Case Study for Jon Doe

Summary and Critical Factors

Jon Doe is a 29-year old male with suicidal ideations. The patient is also diagnosed with high

functioning autism. He has been admitted to St. Mark’s Behavioral Health Unit (SMBHU). He was

recently discharged from a prior SMBHU one-week admission. The patient’s last admission was also due

to suicidal ideations and during that time patient expressed his desire to learn skills to effectively

manage in his high level of anxiety. With his return, he expressed that in a moment of distress he was

not able to utilize coping skills learned and that he acted on instinct. Jon Doe is married and currently

lives with his wife. Patient has a high level of family and friend support. Critical factors for recreational

therapy and the rest of the treatment team to consider are his suicidality, his symptoms related to his

high functioning autism including rigidity in thought, increased anxiety and depression, and his desired

leisure interests.

As previously mentioned, Jon Doe is diagnosed with high functioning, which he was diagnosed

with within the last few years. He is open about how his diagnosis effects his life. He is able to function

independently and complete all his ADL’s and IADL’s. He was able to function in school, maintains

employment, and ultimately obtains a high level of independence. However, he experiences cognitive

effects such as rigidity of thought from his ASD. He prefers structure and struggles with change. He

experiences black-and-white thinking and struggles with problem solving. For this reason, coping with

life stressors and inherit changes is difficult and contributes to his feelings of anxiety and depression.

This is important for the treatment team to consider. Jon Doe would benefit from programming that

educates and encourages him use skills to combat thinking errors, teach distress tolerance, and flexible

thinking.

From a recreational therapy perspective, his expressed needs in addition to his leisure interests

are important to keep in mind while planning interventions. He expresses interest in learning more

coping skills to be accepting and mindful so that he can more appropriately respond to stress. He also

expresses interest in video and board games. When planning groups, incorporating his preferred leisure

can act as fulfilling and meaningful for the patient. These critical factors can help the treatment to

provide programming that helps the patient meet his goals and feel safe to return to everyday life.

Assessments

At St. Mark’s Hospital we utilize an interview assessment to gather pertinent information from clients

about themselves, their interests, and their goals. Here is Jon Doe’s assessment entered into EPIC

documentation program.

Activities Assessment

Reason for admission SI, depressed mood "I had a suicide threat. It had to do with my relationship."

Able to assess YesDegree of alertness/orientation A&OX4

Communication problems NonePatient mobility AmbulatoryPatient prefers to be calledLeisure activitiesWhat are your current preferred leisure activities

Electronic games; Board Games; Watching TV/Movies; Music; Walking outside; Art

Hobbies/Interests/Leisure Video games - preferred

How do you cope with stress

"Breathing. I try to be accepting of things. I need to work on my mindfulness. Because in the moment there was no mindfulness - there was only impulsivity and instinct. I didn't use those skills that I had been taught."

Describe any social groups/community organizations to which you belong

none

StrengthsPt has leisure interests and has the skills and abilities to engage in desired leisure. Pt has social support and has a stable living situation, income, job, and transportation.

BarriersDescribe barriers for recreational activities

SI, high functioning autism with rigid thinking. Pt is experiencing marital discord.

ActivitiesWhat do you want to accomplish during your hospitalization

"I want to focus on addressing my sadness and depression. Last time I focused too much on my anxiety. I need to focus on myself. To focus on getting healthy and staying healthy so this doesn't happen again."

GoalsGoals Gain coping skills

Plan/Summary

Pt will engage in positive self-talk daily in recreation therapy interventions as a means to improve mood as observed by the TRS/CTRS. Pt will identify and utilize a minimum of two coping skills during recreation therapy interventions to manage stress as observed by the TRS/CTRS.

Diagnostic Protocol

1. Diagnostic Grouping: Neurodevelopmental Disorder Neurodevelopmental disorders are impairments of the growth and development of the brain or

central nervous system. A narrower use of the term refers to a disorder of brain function that affects emotion, learning ability, self-control and memory and that unfolds as an individual develops and grows.

