Case Study: Person Who Is Currently Incarcerated With Schizoaffective Disorder

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CASE STUDY SCHIZOAFFECTIVE DISORDER
Case Study
Person Who Is Currently Incarcerated with Schizoaffective Disorder
Shane Brooks
RECTH 4330 RT and Mental Health Services
Professor Dr. Steven Bell
April 29, 2022

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Table of Contents
Introduction...................................................................................................................................p 3
Assessment....................................................................................................................................p 4
Diagnostic Protocol ....................................................................................................................p 10
Pharmacology Report .................................................................................................................p 15
Goals and Objectives..................................................................................................................p 28
Intervention Protocol..................................................................................................................p 29
Intervention Report ....................................................................................................................p 33
Case Study Intervention Response..............................................................................................p 35
Evaluation ..................................................................................................................................p 36
Signature.....................................................................................................................................p 36
References...................................................................................................................................p 37
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Introduction
Over two months and 40 hours of observation, the following information was gathered to
compile a recreational case study. The case study was conducted at the Utah State Prison,
Timpanogos facility in Draper, Utah. The Timpanogos facility is reserved explicitly for females
who are currently incarcerated. The mission of the Utah State Prison is to provide maximum
opportunities for offenders to make lasting changes through accountability, treatment, education,
and positive reinforcement within a safe environment (Utah Department of Corrections, 2022).
The mental health services, which is the location of the recreational therapists (RTs), fall
underneath the healthcare department, which has an additional mission of providing
constitutionally mandated offender healthcare in a competent, caring, and cost-effective fashion
within the overall mission of the Utah Department of Corrections (Utah Department of
Correction Healthcare, 2021). For this case study going further, individuals at the prison will no
longer be referred to as offenders, inmates, or prisoners. As RTs, we must advocate those
individuals are not their status of housing, past actions, or identified by words with negative
stereotypes. They will be referred to either as person/people who are currently incarcerated or by
a specified surname. Distinguishing that they are currently incarcerated emphasizes this being a
fleeting moment in their lives and that, as RTs, a focus needs to be on services provided after
incarceration.
In the Timpanogos facility, there is a special section for women exhibiting mental health
diagnoses or mental distress. In this section, no more than 28 people are currently incarcerated.
The women's mental health section saw people who are currently incarcerated between the age of
20 and 50 during the observation time for this case study. However, they can technically serve
people who are currently incarcerated from age 18 and up.
The Timpanogos mental health section has access to a gym with exercise bikes,
treadmills, ellipticals, Stairmasters, weight machines, free weights, yoga mats, and basketball
hopes. The women can use this facility provided the RT is with them, and a gym correctional
officer is present. Due to staffing issues with correctional officers, the gym is not always
accessible to women. There is also a modular unit that the women are provided access to as long
as the RT is with them. In the modular, there are supplies for art, a radio, and desks for the
people who are currently incarcerated to partake in the RT group interventions. There is a giant
track outside with a grass field in the middle; however, the people who are currently incarcerated
and receiving mental health services cannot use the track to walk. The reasoning behind this is
that previously they used to let the people who are currently incarcerated with mental health
diagnoses out onto the track at the same time as the general population of people who are
currently incarcerated. There became a pattern of the general population individuals performing
an action called "strong-arming" on the individuals receiving mental health services. Strong-
arming refers to using force or violence (Merriam-Webster, 2022). In this situation, it is
regarding the medications of those receiving mental health services. As a result, the corrections
staff noticed this trend and decided that both parties could not simultaneously be out on the track.
However, in their attempt to ensure the safety of those receiving mental health services, the staff
took the track away from them together because it is not fair to restrict the general population of
people who are currently incarcerated. As for the grass field, none of the currently incarcerated
people can use it for any activities. Despite it being ideal for some recreational games and even
some things that the males are allowed to partake in like softball, kickball, and a game made up
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by the RT and people who are currently incarcerated called yard ball. The women at the
Timpanogos facility are unable to use it because the correctional staff fears that the gopher holes
will cause the women to break a leg, sprain an ankle, or injure themselves in another manner.
These reasons are a fine example of sexism within the Department of Corrections because the
males have two fields that also have gophers. However, they are allowed to engage in softball
and yard ball without any injury concerns.
Recreational Therapy is vital for people who are currently incarcerated, whether or not
they are exhibiting mental health diagnoses. At the Utah State Prison, it is simply referred to as a
recreational therapy program. There are two recreational therapists on staff; however, only one
was seen during the time of observation. On the Timpanogos mental health unit, two talk
therapists and one provider are also on staff. During the observation time, the supervisor was
Katie Atencio. She has been a Therapeutic Recreation Specialist (TRS) and a Certified
Therapeutic Recreation Specialist (CTRS) since 2018 and has been working at the Utah State
Prison for three years.
Over the 40 hours of the observation, one individual was focused on for this case study.
The person who is currently incarcerated was initially incarcerated in 2020 for her current
charges. For her protection, the omission of her length of stay will occur for this case study. As
RTs, it is crucial to think about what comes next for the people who are currently incarcerated.
Publishing any information that might lead to an identification of the individual would not only
go to the American Therapeutic Recreation Association (ATRA) Standards of Practice and Code
of Ethics (American Therapeutic Recreation Association, 2009; (American Therapeutic
Recreation Association, 2015). It also does not serve any other purpose other than to create a
negative precedent for judgment around the person who is currently incarcerated based upon
when they may or may not get out of prison. For this case study, the person that is currently
incarcerated will either be referred to as such or by the surname Smith. Smith is a 32-year-old
Caucasian female with a primary diagnosis of schizoaffective disorder bipolar type (ICD-10 code
F25.0). Smith also has comorbidities of Mild Alcohol Use Disorder (ICD-10 code F10.10), Mild
Opioid Use Disorder (ICD-10 code F11.10), Mild Cannabis Use Disorder (ICD-10 code F12.10),
Moderate Cocaine Stimulant Use Disorder (ICD-10 code F14.20), Severe Amphetamine-type
substance Stimulant Use Disorder (ICD-10 code F15.20), and Antisocial Personality Disorder
(ICD-10 code F60.2). Smith is in a unit that is fully locked down with only other women
experiencing other mental health diagnoses. They are allowed time out of their cell for most of
the day unless on a "lay in ."A lay-in refers to disciplinary action in response to actions that
people who are currently incarcerated may perform against the Utah State Prison rules. During a
lay-in, the person who is currently incarcerated will only be allowed out of their cell for one hour
a day to walk the yard and for appointments with the therapists and provider. The RT is not
considered a reason to allow a person who is currently incarcerated out of a lay-in.
Assessment
It was discovered that the RTs at the Utah State Prison are using the CERT-Psych/R as
their assessment tool for people who are currently incarcerated. The CERT-Psych/R is both a
valid and reliable assessment tool. However, it does not fully apply to people who are currently
incarcerated as some of the questions the individuals cannot be observed in. Not only that, but
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the RTs are trying to assess people who are currently incarcerated based on a diagnosis that is
defined by the Diagnostic and Statistical Manual of Mental Disorder Third Edition (DSM-III).
