Case Study Review

Schizophrenia
Andrea Reeder

Describe Client:
The patient, Ms. L is a 36 year old, white, single, and female of Eastern European origin. Patient is fluent in
English as well as Ukrainian. She has one sister who is older. The patients mental illness history is told by her
mother because there has only been a very brief hospitalization before the patients admission to the unit. Ms. L
was a shy child and was withdrawn from others, Ms. L was described as shy and had few friends butt was very
close with her family. At age 16 the patient learned about bacteria and formed a fear of bacteria and began
cleaning and sanitizing rituals. Ms. L was then not able to attend school anymore because of her routines, she
would go to the family physician weekly and the doctor would give her shot and vitamins saying that it will
pass. By age 17 the patient was sent to a psychiatrist and was diagnosed with compulsive behavior disorder
and was put on antipsychotic medication. She continued her rituals and eventually refused going to the doctor
but was still on medication, she isolated herself and refused to go outside. Ms. L was admitted to a psychiatric
hospital, after the patients father had died, and it began to be too hard for her mother to take care of Ms. L.

Describe Diagnoses:
The patient is diagnosed with Schizophrenia, and compulsive behavior disorder. Ms. L was diagnosed with
compulsive behavior disorder or Obsessive Compulsive Disorder (OCD) when she learned of bacteria when she
was 16 and began her compulsions. She was diagnosed with Schizophrenia after her family and Ms. L had
moved into a new apartment and had been seeing people in her bedroom and on her pillows and said she doesnt
recognize her family. The Psychiatrist diagnosed Ms. L with Schizophrenia at the point when she would
occasionally say she was going to commit suicide and had a plan. She was on and off antipsychotic medication.

Schizophrenia:
In the DSM V two or more of the following must be present for at least 1 month. One of the symptoms must
have a clear presence of delusions.
Hallucinations
Disorganized speech
Cationic behavior or gross motor is disorganized
Negative symptoms
Ms. L met the criteria of having schizophrenic symptoms and was prescribed a low dose of antipsychotic
medications. The diagnoses was made after the family had moved and Ms. L started seeing faces and people
in her bedroom and had said she was going to commit suicide.
Obsessive Compulsive Disorder, (OCD):
OCD is a series of obsessions and compulsions with repetitive thoughts, images, or urges.
The compulsions must last at least 1 hour per day or to cause substantial distress or impairment
The obsessive-compulsive symptoms are not to be caused by any side effects from substances such as;
drug use and medication.
Ms. L was diagnosed with OCD when she was 17 years old, she was having compulsions of washing and
sanitizing her hands with water and soap and couldnt stop and would obsessively wash her hands for 4 to 5
hours at times.

Behaviors:
The patient has little social and leisure functioning, the patient has been isolated in her room for about 17 years.
Community reintegration would be a crucial aspect of her Recreation Therapy treatment. Malnutrition, refusal
to eat or talk, she would spit constantly for fear of bacteria entering the body. When she was 17 she wouldnt
open her mouth to talk because she didnt want bacteria to enter. The psychiatrist had her write down her
questions and answers in their sessions.
 Family relationships had been strained over the course of Ms. Ls mental illness. The patient would not
converse or acknowledge her mother when she would visit, but would accept gifts and snacks from her mother.
Ms. Ls mother was integrated into family leisure education to regain a relationship with Ms. L with the help of
staff at the hospital.

Interprofessional Information
Ms. L first went to a family physician who prescribed her valium when she was 16 for the anxiety of bacteria;
the physician then referred Ms. L to a psychiatrist who she met with once to 2 times a week. The psychiatrist
diagnosed Ms. L with Compulsive Behavior Disorder for her compulsive washing of her hands, and for fear of
bacteria. The psychiatrist prescribed Ms. L Haldol and Thorazine. The medication was being taken regularly;
MS. L would still continue to wash and to spit while on the medication. Ms. started hallucinating at her new
apartment and showed symptoms of Schizophrenia (talking to herself, arguing with herself, laughing and then
crying.)
Ms. Ls mother had been taking her to the doctor but Ms. L started refusing and also ended up not going to
school and refusing to go outside. Patient was admitted to a private psychiatric hospital and remained bed bound
and was very withdrawn, the doctors prescribed her low doses of Prolixin and Cogentin (neuroleptics) and
became less withdrawn and started speaking, and Ms. L was admitted to a teaching and research hospital where
she would participate in Biological, neurological, occupational and recreation therapy, and family treatment.

RT Process:
Assessment:
There was a Record Review, and an initial interview upon admission.
Plan:
The TRS showed that she had an objective and 2 goals for Ms. L.
The RT objectives were:
Restore social and leisure functioning, and increase social skills.
The goal was:
To attend one RT group per day with prompts.
There werent very specific objectives and goals for the patient in the case study.
Implementation:
Ms. L had RT groups where at first she would just observe the groups and then slowly integrated into the groups
by:
Cleaning tables at the facility with supervision
Would do cooking tasks with prompts
Attended local restaurants
Museum trip with small groups of patients or 1:1 with staff.
Family Leisure Education.
Evaluation:
There wasnt much mention of what evaluation was used, but the TRS did use Summative evaluation and
Formative evaluation. The Formative evaluation was shown in the case study by what the client had done in the
groups for example, she showed she could independently pay for her things when out of the facility on an
outing.