2. Specific Diagnosis: High Functioning Autism (HFA) High functioning is on the autism spectrum. It is a term applied to people with autism who are

deemed to be cognitively "higher functioning" (with an IQ of 70 or greater) than other people with autism. Symptoms of HFA include

o repetitive routines or rituals,o peculiarities in speech and language, such as speaking in an overly formal manner or in a

monotone or taking figures of speech literallyo socially and emotionally inappropriate behavior and the inability to interact successfully

with peerso problems with non-verbal communication, including the restricted use of gestures

limited or inappropriate facial expressions or a peculiar, stiff gazeo clumsiness and uncoordinated motor movements

3. Identified Problems (symptoms or issues relevant to RT):

Pt needs level 1 support: Deficits in social communication cause noticeable impairments in initiating and maintaining social interactions. The inflexible behaviors interfere with functioning in one or more situations.

Restricted, repetitive patterns of behavior, interest, or activities with presence or insistence on sameness, inflexible adherence to routines or patterns of behavior.

Lack of eye contact

4. Related Factors/Etiologies:

Anxiety Depression Cognitive impairment Self-injurious behaviors

5. Process Criteria (Interventions):

Functional skills and education Community integration Social skills training Effective coping skills Flexible thinking Distress tolerance

6. Outcome Criteria:

Pt will engage in positive self-talk as a means to improved mood. Pt will identify and utilize coping skills as a means to reduce anxiety and depression. Pt will initiate at least one positive interaction with peers. Pt will engage in flexible thinking.

Intervention Protocol - Jenga For Resilience

Group Size: 2-10

Supplies:

Jenga Hand sanitizer Resilience handout (provided below)

Setting Considerations: This intervention will need to take place in a room that has table and chairs. This room must also have adequate space for individuals to ambulate in a clear path. This room preferably should have little foot traffic and noise. Have a table set up with no chair in a central location. It should be free of sharp objects that could be used to intentionally harm oneself or others.

Risk Management Considerations:

Sharp objects such as pencils and pens are to be kept in a place monitored by staff. Therapist must keep track of how many of these items are being given to clients and make sure that same number of items are returned after group and then cleaned.

Therapist should have an awareness of the medications that the clients are taking and possible side effects. Client should have a working knowledge of how to address possible side effects and what procedures to follow.

Therapist should have a working knowledge of client diagnoses and possible behavioral symptoms. The therapist should be trained to appropriately address these problems.

Intervention Purpose: Jenga can have many purposes. For this intervention, it can be used as an opportunity for the participants to practice awareness of self and the environment, practice flexible thinking skills, and practice distress tolerance/perseverance. Self-awareness is a crucial step towards self-care. These things in addition to flexible thinking and perseverance are elements that contribute to a person’s ability to be resilient. In addition to focusing on resilience, this intervention utilizes concepts from the ACT Mindfulness model.

Intervention Outcomes:

Client will identify and utilize productive coping skills. Client will utilize effective communication skills. Client will demonstrate the ability to utilize stress management techniques. Client will demonstrate flexible thinking through a leisure initiative.

Implementation Instructions:

Prepare room with tables and chairs. The tables do not need to be placed together. However, there should be a central table clear of chairs to place the jenga set on. There should be clear paths for group participants to ambulate.

After group participants have gathered in the room, introduce Jenga and its rules while setting it up.

Engage in one round of game play.

Processo What were your observations? What were you aware of? o Did you feel like you were being aware or was it a mindless activity?o What are the benefits and disadvantages of mindless activities?

Benefits: distraction, short term relief Disadvantages: lack of long term benefits, does not result in behavior change

o Introduce model from ACT mindfulnesso Did you have to utilize any flexible thinking through this game? Did you have to make

any adjustments to plans that you had made? Do you have to do that in real life? Was it beneficial? Is it always?