The DSM-III was published in 1980 and was replaced by the DSM-III-R in 1987, the DSM-IV in
1994, and then the current edition, the DSM-V, in 2013 (American Psychiatric Association.,
2022). The Utah State Prison is using a Diagnostic Manual that has since been replaced by three
different versions at the time this case study was being conducted and a fourth at the time of
publication of the study. It creates significant issues when the assessment tools are designed to
utilize the newer diagnostic manuals, and the modern diagnostic criteria are used to grade their
reliability. Despite these possible errors, the RTs still go forth with what they know are reliable
assessments. The following images are copies of the assessment for Smith:
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Image 1:
Page 1 of CERT-Psych/R for case study Smith
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Image 2:
Image 3:
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Image 4:
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The assessment is only administered to the people who are currently incarcerated about
once a year unless significant changes are being noticed. This is because of the time it takes for
the RT to do the assessments in the prison setting correctly. Typically, individuals could be
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pulled into one on ones for assessments. However, in the prison setting, that does not create a
therapeutic environment as there is a large glass wall between the RT and the person who is
currently incarcerated. The assessments must be conducted through a series of groups and
individual interactions with the people who are currently incarcerated that way.
Diagnostic Protocol
Diagnostic Grouping:
Schizophrenia Spectrum and Other Psychotic Disorders:
The American Psychiatric Association has determined the diagnostic grouping to
include “schizophrenia, other psychotic disorders, and schizotypal (personality) disorder
(2013). The number of disorders that can fall under this classification can be vast, but the
definition of “Abnormalities in one or more of the following five domains: delusions,
hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor
behavior (including catatonia), and negative symptoms” (American Psychiatric
Association, 2013). The definition does not clear it up much. It does remove a good
number of diagnoses. However, looking into the five domains clarifies what classifies a
schizophrenic spectrum and other psychotic disorders.
Delusions can be looked at in many ways regarding the schizophrenia spectrum
and other psychotic disorders. Delusions, in general, are fixed beliefs that do not change
when presented with conflicting information (American Psychiatric Association, 2013).
The American Psychiatric Association has six different delusions for this classification of
disorders (2013). All six types of delusions fall under two different categories: they are
bizarre or not (American Psychiatric Association, 2013). A bizarre delusion exhibits a
feature that is impossible, not understandable to peers, and not related to ordinary life
experiences (American Psychiatric Association, 2013). The opposite is said about not
bizarre delusions; these exhibit features tied to reality and are plausible (American
Psychiatric Association, 2013). Just lack the actual proof or convincing evidence to show
they are real (American Psychiatric Association, 2013). To distinguish which disorder out
of the 12 within the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition
(DMS-V) helps to know what type of delusion is occurring. The most common type of
delusion is when a person believes that they will be harmed by an individual, group, or
organization; these are called Persecutory delusions (American Psychiatric Association,
2013). Another common type is the Referential delusion, in which the individuals believe
that gestures, comments, or environmental cues are directed at them (American
Psychiatric Association, 2013). Grandiose delusions are where individuals believe in
wealth, fame, or exceptional abilities (American Psychiatric Association, 2013).
Erotomanic delusions, when they believe that another person is in love with them, can
also be present (American Psychiatric Association, 2013). If the individual believes that a
major catastrophe will occur is called Nihilistic delusion (American Psychiatric
Association, 2013). The final type of delusion that an individual can experience is the
preoccupations around health and organ function called Somatic delusions (American
Psychiatric Association, 2013).
Hallucinations are perception-like experiences that occur when no external
stimuli are present (American Psychiatric Association, 2013). Hallucinations can occur
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within all sensory modalities; auditory hallucinations are the most common when it
comes to schizophrenia and other psychotic disorders (American Psychiatric Association,
2013). This is when the individual is experiencing voices that are distinct from their
thoughts (American Psychiatric Association, 2013). However, a significant defining
characteristic is that they must occur during a clear sensorium or not while falling asleep
or waking up (American Psychiatric Association, 2013).
Disorganized Thinking (Speech) is a formal thought disorder inferred from the
individual's speech (American Psychiatric Association, 2013). The individual might be
switching from one topic to another (loose associations), answering with things unrelated
to the questions (tangentiality) (American Psychiatric Association, 2013). In rare cases,
the speech becomes so disorganized that it resembles receptive aphasia; this is often
called word salad (American Psychiatric Association, 2013).
Grossly disorganized or abnormal motor behavior can show from childlike
behavior to unpredictable agitation (American Psychiatric Association, 2013). There can
be problems in goal-directed behavior and performing activities of daily living (ADLs)
(American Psychiatric Association, 2013). The grouping of these behaviors includes
Catatonic behavior, which is a decrease in reactivity to the environment (American
Psychiatric Association, 2013). Everything from negativism to mutism, stupor and
catatonic excitement is included in catatonic behavior (American Psychiatric Association,
2013).
The last of the five domains are negative symptoms which account for most of
the morbidity with schizophrenia but not the other psychotic disorders (American
Psychiatric Association, 2013). The two negative symptoms most associated with
schizophrenia are diminished emotional expression and avolition, which decrease
motivated self-initiated purposeful activities (American Psychiatric Association, 2013).
Alogia or a diminished speech output, anhedonia, inability to experience pleasure from
positive stimuli, and asociality or lack of interest in social interactions are also negative
symptoms (American Psychiatric Association, 2013).
Specific Diagnosis:
This diagnosis protocol focuses on a person currently incarcerated at the Utah State
Prison. They are housed in the female mental health section of the prison and have been
receiving treatment for their mental health conditions on and off again since 2019. In this
protocol, the person who is currently incarcerated will either be referred to as to aforementioned
or by the surname Smith. Smith has several mental health diagnoses that they were being treated
for. Their primary diagnosis is schizoaffective disorder bipolar type.
Schizoaffective Disorder Bipolar Type:
Schizoaffective Disorder Bipolar Type is a schizophrenia spectrum disorder that
follows some of the same diagnostic criteria as schizophrenia (American Psychiatric Association,
2013). There are two subtypes of schizoaffective disorder which are depressive and bipolar type
(American Psychiatric Association, 2013). The two are distinguishable not only by the diagnostic
criteria of either a major depressive episode present or a manic episode present (American
Psychiatric Association, 2013). Their respective ICD-10 codes of F25.0 can quickly identify
them for Bipolar type and F25.1 for Depressive type (American Psychiatric Association, 2013).
To gain a diagnosis of schizoaffective disorder bipolar type, an individual must present with the
following diagnostic criteria (American Psychiatric Association, 2013):
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A. There is an uninterrupted period of illness during which there is a major mood episode
(major depressive or manic) concurrent with Criterion A of schizophrenia.
Note: The major depressive episode must include Criterion A1: Depressed mood.
B. Delusions or hallucinations for two or more weeks in the absence of a major mood
episode (depressive or manic) during the lifetime duration of the illness.
C. Symptoms that meet the criteria for a major mood episode are present for the majority of
the total duration of the active and residual portions of the illness.
1. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a
medication) or another medical condition.
Now Criterion A of schizophrenia is as follows (American Psychiatric Association, 2013):
A. Two (or more) of the following, each present for a significant portion of time during 1
month (or less if successfully treated). At least one of these must be (1), (2), or (3)
1. Delusions
2. Hallucinations
3. Disorganized speech (e.g., frequent derailment or incoherence)
4. Grossly disorganized or catatonic behavior
5. Negative symptoms (i.e., diminished emotional expression or avolition)
Classifications/stages/levels/progression of the disorder
Some additional criteria need to be met to be diagnosed as either depressive or bipolar
type. The Bipolar type is just the presence of a manic episode; depressive episodes can still occur
with this type (American Psychiatric Association, 2013). For a depressive type, they must meet
the requirements of criterion A1 for a depressed mood under the Major Depressive Disorder
diagnosis. Criterion A1 for the depressed mood, which is required to fulfill diagnostic criterion A
for a major depressive episode of schizoaffective disorder, is as follows (American Psychiatric
Association, 2013):
A. Five (or more) of the following symptoms have been present during the same 2-week
period and represent a change from previous functioning; at least one of the symptoms is
either (1) depressed mood or (2) loss of interest or pleasure.
1. Depressed mood most of the day, nearly every day, as indicated by either
subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g.,
appears tearful). (Note: In children and adolescents, can be irritable mood.)
Schizoaffective disorder can also come with catatonia; if the individual meets the criteria for
catatonia, the ICD-10 code of F06.1 will accompany the code for the schizoaffective diagnosis to
indicate the presence of the comorbid catatonia (American Psychiatric Association, 2013). The
following are the diagnostic criteria for catatonia (American Psychiatric Association, 2013):
A. The clinical picture is dominated by three (or more) of the following symptoms:
a. Stupor (i.e., no psychomotor activity; not actively relating to environment).
b. Catalepsy (i.e., passive induction of posture held against gravity).
c. Waxy flexibility (i.e., slight, even resistance to positioning by examiner).
d. Mutism (i.e., no, or very little, verbal response [exclude if known aphasia]).
e. Negativism (i.e., opposition or no response to instructions or external stimuli).
f. Posturing (i.e., spontaneous and active maintenance of posture against gravity).
g. Mannerism (i.e., odd, circumstantial caricature of normal actions).
h. Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements).
i. Agitation, not influenced by external stimuli.
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j. Grimacing
k. Echolalia (i.e., mimicking another’s speech).
l. Echopraxia (i.e., mimicking another’s movements).
Other things that have to be specified when it comes to the schizoaffective disorder are the
severity assessed quantitatively based on the five domains of psychosis (American Psychiatric
Association, 2013). The remaining specifiers are only after a 1-year duration of the disorder and
are not in contradiction to the diagnostic course criteria (American Psychiatric Association,
2013). Those specifiers are the following (American Psychiatric Association, 2013):
A. First episode, currently in acute episode: First manifestation of the disorder meeting the
defining diagnostic symptom and time criteria. An acute episode is a time period in
which the symptom criteria are fulfilled.
B. First episode, currently in partial remission: partial remission is a time period during
which an improvement after a previous episode is maintained and in which the defining
criteria of the disorder are only partially fulfilled.
C. First episode currently in full remission: Full remission is a period of time after a
previous episode during which no disorder-specific symptoms are present.
D. Multiple episodes, currently in acute episode: Multiple episodes may be determined after
a minimum of two episodes (first episode, a remission, and a minimum of one relapse)
E. Multiple episodes, currently in partial remission
F. Multiple episodes, currently in full remission
G. Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are
remaining for the majority of the illness course, with subthreshold symptoms periods
being very brief relative to the overall course.
H. Unspecified
Etiologies:
While the exact cause of the schizoaffective disorder is unknown, a few things can
contribute to the development of the schizoaffective disorder.
 Genetic
o Having a close relative is typically a first-degree relative with schizophrenia,
schizoaffective disorder, and or bipolar disorder (Mayo Clinic Staff, 2019;
NAMI, 2022; U.S. Department of Health and Human Services, 2018).
o The genes that regulate the body’s circadian rhythms, control the migration of
nerve cells during brain development, and send and receive chemical signals
in the brain have been associated with a risk of schizoaffective disorder (U.S.
Department of Health and Human Services, 2018)—interfering with the
brain's ability to build parts of gamma-aminobutyric acid (GABA) which is to
help the brain from being overloaded with too many signals (U.S. Department
of Health and Human Services, 2018).
 Stress
o Stressful situations have been indicated as a possible cause for triggering
symptoms (Mayo Clinic Staff, 2019; NAMI, 2022).
 Drug use
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o Substance abuse of psychoactive drugs such as LSD may worsen the

underlying condition, schizoaffective disorder (Mayo Clinic Staff, 2019;
NAMI, 2022).
Demographic Information:
For this case study, the demographic was a 32-year-old Caucasian female who goes
against the prevalence of most schizophrenia spectrum and other psychotic disorders. With a
male to female ratio of 1.4, usually, men are more diagnosed than females (Porter, 2015). Two
females will have a schizophrenia spectrum and other psychotic disorders for every three males
(Porter, 2015). For schizoaffective disorder, the male-to-female rate is equal; the only difference
is the age of onset (NAMI, 2022). The onset of schizoaffective disorder is typically between the
late teens and 30 (Cleveland Clinic medical professional, 2021; Porter, 2015), which makes the
case study for Smith even more interesting as she was not diagnosed until she became currently
incarcerated three years ago, right before her 30th birthday. As far as racial disparities, results
have shown that disproportionally, African Americans (25%) and Latino Americans (24%) are
diagnosed with schizophrenia spectrum and other psychotic disorders in comparison to Euro-
Americans (18%) (Schwartz, 2014). Schizoaffective disorder overall is infrequent and is less
prominent than schizophrenia, with about a 0.3% lifetime prevalence (NAMI, 2022).
Person Who is Currently Incarcerated’s Identified Problems:
Smith has exhibited numerous problems since being currently incarcerated. Some of the
problems are attributed to the symptoms of schizoaffective disorder, and others are attributed to
highly prevalent comorbidities. For Smith, the common comorbidities around substance use
disorders are present, and one not so common comorbidity of antisocial personality disorder
(American Psychiatric Association, 2013).
 Schizoaffective related problems
o Manic episodes
o Responds to negative internal stimuli
o Lack of responses to external stimuli at times
o Inability to make goals
o Difficulty performing ADLs
 Comorbidities
o Mild Alcohol Use Disorder (ICD-10 code F10.10)
o Mild Cannabis Use Disorder (ICD-10 code F12.10)
o Mild Opioid Use Disorder (ICD-10 code F11.10)
o Severe Amphetamine-type substance Stimulant Use Disorder (ICD-10
code F15.20)
o Moderate Cocaine Stimulant Use Disorder (ICD-10 code F14.20)
o Antisocial Personality Disorder (ICD-10 code F60.2)
 Problems Associated with Comorbidities
o Inability to regard consequences is connected with all comorbidities for
Smith (American Psychiatric Association, 2013).
o Impulsivity is linked to all the comorbidities for Smith (American
Psychiatric Association, 2013).
o A lack of remorse is connected to antisocial personality disorder
(American Psychiatric Association, 2013).