Student Evaluation:
Assessment:
There was an interview and what seemed like a really detailed record review from the mother and the previous
hospitalization, and observation in her participation patterns.
Plan:
The goals and objectives were clearly established for the patient and were set from the assessed needs. From the
information the mother had given the staff the patient had a very withdrawn, isolated life. Clearly, the patient
needed some leisure education and social development by going to RT groups every day, and then eventually
going on group outings or 1:1 outings with a staff member. 6 months into the treatment a psychiatrist was called
in to consult on Ms. Ls case and the doctor had wanted to focus on re-establishing a relationship with her
mother, since Ms. L hadnt made much progress in conversing with her mother; the RT had decided that family
leisure education would be beneficial.
Implementation: (Were the interventions implemented designed with the intent to reach the established goals
and objectives?-Explain. Were there additional interventions that you feel could have been implemented to
reach goals and objectives? Explain.)
The implementation of the interventions had been met with the goals and objectives in mind. Since Ms. L was
hard to communicate with and to initially get to come to the RT groups, I think the family leisure education
program was a really good way to get her more involved with her mother again, and to get her involved in her
own leisure activities. One of the interventions was meeting at a local restaurant.
Evaluation: (Did the author discuss the clients RT outcomes? What are your unanswered questions regarding
the outcomes of the client---regarding RT services?
The Author did discuss the outcomes of the patient and was very thorough in how the patient improved while
hospitalized. I am wondering how the mother and Ms. L get along now, and what leisure interests they do
together to bond again. I hope they both rekindled a connection like they had before and it sounds like there is
hope that that happened.

Ethical Issues:
Based off of the ATRA code of ethics, it was clear that the RT adhered to the ethical practices. The principles
are as follows:
1. Beneficence: Based on the case study, the TRS showed that she was making the well-being of the client,
to initiate leisure and community reintegration to Ms. L to benefit her in the long term.
2. Non-Maleficence: The TRS appeared to use her best knowledge of how to handle Ms. from self-harm
and showed great respect and patience of the pace of Ms. Ls progress in the program.
3. Autonomy: Ms. L was given opportunities to engage or not engage in the RT groups. She made the
decision in the beginning to just sit and observe rather than participate and gradually worked up to
participating in the group.
4. Justice: The treatment provided showed that it was given without conflict to race, color, creed, gender,
sexual orientation, age, and disability/disease, social and financial status.
5. Fidelity: The TRS seemed to be loyal and committed to Ms. Ls treatment
6. Veracity: The TRS was honest and truthful about the structured plan to help Ms. L gain a relationship
with her mother.
7. Informed Consent: The client was informed of the services being provided, and was given the
opportunity to participate or not to participate in the group activities.
8. Confidentiality and Privacy: There wasnt any indication in the case study that the information of the
client was being given out.
9. Competence: Within the 15 months of treatment at the hospital the TRS complied with the laws and
regulations and would research and educate themselves based on interventions.
10. Laws and Regulations: There was no indication or evidence that the TRS was not obeying the laws and
regulations based off the article.

Evidence-based Practice:
The TRS showed that she wanted to integrate leisure education to the mother so Ms. L and the mother can find
some common ground and from the help of the staff to nudge Ms. L in the direction of her mother. The TRS did
research leisure education in Therapeutic Recreation Program Design Principles and Procedures, and
concluded that the mother and Ms. L needed to find out what the family did together before Ms. L got ill.

In the article taking leisure seriously: new and older considerations about leisure education discusses how
taking leisure activities more seriously, by committing to the leisure activity. In one part of the article the
author states Finding security, becoming capable, establishing an identity, and finding intimacy and
integrity are core issues throughout the lifespan, but each becomes particularly salient at different points
 and in response to different life events. (Kleiber, 2012). This aspect of leisure education is really important
for Ms. L and her mother to find intimacy with one another and establishing an identity in their relationship
is the most crucial in the leisure they partake in. In the case study Ms. L ended up being able to be
discharged and the mother began to join in the staffs heavily structured plan for Ms. L and their relationship
improved.

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Arlington, VA: American Psychiatric Publishing.

Gimmestad, Kay. (1995). A comprehensive Therapeutic Recreation Intervention: A Women with Schizophrenia
Therapeutic Recreation Journal. Volume 29, Pages 56-61

Kleiber A. Douglas. 01 May, 2012. Taking Leisure Seriously: New and Older Considerations
aboutLeisureEducation. World Leisure Journal. Vol. 54, iss 1,2012. Retrieved from:
http://www.tandfonline.com.ezproxy.lib.utah.edu/doi/abs/10.1080/04419057.2012.668278