Engage group participants in a second round of Jenga, this time asking them to be more aware of themselves and the environment as well as with the intention to think flexibly and see if they come out of the second round feeling any differently.

o Notice any differences?o Any more observations of feelings and environment?o Did going into the second round setting an intention to be more self-aware make any

difference in your game play? How does that apply to real life? o Did setting an intention to be flexible during the game make a difference in your game

play? How so? o Did you make any observations of the Jenga set itself? Notice how it was about to tip

over and fall, but then it ended up straightening itself out in the end? The Jenga set itself is able to bounce back!

Tie all of this in, all of these skills discussed to the concept of resilience! What is resilience? Teach using handout. (provided below)

Program Evaluation:

Gathering of formative information at specified intervals:o Observation of client’s progress towards the accomplishment of individual treatment

goalso Conduct patient satisfaction surveys/group feedback forms after each group

intervention

Staff License/Certifications/Training:

Recreational therapist is required have a Utah State license as a TRS or MTRS and hold NCTRS certification as a CTRS.

CPR/First Aid Certification CPI – behavior management

M. Burgess (RT Student)

7/12/2018

References/Sources:

Adapted from Information given by Jeremiah Cox at 2018 URTA Conference.

Bonanno, G. A., Westphal, M., & Mancini, A. D. (2011). Resilience to loss and potential trauma. Annual

Review of Clinical Psychology,7, 511-535

Green, R. R., PhD, Galambos, C., DSW, & Lee, Y., DSW. (2004). Resilience theory. Journal of Human

Behavior in the Social Environment,8(4), 75-91. doi:10.1300/J137v08n04_05

Roberts, A. C., Galassi, J. P., Mcdonald, K., & Sachs, S. (2002). Reconceptualizing Substance Abuse

Treatment in Therapeutic Communities: Resiliency Theory and the Role of Social Work

Practitioners. Journal of Social Work Practice in the Addictions,2(2), 53-68.

doi:10.1300/j160v02n02_06

Zimmerman, M. A., PhD. (2013). Resilience theory: A strengths-based approach to research and practice

for adolescent health. Health Education and Behavior,40(4), 381-383.

doi:10.1177/1090198113493782

Resilience can be defined as “the capacity to spring back, rebound, successfully adapt in the face of adversity and develop social, academic, and vocational competence despite exposure to severe stress or simply to the stress inherent in today’s world” (Henderson and Milstein, 1996, p. 7). It includes the capacity to bounce back, to withstand hardship, and to repair yourself (Wolins and Wolins, 1993, p. 5). It can also be defined as “the ability to tolerate, to adapt to, or to overcome life crisis” (Beauvais, and Oetting, 1999, p. 103).

Protective factors are conditions or attributes that mitigate or eliminate risk and increase health and well-being.

Risk factors are conditions or attributes that increase the likelihood of developing disease or injury.

Evaluating and Documenting Services

Individualized Group Note:

Group Therapy

Group Type Activity;Leisure;Skills(ACT Mindfulness and Elements of Resilience)

Start time 1400End Time 1500Level of Participation Active

Participation QualityAttentive;Sharing(offered insightful comments about mindfulness and the differences between reacting vs responding. Focused on group task.)

Affect/Mood/Behavior

Anxious(engaged, interested, appropriate. Stated that setting the intention to be more mindful and practicing acceptance helped him deal with his anxiety during group task.)

Cognitive Alert;Oriented

Intervention mode

Exploration;ReflectiveEngaged group in a round of Jenga. Group participants shared their personal observations. Related these observations to the ACT model of mindfulness, focusing on the concept of reacting vs responding, educated about the meaning and usefulness of both. Engaged in a second round of Jenga, encouraging group participants to use this concept and be mindful of self and the environment. Processed personal observations and insights gained and related to mindfulness in addition to flexible thinking. Incorporated the concept of resilience and how these concepts applied to their ability to be resilient in everyday life. Gave out "Resilience" Handout.

Progress toward problem/goal Continue

Continue group therapy per plan of care Yes

Client Feedback Form: