Introduction:

This essay is about Josh’s case study, who is the son of Alice. He is 17 years old. He dropped out

from schools and is currently suffering from substance abuse. He takes drugs like marijuana. Her

mother thinks that Josh has schizophrenia. She has seen his elder son experiencing same

symptoms like hearing of voices just like Josh his mother reported. Josh also appears to have

anger issues. He yells and strokes holes in the wall. This essay will explore the mental health’s

psychological consequences over Josh and family. It will conduct assessment of mental health

using appropriate tools to determine metal complications which Josh is going through. It will

also highlight ethical, legal, and theoretical and policy related frameworks to explain why Josh’s

freedom should be deprived. The recovery model framework for Josh will also be discussed.

This framework will be focused under community based method to help Josh overcome his

psychological health problems and drug abuse.

Critical Appraisal:

CTO (Community Treatment Orders) was firstly used for treatment of patients with mental

health issues without isolating them from society. The people with mental health issue already

have the burden of social isolation, if the treatment is enforced onto them there will be another

case of hostility. They could feel that they are being punished in this way for being isolated. The

relation between mental physician and patient requires trust. But in CTO, this trust is not

developed as physician has control over the decisions of the patient so psycho-social aspect of

law remains unfulfilled.

Many problems in patients with mental instability is due to non-compliance of patient with the

course of treatment. Josh is facing mental health complications. He hears voices, and is involved

in drug abuse. He remain away from home for many days without any contact. These mental
health issues not only impact Josh but also on the people who are related to him. Like Alice his

mother is afraid of him when he visits her house. Josh is also causing harm to the neighbors as he

abuses them verbally and damages their property. The patient with mental instability often fails

to realize how much damage he is causing to himself and others. As he is unable to think

rationally, he might be involved in dangerous crimes. Before it gets too late, the family members

of the patient should seek immediate medical help even if it hinders the patient’s freedom.

Assessment:

The mental health assessment is used to examine emotional wellbeing using some questions and

physical examination like lab tests. In Josh’s case, he consumes alcohol and marijuana. Alice

(his mother) found used needles in his room. She also complained how bad tempered Josh is. She

also talked about his bad company and how he strokes holes inside walls to let his anger out. He

also yells and steals things. Therefore, CYMHS (Child & Youth Mental Service) is obliged to

do a mental assessment of Josh to understand his condition. The correct diagnosis will help in

designing proper care for Josh to yield better result. Alice thinks he suffers from Schizophrenia.

According to DSM 5 (The diagnostics and statistical Manual of Mental disorders 5) the criteria

to identify schizophrenia include these symptoms: hallucinations, disorganized speech, delusions

and catatonic behavior & negative symptoms .The uncontrolled consumption of alcohol and

marijuana may be associated with onset of depression and anxiety (Mezquida et al., 2018). Josh

had history of depression and anxiety so it increases his chances of developing other mental

complications. It is also said that people with drug addiction have a tendency of hallucination

(Mezquida et al., 2018). Though the case doesn’t show any significant symptoms of

schizophrenia in Josh.

How mental health condition impacts the patient and family:

There are two perspectives regarding the impact of mental health issues on the patient’s family.

Although CTO gives the family an option to stay with their loved one throughout the treatment

on one hand. The family is also relieved if the government takes responsibility for handling the

patient as dealing with such patient is a huge responsibility.

People who have mental health complications are more vulnerable to poor life quality. Six

domains of ill-being and well-being are hindered among people with mental health issues. They

include: poor self-image, a sense of not belonging, bad health, and lack of confidence,

hopelessness. The good life quality includes: high self-esteem, a sense of belonging, being in

control of symptoms (Connell et al., 2012).

When a person is suffering from mental health complications, it also impacts his/her family. The

family members are focused on the mental health of that person. The perception of each family

member is different from one another. The conflicts may arise within the family. The outcomes

may also include helplessness, frustration, guilt, lowered morale (Frank et al., 1981). Alice is

worried about her son so she contacted social services. She is afraid of Josh’s behavior and his

bad company. Alice’s other son Daniel has moved out due to trouble created by his brother.

Alice would be relieved that his son is getting care he needs instead of worrying about he may

cause harm to himself and others.

Justification:

Theoretical Framework:

The whole family is experiencing the consequences of SUD (substance use disorder). Alice has

vital information about development of SUD. She is aware about Josh’s tendency of illicit drug

abuse. The family members have a significant impact both positive and negative on the treatment
of this disorder. The Attachment theory and Family system theory can provide explanation in

this case. Family System theory says that if one member suffers from mental health condition,

the whole family should be taken into account and looked at (Lander et al., 2013). So, Josh

should not be restricted from personal independence. Alice need to be studied first. Depriving a

person of his freedom because he suffers from psychological complication is justified if he has

substance abuse. If this person is allowed to stay free he might cause harm for others. It may also

lead to spread of SUD among friends and other members of family. Substance abuse is a habit

which leads to harmful lifestyle and it increases the vulnerability of a person developing

psychological and physiological complications. Therefore, in order to reduce the chances of

spreading of substance abuse among related people, it is justified to restrict the person as siblings

of abusers are at greater risk of developing it (Vakalahi, 1999).

Attachment theory deals with how a person develops relative to others (Bowlby, 1979). The

attachment between a child and caregiver determines later functioning (Fonagy et al., 2002). This

concept can be applied here as Alice smokes and drinks consequently, Josh does. Alice has no

problems with Josh’s consumption. The children of drug abusers deal with substance and anxiety

disorders, depression and conduct disorders (Merikangas et al., 1998). Children who underwent

divorce, had more drug involvement (Needle et al., 1990).

Legal Framework:

According to Alice, Josh does not comply with medication for his depression suggested by his

physician. People who suffer from psychological issues are a risk for the citizens and show

abnormal behavior cannot be questioned until they cause any harm (Carhart et al., 2018). The

people related to substance abusers remained unable to act on time to prevent such cases until

there were serious repercussions like murder, robbery etc. So, Community Treatment Orders
(CTO) in legislative can help prevent such cases in future. This will help the community to stop

substance abusers before they carry illegal activities. Legal action is important to protect citizens

and support patients without controlling their social relations and environment.

The laws however should be coercive to prevent people like Josh to take control from

compliance to treatment. Laws that are coercive are necessary to gain patient’s compliance and

prevent citizens from harm (Carhart et al., 2018). The person would not comply because he

would not be willing. There are some external factors in literature which would cause non-

compliance like shortage of funds for transportation or illness (DeRidder et al., 2016). These

factors add to the non-compliance of patients. So unwillingness is not the sole reason. The

government should facilitate such individuals regarding transportation, childcare help which

would improve the probability of compliance. Legal action is necessary to prevent harm to

community and patients. CTO can help the state to hamper individuals like Josh before they get

involved in illegal activities. So legal actions are beneficial for both the citizens and patients

Ethical Framework:

The ethical theory of beneficence says, it is nurse’s duty to promote good. It can also be said that

nurse’s duty must be designed in a way that it helps in betterment of patient (Zwitter, 2019).

CTO has caused a debate among people who believe it causes human rights violation. If Josh is

kept under confinement, it would increase his anger level and may cause himself harming.

People who suffer from drug abuse have greater risk of suicide thoughts and tendency compared

to general population (Qin, p et al., 2011).

CTO leads to positive start of freedom (Carhart et al., 2018). If Josh is confined and restricted in

his independence, it will reduce his negative behavior and reduce the harm he does to others.
This will also restrict in taking intravenous medication which will reduce the harm he causes

himself (Jones et al., 2011)

Contrary, if a person is deprived of his freedom, it is against the morale of utilitarianism.

Utilitarianism holds that if an action does good for greatest number of people it is most ethical.

This theory discourages actions which cause harm or unhappiness. In this perspective, If Josh’s

is restricted in public and his independence is violated, it may cause him unhappiness which

violated utilitarianism. But this theory is also focused on betterment of society by making

political, economic and social aims (Zwitter, 2019). If we look at this perspective, confining Josh

will help other people around him stay in peace and provide relaxation to his mother which

doesn’t violate utilitarianism theory.