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Smith has exhibited all these issues, which have become the most significant
complications to her quality of life. During her time currently incarcerated, there has been
minimal improvement in her schizoaffective disorder bipolar type symptoms.
Pharmacology Report
Traditional pharmacology reports would not be included in a case study. However,

regarding people who are currently incarcerated, some issues of concern were brought to light
during the investigation of prescribed medication to Smith. The pharmacology report is being
provided to demonstrate the importance of RTs to examine medications for contraindications and
safety concerns during interventions and to notice possible causes for concern. Advocating for
the individuals that RTs service is standard across all settings being an extension of their voice is
sometimes what is required to ensure the optimal care. The following information is the
pharmacology report for Smith:
Medications
Current Medications
 Aristada (Aripiprazole)
o Dosage:
 The person who is currently incarcerated currently receives this
medication every 28 days, beginning on 11/16/2021. Aristada is
administered via an injection of 1064 mg American Hospital Formulary
Service, 2019).
o Classification
 Aristada is a second-generation antipsychotic (SGA) used to treat
schizophrenia, bipolar disorder, schizoaffective disorder, and related
mental health conditions (Khan, 2022).
o Side Effects
 Below are the mild side effects that should go away. However, if they do
not, then the person who is currently incarcerated should speak with the
provider (American Hospital Formulary Service, 2019):
 Pain, swelling, and redness at the injection site
 Weight gain
 Increased appetite
 Extreme tiredness
 Stomach pain
 Constipation
 Vomiting
 Dry mouth
 Back, muscle, or joint pain
 Difficulty falling asleep or staying asleep
 Dizziness, feeling unsteady, or having trouble keeping your
balance
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o Adverse Reaction
 The person who is currently incarcerated should immediately speak with
prison staff to get medical care if any of the following reactions occur
(American Hospital Formulary Service, 2019):
 Rash/itching/hives
 Swelling of the face, throat, tongue, lips, eyes, hands, feet, ankles,
and/or lower legs
 Difficulty swallowing or breathing
 Muscle stiffness
 Excessive sweating
 Irregular heartbeat
 Confusion
 Falling
 Unusual movement of the face or body that you cannot control
 Uncontrollable shaking of a part of the body
 Restlessness
 Need to get up and move
 Slow movements
 Sore throat, fever, chills, or other signs of infections
 Seizures
o Impacts of Overdose
 An overdose on Aristada can be fatal; the RT needs to be aware of the
signs of an overdose. Being aware of an overdose ensures optimal care for
the person who is currently incarcerated. The following are the signs and
symptoms of an Aristada overdose (American Hospital Formulary
Service, 2019):
 Confusion
 Disorientation
 Vomiting
 Slowed or uncontrollable movements
 Drowsiness
 Seizures
 Aggressive Behavior
 Coma (loss of consciousness for a period of time)
o Special Populations
 Important note:
 Aristada is not approved by the Food and Drug Administration
(FDA) for the treatment of dementia in older adults. Studies have
shown that antipsychotics like Aristada can increase the chance of
stroke or ministroke, leading to death in older adults with dementia
(American Hospital Formulary Service, 2019).
o TRS, CTRS Additional information
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 As an RT, it is crucial to know if the person who is incarcerated is on

Aristada. Some of the side effects can create potential risk management
considerations for interventions. Aristada might also be a contraindication
for an individual to not participate in an intervention. For example,
suppose the person who is currently incarcerated is experiencing the side
effect of dizziness. In that case, the RT should not have them partake in an
intervention where falling is a high probability. The RT should also be
aware of the injection day for the individual who is currently incarcerated
as the medication is a slow-absorbing drug. It can have a weaker effect in
the latter part of the dosage. For this reason, the individual who is
currently incarcerated might begin to respond to internal stimuli more as
their injection date approaches, and the RT can be of more help during this
time.
 Depakote (Valproic Acid)
o Dosage
 The person who is currently incarcerated is prescribed one 500 mg
delayed-release tablet per day. They began taking the prescription on
11/03/2021.
o Classification
 Depakote has been classified as a first-generation antiepileptic drug
(AED) used to treat complex partial seizures, simple and complex absence
seizures, and individuals with bipolar disorder who are experiencing acute
manic symptoms (AbbVie Inc, 202).
o Side Effects
 Depakote could cause side effects, several of which are mild. However, if
they become severe, then the person who is currently incarcerated should
speak with the provider. The following is a list of those side effects
 Drowsiness
 Dizziness
 Headache
 Diarrhea/Constipation
 Changes in appetite
 Weight changes
 Back pain
 Agitation
 Mood Swings
 Abnormal thing
 Problems with walking or coordination
 Blurred or double vision
 Ringing in the ears
 Hair loss
o Adverse Reaction
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 Depakote can have more severe side effects or adverse reactions to the
medication. The person who is currently incarcerated should immediately
speak with prison staff to get medical care if any of the following
reactions occur (American Hospital Formulary Service, 2019):
 Unusual bruising or bleeding
 Tiny purple or red spots on the skin
 Fever
 Rash/Bruising/Hives
 Difficulty breathing or swallowing
 Swollen glands
 Swelling of face, eyes, lips, tongue, or throat
 Peeling or blistering skin
 Confusion
 Tiredness
 Vomiting
 Drop-in body temperature
 Weakness or swelling in the joints
 An overdose on Depakote can be fatal; as an RT, it is critical to be aware
of the signs of an overdose to ensure optimal care for the person who is
currently incarcerated. The following are the signs and symptoms of a
Depakote overdose (American Hospital Formulary Service, 2019):
 Sleepiness
 Coma (loss of consciousness for a period of time)
 Important note
 Depakote can cause life-threatening damage to the liver within six
months of starting treatment for children younger than two years of
age. These children also need to be taking more than one other
medication to prevent seizures (American Hospital Formulary
Service, 2019.
 Pregnant women should not take Depakote as it can cause severe
congenital disabilities. The defects can consist of the brain and
spinal cord, lower intelligence, movement and coordination
problems, communication, emotions, learning, and behavior in
babies exposed to Depakote prior to birth (American Hospital
Formulary Service, 2019.
 The RT needs to be aware of the person who is currently incarcerated and
if they are suicidal. As Depakote can worsen suicidal ideations, the RT
must help monitor their behavior. Checking with the contraindications and
risk management guidelines for each intervention to make sure that it is in
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the best interest of the person who is currently incarcerated (Haymarket

Media, Inc, 2022).
 Excedrin Migraine (Acetaminophen 250mg, aspirin 250mg, caffeine 65mg)
o Dosage
 The person who is currently incarcerated was given the ability to take one
tablet of Excedrin Migraine in either the morning or the evening. This
medication was started on 10/29/2021 and is available every day to the
person who is currently incarcerated.
o Classification
 Excedrin Migraine is classified as an over-the-counter (OTC) Analgesic +
salicylate drug used for migraines (Haymarket Media, Inc, 2022).
o Side Effects
 Excedrin Migraine can present several side effects, and the person who is
currently incarcerated should ask to speak with the provider if any of the
following are occurring (GSK, 2021):
 Skin reddening/blisters/rash
 Hives
 Facial swelling
 Asthma (wheezing)
 Shock
o Adverse Reaction
 Excedrin Migraine can have more severe side effects or adverse reactions
to the medication. Use of the drug should be stopped, and the person who
is currently incarcerated should speak with the provider immediately
(GSK, 2021):
 Feel faint
 Vomit blood
 Have bloody or black stools
 Have stomach pain that does not get better
 An overdose on Excedrin Migraine will not be fatal. As an RT, it is critical
to be aware of the signs of an overdose to ensure optimal care for the
person who is currently incarcerated. The following are the signs and
symptoms of an Excedrin Migraine overdose (GSK, 2021):
 Headaches worsen due to the medication being taken ten or more
times during the month.
 Important note
 Individuals that are 60 years or older should be cautious about
taking Excedrin Migraine because of the chances for stomach
bleeding (GSK, 2021).
 As an RT knowing that the person who is currently incarcerated is taking
Excedrin Migraine is vital because they could very quickly be taking it to
20
get the effects of the caffeine rather than for its intended purpose. Since
people who are currently incarcerated are not allowed to have caffeine in
the mental health units.
 Ibuprofen
o Dosage
 The person who is currently incarcerated was given a prescription for
Ibuprofen on 10/29/2021. They are allowed to take two 200 mg tablets as
needed.
o Classification
 Ibuprofen is classified as a nonsteroidal anti-inflammatory drug (NSAID)
used to relieve pain, inflammation, and bring down a fever (American
Hospital Formulary Service, 2022).
o Side Effects
 Ibuprofen has a small amount of mild side effects, and the person who is
currently incarcerated should talk with the provider if they are
experiencing any of the following (American Hospital Formulary Service,
2022):
 Constipation
 Diarrhea
 Gas or bloating
 Dizziness
 Nervousness
o Adverse Reaction
 Ibuprofen has several symptoms and indicators or an adverse reaction; the
person who is currently incarcerated should talk with the provider if they
are experiencing any of the following (American Hospital Formulary
Service, 2022):
 Unexplained weight gain
 Shortness of breath or difficulty breathing
 Swelling of the abdomen, feet, ankles, or lower legs
 Fever
 Blisters
 Rash/itching/hives
 Swelling of the eyes, face, throat, arms, or hands
 Hoarseness
 Excessive tiredness
 Pain in the upper right part of the stomach
 Nausea
 Loss of appetite
 Yellowing of skin or eyes
 Flu-like symptoms
21
 Pale skin
 Fast heartbeat
 Cloudy, discolored, or bloody urine
 Back pain
 Difficult or painful urination
 Blurred vision, changes in color vision, or other vision problems
 Red or painful eyes
 Stiff neck
 Headache
 Confusion
 Aggression
 An Ibuprofen overdose can be complicated to see and needs medical
attention for the person who is currently incarcerated. The following are
ways that an overdose can present itself (Borke, 2022):
 Blurred vision
 Diarrhea
 Heartburn
 Nausea, bloody vomiting
 Stomach pain, bleeding in the stomach and intestines
 Low blood pressure
 Little or no urine production
 Slow or difficult breathing
 Wheezing
 Agitation, confusion, incoherent
 Drowsiness, Coma
 Convulsions
 Dizziness
 Severe headache
 Unsteadiness, trouble moving
 Rash
 Sweating/Chills
 There are no warnings for special populations for Ibuprofen.
 The RT needs to be aware that the person who is currently incarcerated is
on an NSAID other than aspirin (American Hospital Formulary Service,
2022). This is because this can put them at a higher risk of having a heart
attack or stroke. For an RT, this is vital information for contraindications
and risk management considerations.
 Invega (Paliperidone)
o Dosage
22
 For the person who is currently incarcerated, a 9 mg tablet dosage once a

day was started on 2/10/2022
o Classification
 Invega is classified as an atypical antipsychotic used to treat schizophrenia
and schizoaffective disorder (Haymarket Media, Inc, 2022).
o Side Effects
 With Invega comes some mild side effects, and the person who is
2017):
 Dizziness, feeling unsteady or having trouble keeping balance
 Extreme tiredness
 Weakness
 Headache
 Dry mouth
 Increased saliva
 Weight gain
 Stomach pain
o Adverse Reaction
 Invega can create an adverse reaction that the person who is currently
incarcerated needs be aware of and speak with the provider immediately
2017):
 Fever
 Muscle pain or stiffness
 Falling
 Confusion
 Fast, pounding, or irregular heartbeat
 Sweating
 Unusual movements of face or body that cannot be controlled
 Slow or stiff movements
 Restlessness
 Painful erection of the penis that lasts for hours
 An overdose on Invega can be lethal; the following are symptoms of
overdose that need to be monitored (American Hospital Formulary
Service, 2017):
 Slow or stiff movements
 Restlessness
 Unsteadiness
 Drowsiness
 Fast heartbeat
23
 Important Note
 Older adults with dementia should not take Invega. Invega is not
approved by the FDA for use in this population because it
increases their likelihood of death via stroke or ministroke during
treatment (American Hospital Formulary Service, 2017).
 It is crucial for the RT to know that the person who is currently
incarcerated might be experiencing unsteadiness and weakness. The
interventions they can participate in will be limited if they are
experiencing these side effects.
 Propranolol
o Dosage
 The person who is currently incarcerated was given a once-a-day 10 mg
prescription for Propranolol on 10/29/2021.
o Classification
 Propranolol is classified as a noncardioselective beta-blocker + diuretic
(Haymarket Media, Inc, 2022).
o Side Effects
 Propranolol can display some mild side effects, and the person who is
2017):
 Dizziness or lightheadedness
 Tiredness
 Diarrhea
 Constipation
o Adverse Reaction
 The person who is currently incarcerated might experience an adverse
reaction to Propranolol. If that is occurring, the following symptoms can
be indicators (American Hospital Formulary Service, 2017):
 Rash/hives/itching
 Blistering or peeling skin
 Swelling of the face, throat, tongue, or lips
 Feeling faint
 Weight gain
 An overdose on Propranolol can be lethal, the symptoms of which need to
be monitored. The following items are possible indicators of an overdose
 Slow heartbeat
24
 No special populations to note for Propranolol
 The RT should be a way that if the person who is currently incarcerated
stops taking the prescription suddenly, it can lead to a heart attack. This
information is vital for the RT if the person who is currently incarcerated
begins to experience the symptoms of a heart attack during an
intervention.
