) tested Housing First, which places homeless people with serious mental illness directly into permanent housing without requiring treatment or sobriety first. Compared with a treatment-first approach, participants in Housing First obtained housing sooner and remained stably housed longer, without worse outcomes for substance use or symptoms.

Darla's plan combines these approaches. First, referral to the region's assertive community treatment team, with her trusted case manager introducing the team and staying involved during the transition. Second, an application for a Housing First apartment, framed as a choice she controls, with no requirement that she stop drinking first. Third, a long-acting injectable antipsychotic, with a written agreement among the jail, the crisis center and the community team to continue it during any future jail stay. Fourth, an application to restore her disability benefits, which the case manager will complete with her. Fifth, contact with her sister and her pastor, with Darla's permission, as part of her support network. Finally, an offer of art supplies and a place to draw at the drop-in center, building on a strength she values.

Conclusion

Darla's schizophrenia explains her symptoms, but it does not explain her eleven arrests. A conceptualization that moves across biological, psychological, social and cultural levels shows how each crisis began with the loss of a stabilizing support and was prolonged by medication gaps, distrust, lost benefits and stigma. Assertive community treatment and Housing First address those levels together, and her trust in one case manager is the thread that may hold the plan together.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Coldwell, C. M., & Bender, W. S. (2007). The effectiveness of assertive community treatment for homeless populations with severe mental illness: A meta-analysis. American Journal of Psychiatry, 164(3), 393-399. https://doi.org/10.1176/ajp.2007.164.3.393

Howes, O. D., & Kapur, S. (2009). The dopamine hypothesis of schizophrenia: Version III, the final common pathway. Schizophrenia Bulletin, 35(3), 549-562. https://doi.org/10.1093/schbul/sbp006

Tsemberis, S., Gulcur, L., & Nakae, M. (2004). Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. American Journal of Public Health, 94(4), 651-656. https://doi.org/10.2105/AJPH.94.4.651