Recovery Framework:

The mental health framework which is suitable for this case is National Recovery Oriented

Framework. It is was launched by Department of Health, Australian Government. The goal of

this framework is to improve the quality of life of people suffering from mental health issues.

This framework suggests that status of mental health depends upon socio-economic factors

(psychological, physical, biological, education, family relationships etc.) In this case, Josh tried

to contact his biological father who is native. His mother refused to do so. Josh is not concerned

about native culture and community. Aboriginals live under bad socio-economic status

determinants of health. But josh doesn’t live with his father so social determinants are not

important. Josh’s psychological state of mind is not good. He is trying to reach his father and he

is being restricted to do so. So he is engaging in drug abuse more and more.

If Josh needs to recover, he need his family’s support most importantly. Alice should allow him

to reach his biological father. The positive support from the family may act as a keystone to
recovery for substance abusers (Wang et al. 2016). Another tool to recovery would be usage of

personal resources of recovery. Nursing professionals should be allocated for Josh. He should

seek good counselling by mental health practitioner who would help Josh to understand personal

resources and recover from psychological issues (Jones, 2018). Support network would also

serve the purpose of recovery. Josh’s ‘bad friends’ as narrated by his mother are not an option.

The recovery plan should be customized for Josh to improve care facilities for him. Lastly, his

father should be contacted. An integral part to recovery would be incorporation of family therapy

into drug abuse treatment (Substance Abuse & Mental Health Services Administration, 2014).

Family support increases the confidence to recover from substance abuse (Manaffe, 2010).

Health Care Plan:

According to (Patel et al., 2013) the interventions which are community based are effective in

minimizing mental health issues in groups and individuals. This is done in groups mostly to

increase the participation of the service users. The first intervention which is community based is

that Alice will be educated regarding how drug abuse and consumption of alcohol in

uncontrollable amount has horrendous consequences. Moreover, she herself will be advised to

reduce alcohol consumption and smoke less while forbidding his son to do so. The community

nurses will create health awareness. Awareness of family helps in promotion of health and

increases therapy adherence (Patterson et al., 2018).

The second step would to conduct a counselling session with Josh and understand the cause of

his destructive attitudes and drug abuse. This can help in creating customized intervention for

Josh. This will be done under supervision of community health and mental health nurse. The

physical activity reduces frequency of smoking and alcohol consumption and reduces risky

behavior (Tesler et al., 2018). Josh will therefore be asked to join in a physical activity in group
activity. People who are involved in intravenous drugs can stay at rehabs to reduce withdrawal

symptoms (Kim & Harley, 2019). In order to keep Josh at rehab, the permission of his mother

will be required as he is still not an adult. He will be trained in his anger management to ease his

bad attitude. Anger management can be done with meditation, breathing techniques,

psychodynamic therapy. Eventually Josh can recover from drug abuse with Community based

intervention and counselling.

Conclusion:

It can be concluded from above case study that Josh has some mental health complications and

along with it he is involved in drug abuse. The theoretical aspect forbids Josh from executing the

personal independence to improve his health and to stop the harm he is causing to the society.

From ethical point of view, it is fair to restrict Josh in executing his own wish. The legal factor

is also in favor of restricting Josh as he takes marijuana. The counselling and family education

help to identify mental complications Josh is going through. Breathing, meditation and

psychodynamic therapy will assist in his anger management. The overall health of Josh can be

improved using recovery framework as discussed. Coercive nature law can be justified on the

basis that a mentally unstable person does not have the ability to think rationally and make

appropriate decisions for himself. Patients who are suffering from mental health issues are not

aware about their mental state and they refuse to get treated because of the stigma that is attached

to the mental health in our society and the lack of their own insight about mental health.

Community based intervention puts the medical practitioners in a position where they can make

decisions which are important for the wellbeing of the patient without his autonomy. However,

some practitioners hold the view that such laws hinder the development of the trust between

patient and doctor. There are several arguments in this regard, but the number of benefits is far
greater than the number of risks. The only thing that needs to be done is that patients should be

provided facilities by the government like childcare and transportation.

References:

Bowlby, J. (1979). The making and breaking of affectional bonds. London: Tavistock.

Carhart-Harris, R. L., Bolstridge, M., Day, C. M. J., Rucker, J., Watts, R., Erritzoe, D. E., ... &
Rickard, J. A. (2018). Psilocybin with psychological support for treatment-resistant
depression: six-month follow-up. Psychopharmacology, 235(2), 399-408.

Connell, J., Brazier, J., O’Cathain, A., Lloyd-Jones, M., & Paisley, S. (2012). Quality of life of
people with mental health problems: a synthesis of qualitative research. Health and
quality of life outcomes, 10(1), 138.

Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2002). Affect regulation, mentalization, and the
development of the self. New York: Other Press.

FrankftFranks, D., Smith, M., & Caro, F. (1981). Family care of the elder: Public initiatives and
private obligations.

Jones L, Hughes K, Atkinson AM, Bellis MA. (2011) Reducing harm in drinking environments:
A systematic review of effective approaches. Health Place;17(2):508-518.

Jones, E. B. (2018). Practice characteristics of nurse practitioners in mental health and

psychiatric settings. Archives of psychiatric nursing, 32(4), 599-603.

Kim, B. J., & Harley, D. A. (2019). Needle and Syringe Programs in Rural Areas: Addressing
the Intravenous Drug Use Epidemic. Rehabilitation Research, Policy, and
Education, 33(1), 56-64.

Lander, L., Howsare, J., & Byrne, M. (2013). The impact of substance use disorders on families
and children: from theory to practice. Social work in public health, 28(3-4), 194-205.

Manaffe, Y. (2010). Advokasi Pencegahan Penyalahgunaan Narkoba. Jakarta: Direktorat

Advokasi Deputi Bidang Pencegahan BNN.
Merikangas, K. R., Dierker, L. C., & Szamari, P. (1998). Psychopathology among offspring of
parents with substance abuse and/or anxiety disorders: A high risk study. Journal of Child
Psychology and Psychiatry and Allied Disciplines, 39, 711–720.

Mezquida, G., Cabrera, B., Martínez-Arán, A., Vieta, E., & Bernardo, M. (2018). Detection of
early psychotic symptoms: Validation of the Spanish version of the “Symptom Onset in
Schizophrenia (SOS) inventory”. Psychiatry research, 261, 68-72.

Needle, R. H., Su, S. S., & Doherty, W. J. (1990). Divorce, remarriage, and adolescent substance
use: A prospective longitudinal study. Journal of Marriage and the Family, 52, 157–169.

Patel, V., Saxena, S., De Silva, M., & Samele, C. (2013). Transforming lives, enhancing
communities: innovations in mental health. World Innovation Summit for Health. Qatar:
Qatar Foundation.

Patterson, J. E., Edwards, T. M., & Vakili, S. (2018). Global mental health: A call for increased
awareness and action for family therapists. Family process, 57(1), 70-82.

Qin P. (2011) The impact of psychiatric illness on suicide: differences by diagnosis of disorders
and by sex and age of subjects. J Psychiatr Res; 45: 1445–52

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health
Statistics and Quality. (September 11, 2014). The N-SSATS Report: Recovery services
provided by substance abuse treatment facilities in the United States. Rockville, MD.

Tesler, R., Plaut, P., & Endvelt, R. (2018). The effects of an Urban Forest Health Intervention
Program on physical activity, substance abuse, psychosomatic symptoms, and life
satisfaction among adolescents. International journal of environmental research and
public health, 15(10), 2134.

Vakalahi, H. F. (1999). Adolescent substance use in Utah: The influence of family-based risk
and protective factors. Dissertation Abstracts International Section A: Humanities and
Social Sciences, Feb., 59 (8-A), 3214.

Wang, M. C., Wong, Y. J., Nyutu, P. N., Spears, A., & Nichols III, W. (2016). Suicide protective
factors in outpatient substance abuse patients: Religious faith and family support. The
International Journal for the Psychology of Religion, 26(4), 370-381.
Zwitter, M. (2019). Ethics and Law. In Medical Ethics in Clinical Practice (pp. 1-5). Springer,
Cham.