Past Medications
 Paliperidone (Invega)
o Dosage
 The person who is currently incarcerated was given a prescription of one 6
mg tablet of Paliperidone per day. This medication has now been
discontinued as the person who is currently incarcerated changed dosages.
o Classification
 See Invega under current medications
o Side Effects
o Adverse Reaction
 Risperidone
o Dosage
 The person who is currently incarcerated was given a prescription that is
now discontinued of 3 mg per day (1 mg in the AM and 2 mg in the PM)
on 11/04/2021.
o Classification
 Risperidone is classified as an atypical antipsychotic used to treat acute
manic or mixed episodes associated with bipolar I, schizophrenia, and
schizo spectrum disorders (Haymarket Media, Inc, 2022).
o Side Effects
 Risperidone can induce some side effects in those that take it. The person
who is currently incarcerated should be aware of the following indications
and request to speak with the provider if they do not go away (American
Hospital Formulary Service, 2022):
 Nausea/vomiting
 Diarrhea/constipation
 Heartburn
 Dry mouth/increased saliva
25
 Increased appetite
 Weight gain
 Stomach pain
 Anxiety
 Agitation
 Restlessness
 Dreaming more than usual
 Difficulty falling asleep or staying asleep
 Breast enlargement or discharge
 Late or missed menstrual periods
 Decreased sexual ability
 Vision problems
 Muscle or joint pain
 Dry or discolored skin
 Difficulty urinating
o Adverse Reaction
 Risperidone can cause an adverse reaction. The person who is currently
incarcerated should be aware of the indications of a reaction and request to
speak with the provider immediately if any become present. The following
are indicators of an adverse reaction (American Hospital Formulary
Service, 2022):
 Fever
 Falling
 Confusion
 Fast or irregular pulse
 Sweating
 Unusual movements of face or body that cannot control
 Faintness
 Seizures
 Slow movements or shuffling walk
 A Risperidone overdose can be lethal, although rare. In the event of an
overdose, the following are the indicators (American Hospital Formulary
Service, 2022):
 Drowsiness
 Fast, pounding, or irregular heartbeat
 Upset stomach
 Blurred vision
26
 Fainting
 Dizziness
 Seizures
 Important Note
 Risperidone should not be given to older adults with dementia.
Older adults with dementia can have a stroke or ministroke when
on Risperidone as it increases their likelihood of these events
occurring. The FDA has not approved Risperidone for use in older
adults with dementia.
 As an RT, it is critical to know that be aware of all the potential
contraindications for interventions that can occur for the person who is
currently incarcerated. How they react to the medication will depend on
what they can do (American Hospital Formulary Service, 2022.
 Geodon (Ziprasidone)
o Dosage
 The person who is currently incarcerated was given prescriptions of both
40 and 60 mg tablets of Geodon.
o Classification
 Geodon is classified as a serotonin and dopamine antagonist used to treat
schizophrenia (Haymarket Media, Inc, 2022).
o Side Effects
 Geodon can induce some side effects in those that take it. The person who
is currently incarcerated should be aware of the following indications and
request to speak with the provider if they do not go away (American
Hospital Formulary Service, 2018):
 Headache
 Restlessness
 Anxiety
 Lack of energy
 Constipation/diarrhea
 Loss of appetite
 Muscle pain
 Stomach pain
 Runny nose
 Cough
 Weight gain
 Breast enlargement or discharge
 Late or missed menstrual period
 Decreased sexual ability
o Adverse Reaction
27
 Geodon can cause an adverse reaction. The person who is currently

incarcerated should be aware of the indications of a reaction and request to
speak with the provider immediately if any become present. The following
are indicators of an adverse reaction (American Hospital Formulary
Service, 2018):
 Fast, irregular, or pounding heartbeat
 Blisters or peeling of skins
 Mouth sores
 Swollen glands
 Fever
 Chills
 Shaking
 Falling
 Confusion
 Sweating
 Loss of consciousness
 A Geodon overdose can be lethal, although rare. In the event of an
overdose, the following are the indicators (American Hospital Formulary
Service, 2018):
 Drowsiness
 Slurred speech
 Sudden movements that cannot be controlled
 Anxiety
 Important Note
 Geodon should not be given to older adults with dementia. Older
adults with dementia can have a stroke or ministroke when on
Risperidone as it increases their likelihood of these events
occurring. The FDA has not approved Risperidone for use in older
adults with dementia (American Hospital Formulary Service,
2018).
 It is vital for the RT to be aware of previous use of Geodon for the
individual who is currently incarcerated. Despite being off the medication,
the medication can still be built up in their system for some time the side
effects can create contraindications for interventions.
28
Summary
In summary, when it comes to Smith and their medications. It can be concluded that they
are being medicated for their schizoaffective disorder. After diving further into the medications,
one of the biggest questions that gets raised concerning Smith could be being over medicated for
schizoaffective. The question is raised because they are on two different antipsychotics in Invega
and Aristada. It is not uncommon for multiple antipsychotics to be used. However, according to
the Aristada manufacturer, 1064 mg is a two-month dosage ( ALKERMES®, 2022). She has
been on this dose for five months, which means that they have received ten months of worth of
the drug. As an RT, this should be concerning, and the advocacy for the person who is currently
incarcerated should be.
Overall, the medications seem to work relatively her. From observations, there is a
reduction in responses to internal stimuli and fewer manic episodes. Smith can participate in the
weekly gym groups. Showing little to no side effects of their medications, they can perform
yoga, high-intensity interval training workouts, and free gym time where they play basketball.
She does not appear to have any trouble walking or moving. Smith can partake in art groups and
work on cognitive skills and coping skills.
Within the Utah State Prison, one of the biggest concerns with all the people who are
currently incarcerated is them being taken advantage of for their medications of "strong-armed."
As an RT, it is critical to observe sudden changes in the person who is currently incarcerated’s
behavior. The RT typically notices this first because of the type of interactions with the people
who are currently incarcerated. Currently, Smith has seen a sudden change in their behavior, and
the RT believes that they are being strong-armed for medications. Since then, their advocacy has
begun with the provider, commanding officers, and therapists to make sure that they are
receiving their medications.
Goals and Objectives
For Smith, the development of the case study went forward into building some
goals and objectives for her. The primary focus of these goals and objectives was to help her
with the most salient problems. As RTs making sure that goals and objectives are working on
different things is just as vital as ensuring that a long-term end vision is the same. Suppose they
are not working to improve the quality of life, physical health, and overall well-being of the
individual; the goals need to be reassessed. The following is a list of Smith's presenting
problems, strengths, and the goals and objectives created for her as part of the case study.
Presenting Problems: Responding to internal stimuli, Manic episodes, potentially being
taken advantage of for medications, communication with peers and family, negative self-talk.
Identified Strengths: Willingness to work, wants not to repeat mistakes, eager to get
back to the general population.
Goals and Objectives:
1. Responding to internal stimuli

a. Goal
i. Increase the number of coping skills that the person who is currently
incarcerated can use when responding to internal stimuli
b. Objectives
29
i. The person who is currently incarcerated will write down three

positive affirmations that they can repeat to ground themselves when
responding to negative internal stimuli without assistance from the RT.
ii. The person who is currently incarcerated will perform High-Intensity
Interval Training during the gym groups two times to help decrease
response to internal stimuli with two verbal prompts from the RT.
iii. The person who is currently incarcerated will collage their positive
coping strategies to reduce the negative response to internal stimuli
during an art-based intervention with only three prompts from the RT.
2. Communication
a. To increase effective communication skills for the person who is currently
incarcerated.
b. Objectives
i. The person who is currently incarcerated will effectively communicate
one movement for the group to perform during the High-Intensity
Interval Training group with only one prompt from the RT.
ii. The person who is currently incarcerated will share their three favorite
coping skills with the group without assistance from the RT.
iii. The person who is currently incarcerated will communicate the rules to
the card game rummy with their peers with less than three verbal cues
from the RT.
3. Negative self-talk
a. Goal
i. To progress towards positive self-talk
b. Objectives
i. The person who is currently incarcerated will complete their self-talk
journal from the Crossing Bridges program within one week of it
being assigned and with zero verbal prompts from the RT.
ii. The person who is currently incarcerated will complete the core beliefs
segment of the Crossing Bridges program within one week of it being
assigned with only two prompts from the RT.
iii. The person who is currently incarcerated will complete the reframing
section of the Crossing Bridges program within one week of it being
assigned with three prompts from the RT.
Intervention Protocol
To ensure that Smith was working towards the aforementioned goals a new intervention
was designed specifically for people who are currently incarcerated—keeping in mind the sexist
restraints that an RT faces within the Utah State Prison, especially when working with females
who are currently incarcerated. Financial limitations were another factor that had to be brought
into the evaluation process when designing an intervention. On top of that, the therapists who
work with the females of the Timpanogos mental health unit do not want the RT to do any
groups that may trigger the currently incarcerated people. Their reasoning behind this is that the
30
women become too emotional when trigged, making them harder to control. This was learned
when the RT would run the same groups for the women as the men, and the therapists did not
like the fact that the groups would invoke a response from the people who are currently
incarcerated. Despite ensuring that everyone was okay when leaving the group and if not, they
would get the appropriate care to ensure they were okay. That was not enough for the therapists
on the Timpanogos mental health unit. Instead of wanting to help the people who are currently
incarcerated, the response was to try to control all aspects of the RT groups to ensure there was
nothing trigger that could occur. If an RT is doing their job correctly within mental health, some
amount of triggering is going to occur during groups; that is what is required to build the skills to
overcome them. Taking all of this into consideration, the following intervention was developed
for the people who are currently incarcerated:
 Program Title (Process Criteria)
o The Exquisite Individual
 General Program Purpose

o A mindfulness-based art program designed to use interactive group work with
people who are currently incarcerated with mental health diagnoses
 Program Description
o The program is designed for people who are currently incarcerated with mental
health diagnoses that range from substance use disorders, mood disorders, anxiety
disorders, personality disorders, and schizophrenia-spectrum disorders aged from
18 and older. The people who are currently incarcerated are in the Utah State
Prison inpatient mental health facilities. They vary in their incarceration times,
with some recently incarcerated and some having been incarcerated for years. The
Exquisite Individual is a group of interventions using the techniques of
mindfulness-based art. Through this group, people who are currently incarcerated
are allowed to freely express how they see and feel themselves in their
environment. By using prompts about emotions, the people who are currently
incarcerated can begin to cope with the feelings those emotions invoke by staying
grounded in the mindfulness exercises. People who are incarcerated can grow in
their ability to work with each other and grow individually in their coping skills.
 Specific Population
o Diagnosis
 Schizoaffective Disorder
o Age
 32
o Gender
 Cisgender Female
 Program Set-up
o Group-based (two or more)
31
 Program Outcomes
o The participants in the intervention will see an improvement in their ability to stay
in the present moment.
o The participants will be able to demonstrate an ability to express emotions
through mindfulness-based art.
o The participants will be able to use coping strategies to help with overcoming
feelings invoked by emotions during the interventions.
 Client Problems
o Impaired Mental Health
 People who are currently incarcerated will often have a comorbid disorder
and their primary mental health diagnosis. The skills learned through The
Exquisite Individual program can help with primary and comorbid
diagnoses through mindfulness-based art that has been shown to improve
depression, anxiety, sleep, and perceived stress (Beerse et al., 2020;
Goodarzi et al., 2020; Meghani et al., 2018)
o Impaired Physical Health
 People who are currently incarcerated may be experiencing problems with
their physical health. The Exquisite Individual program does not require a
large number of physical capabilities. Mindfulness has been shown to
improve physical health (Creswell et al., 2019).
o Negative self-talk
 People who are currently incarcerated may struggle with self-talk.
Negative self-talk can worsen an individual’s performance and adherence
to goals (Latinjak et al., 2018; Walter et al., 2019). The Exquisite
Individual program provides people who are currently incarcerated with
ways to improve their self-talk throughout the program. Mindfulness
decreases negative coping skills like self-talk and increases self-regulation
(Fuente et al., 2018).
o Responding to internal stimuli
 Responding to internal stimuli is a concern with the bulk of diagnoses of
people who are currently incarcerated. The Exquisite Individual program
uses mindfulness to keep people who are currently incarcerated in the
present moment without judgment (Meghani et al., 2018).
 Activity Intervention
o Mindfulness-Based Art (The Exquisite Individual)
 Group Drawing is based on the art game the exquisite corpse, in which
people who are currently incarcerated will draw a picture in sections based
on a prompt given by the RT. They do not see what the previous person
contributed to the picture creating a unique group picture. (Gotthardt,
2018).
32
o Supplies and equipment

 Paper (1 sheet for the group)
 Pencils
 Pens
 Markers
 Desks or tables
 Radio (to assist in mindfulness)
 Music (mindfulness-based meditative music)
o Intervention Implementation
 A small group of five or less remain in one group for the duration of the
intervention.
1. Go over the group activity and rules, and conduct a check-in
activity.
2. Instruct the people who are currently incarcerated to pick what
they want to draw with and assist them in getting these supplies.
Then take the sheet of paper and fold it (hamburger style) into
enough sections for the group.
o 1-fold = 2 sections
o 2-folds = 3 sections
3. Give out the prompt on what the drawing will be (a person, place,
thing)
4. Begin a mindfulness activity (body scan, paired muscle relaxation,
breathing exercises, etc.)
5. Hand the paper to the first person who is currently incarcerated.
Allow them about five minutes to draw. While they draw, continue
to lead the group in mindfulness exercises.
6. After five minutes, instruct the first person who is currently
incarcerated to extend any lines across the folded line, so the next
person who is currently incarcerated knows where to begin
drawing.
7. Take the paper, fold the first section over to keep it hidden, and
hand it over to the next person who is currently incarcerated.
8. Repeat steps five through seven until every person who is currently
incarcerated has been able to draw.
9. Safely end the mindfulness
10. Reveal their drawing and process.
 For a large group, six or more divide up into equal groups of at least four
people who are currently incarcerated per group.
 Go over the group activity and rules, and conduct a check-in
activity.
