PS531 Unit 5 Psychosis and Cannabis Case Study Example

Joints Before the Voices Get Loud: A PS531 Unit 5 Case Study of a Young Man With Schizophrenia and Daily Cannabis Use

[Student Name]

Purdue University Global

PS531: Co-Occurring Disorders and Treatments

Unit 5 Psychosis and Substance Use Case Study

[Instructor Name]

[Date]

The client, his family, the agency and every detail of the case are composite and illustrative; the sources cited are real.

The Client

Kyle is 22 and lives with his mother in a small house near the harbor. He was diagnosed with schizophrenia at 19 after a year of withdrawing from friends, hearing a voice that criticized him and believing that messages in radio songs were meant for him. He takes an antipsychotic by injection every month, which his mother credits with getting him back. He has smoked cannabis daily since he was sixteen, now about three joints each afternoon. He says cannabis "keeps the voices from getting loud by evening." He was hospitalized twice last year, both times after periods of heavier use and missed injections.

Kyle puts in ten hours a week facing cans and restocking dairy coolers at a supermarket on Lincoln Road, a job his mother found for him through a church friend who manages the night crew. He wants a full-time job, his own apartment and a girlfriend. He does not want to stop smoking.

Diagnoses

Kyle meets criteria for schizophrenia and for a cannabis use disorder of moderate severity: he uses more than intended, has tried and failed to cut back, spends much of his money on it, has continued despite two hospitalizations his treatment team linked to use and shows tolerance. His sense that cannabis quiets the voices is common among people with psychosis, but research and his own history suggest heavy use is linked to worse symptoms and more relapses.

The Integrated Model

Drake et al. (2001) describe integrated dual diagnosis services for people with severe mental illness as care in which one team treats both disorders together. Key features include stage-wise treatment matched to readiness, assertive outreach, motivational interventions, skills-based counseling, social supports and a long-term perspective, since change usually unfolds over months or years. SAMHSA's protocol endorses the same approach and emphasizes engagement, motivational work and persistence (Substance Abuse and Mental Health Services Administration, 2020).

Stage-wise treatment matters most for Kyle. He is not ready to stop. Pushing abstinence now would likely end his engagement with the team. The model's early stages, engagement and persuasion, aim to build trust and help the client connect substance use to his own goals.

Kyle will not quit cannabis to please his mother or his team, but he might cut back to keep a job and an apartment.

What the Evidence Shows

Hunt et al. (2019) reviewed 41 randomized trials, with 4,024 participants, comparing psychosocial interventions for substance misuse with standard care in people with severe mental illness. They found no high-quality evidence that any one psychosocial approach, including integrated models, motivational interviewing, cognitive behavioral therapy and contingency management, was clearly superior to standard care for substance use, mental state or other important outcomes. Much of the evidence was of low quality.

This finding does not mean integrated care is useless. Standard care in many trials already included substantial support, outcomes varied widely and studies were often small. It does mean clinicians should hold their expectations modestly and track whether the plan helps this person.

The Plan

Engagement comes first. I will meet Kyle at the grocery store break room, the harbor or his home rather than requiring office visits, following the outreach principle. We will talk about what he wants, a job, an apartment and a relationship, before talking about cannabis.

Motivational work comes next. Using open questions, I will ask Kyle what an afternoon joint gives him and what it takes away, including money he could put toward an apartment and the two hospitalizations that cost him his last job. A goal he might accept is no cannabis on days before his monthly injection appointment and a limit of one joint a day.

Supported employment, an approach with a strong record for people with serious mental illness, will connect Kyle with the agency's employment specialist, since work is his strongest motivation and gives structure to his afternoons.

Family work will help his mother. She will be invited to sessions on psychosis and substance use, and to learn how to respond to cannabis use without arguments that end in Kyle leaving the house.

Medication monitoring continues: the team's prescriber will track symptoms monthly, and I will remind Kyle of injection dates.

Responding to Setbacks

Integrated care expects setbacks, and Kyle's plan names them in advance. If he misses an injection, the team's nurse will call the same day and offer a home visit. If his cannabis use rises above three joints a day for two weeks, or if he reports the radio speaking to him again, the team will meet within forty-eight hours to review medication, outreach and supports. If he is hospitalized, I will visit him on the unit, and the team will plan his discharge with him and his mother before he leaves, so he does not return to the same afternoon routine without changes.

Kyle's Own Words

When I asked Kyle what would make the plan worth following, he said he wanted to stop being "the guy who always ends up back in the hospital." That sentence is now written at the top of his plan. It gives the team a goal in his language and gives Kyle a reason to track his use that has nothing to do with pleasing anyone. Drake and colleagues stress that people with severe mental illness move toward recovery when treatment connects to their own aims, and Kyle's aims, a job, an apartment and staying out of the hospital, are the measures that matter most.

Measures

Every month, the team will track Kyle's self-reported days of use, urine screens he agrees to, psychiatric symptoms, work hours and hospital days. The stage of treatment will be reviewed every three months.

Limits

Hunt and colleagues' review shows how uncertain the evidence is for any specific psychosocial approach. Kyle's progress may be slow, and setbacks are expected in integrated care.

Conclusion

Kyle's schizophrenia and cannabis use feed each other, and he is not ready to stop. Drake and colleagues' integrated model, endorsed by SAMHSA's protocol, offers a way to engage him through his own goals, step by step. Hunt and colleagues' review is a reminder to measure whether the plan works for Kyle rather than assume it will.

References

Drake, R. E., Essock, S. M., Shaner, A., Carey, K. B., Minkoff, K., Kola, L., Lynde, D., Osher, F. C., Clark, R. E., & Rickards, L. (2001). Implementing dual diagnosis services for clients with severe mental illness. Psychiatric Services, 52(4), 469-476. https://doi.org/10.1176/appi.ps.52.4.469

Hunt, G. E., Siegfried, N., Morley, K., Brooke-Sumner, C., & Cleary, M. (2019). Psychosocial interventions for people with both severe mental illness and substance misuse. Cochrane Database of Systematic Reviews, 2019(12), Article CD001088. https://doi.org/10.1002/14651858.CD001088.pub4

Substance Abuse and Mental Health Services Administration. (2020). Substance use disorder treatment for persons with co-occurring disorders (Treatment Improvement Protocol Series, No. 42; SAMHSA Publication No. PEP20-02-01-004).