33
o Instruct the people who are currently incarcerated to pick what

they want to draw with and assist them in getting these supplies.
Then take a sheet of paper for each group and fold it (hamburger
style) into enough sections for each person who is currently
incarcerated in the smaller groups.
o 1-fold = 2 sections
o Give out the prompt on what the drawing will be (a person, place,
thing)
o Begin a mindfulness activity (body scan, paired muscle relaxation,
breathing exercises, etc.)
o Hand the paper to the first person who is currently incarcerated in
each group. Allow them about five minutes to draw. While they
draw, continue to lead the group in mindfulness exercises.
o After five minutes, instruct the first person who is currently
incarcerated in each group to extend any lines across the folded
line, so the next person who is currently incarcerated knows where
to begin drawing.
o Take the paper, fold the first section over to keep it hidden, and
hand it over to the next person who is currently incarcerated in
each group.
o Repeat steps five through seven until every person who is currently
incarcerated has been able to draw.
o Safely end the mindfulness.
o Reveal their drawings and process.
o Processing Questions
 How did drawing together make you feel?
 Do we have to stay with those feelings, or can we use something
we did today to get past those feelings?
 Why is it important to express our emotions in ways that do not endanger
us?
 What was the best part of the activity?
 How can you use what was practiced here today back in section when
things like negative self-talk or your emotions overwhelm you?
 What is one thing that each of you can take away from the drawing?
 If you cannot draw or use mindfulness like this, what is something that
you could do to help overcome your emotions?
34
 License/National Certification/ Specialty Certification

o TRS
o CTRS
o A mindfulness training certification (preferred but not required)
Intervention Report
The Exquisite Individual was a successful intervention only one person who is currently
incarcerated did not enjoy the group. That person who is currently incarcerated did not enjoy the
group because they were having an off day and did not fully understand what was going on.
However, some participation was accomplished through brief one-on-one, more in-depth
direction. All other nine of the people who are currently incarcerated enjoyed the group and were
able to take something away from it. A few critical things need to be highlighted as a group
facilitator. It is just as essential to pat our backs and celebrate the successes but go on to humble
ourselves and admit where we need to improve.
Some areas for improvement are time management, mindfulness techniques, and group
management skills. Time management because the group was only one hour long, and I was
stuck in the room without an accurate clock. Therefore, I quickly lost track of how long I spent
on one technique or letting one person draw. This did not allow some currently incarcerated
people to be afforded the same amount of time to draw as others. As a provider, I must keep
things equal so that those I am serving do not think there is a sense of favoritism. A few ways
that I could have resolved this mistake would have been to use the clock at the wrong time to
keep track of the hour. Since I did not know that the clock was inaccurate, I did not know to wear
a watch; however, going forward, I can wear one every time I facilitate. To ensure that this
mistake does not occur again. The mindfulness techniques went relatively smoothly, so it might
be a surprise as to why I have them under an area of improvement. I placed them here because
this was my first time facilitating mindfulness for a group. Even though it went well, I can
continuously improve my ability to facilitate paired muscle relaxation, body scans, and boxed
breathing. I can improve my tone and pace and explain what the people who are currently
incarcerated should be experiencing. It was their first exposure to mindfulness for many of them.
Group management skills are probably the most significant area that needs some
improvement. One currently incarcerated person was highly anxious and unable to sit still. For
them, this was a pattern going on for several weeks, and they began cross-talking and moving
around the room. Their actions began to disrupt the rhythm of the group. I tried to redirect them
and get them grounded by switching the mindfulness technique to something that would help
them to let out some energy rather than sit still. After doing paired muscle relaxation, there was a
moment of calmness, and the group could proceed. However, that was a short-lived moment of
success, and they were back to their cross-talk. I failed the group and them as a provider by not
being able to control the group and redirect them. My rotation supervisor controlled them, and I
just continued with the group. As a provider, I am not able to ignore an individual that is in the
group. I need to manage that and find a way to make the group work. Especially in the prison
setting when they cannot leave the group without a movement being called to take them back. I
learned how to do this from the supervisor by observing their engagement with the individual.
35
The things that went well in the group were the drawing, mindfulness, and group
processing. The drawing and the prompt were a nervous focal point going into the group. In all
the art groups before, the people who are currently incarcerated were working on independent art
projects. The Exquisite Individual would be asking them to work together to create something.
The group has an opening for conflict; within the prison environment, a conflict between people
who are currently incarcerated is something to be avoided. Within all recreational therapy
groups, it should be avoided as well. To my surprise, I let them know it was a group drawing,
and they were excited. When I told them that the prompt would be joy, they were less excited.
However, that excitement came right back when I gave them some autonomy and let each group
of five choose if they wanted to draw a person, place, or thing. One group chose a person and the
other a thing. So, with sheets that were folded hamburger style into fifths, one group attempted to
draw a complete picture of a person that brings them joy, while the other was attempting a thing
that brings them joy. The drawings came out so unique and abstract that they accurately reflected
every individual and how they were feeling currently. The person image started with a head and
eyes, then went to water and an ocean. Next was a set of shoulders with a staircase in the chest
and a pair of upside-down legs before finishing off with another complete head. The drawing of
a thing ended up being an image of a family, then an outside scene before going to a heart. A list
of words followed, and an image of someone's grandma finished it off. They perfectly displayed
the busyness of the minds of people who are currently incarcerated while showing the positive
things in life.
Mindfulness was listed as something that could be improved on but is here as something
that went well. There are two perfect reasons why it is here as something that went well. The first
is about the case study of Smith. Smith had been going through a period of manic episodes and
responded to negative internal stimuli the week before. During this group, they could partake in
all the mindfulness techniques and verbally indicated the calmness they were feeling. Smith was
also able to remain present and remain engaged in the group in its entirety because of the
mindfulness, which they could not do the week before. While that was a big win, the biggest was
with another person who is currently incarcerated. The week before this group, they could not
partake in the art group due to a significant, aggressive response to negative internal stimuli.
They took an aggressive posture and ran towards the RT. During this action, they indicated that
the RT used voodoo to kill her baby while punching herself in the stomach. In the days following
the section, therapists reported they were experiencing delusions tied to another person who is
currently incarcerated and mixing their menstrual blood with bleach and attempting to drink it.
With these reports and the previous week's actions, it was uncertain how The Exquisite
Individual would go. To the surprise of the RT, section therapist, and myself, this person who is
currently incarcerated was engaged in the group drawing and mindfulness. The most significant
part was that they appeared to be in a Zen-like state, as reported by the RT. During the
mindfulness, they were fully engaged and saw relief from all of them. They even express
excitement and joy after the body scan "I, really, really love that. I almost fell asleep. I want to
do that before bed. Can I do that again?" This was when I knew the group was a success because
of their reaction.
When it came to group processing, it is something that I say was successful as well, and
this is because of a curveball that came before the group. On the way to the group room, one
person who is currently incarcerated did not want to engage in the group. While waiting for the
group room to be unlocked, they proceeded to have a pseudo-seizure. Therefore, the code of IMS
36
had to be called to tend to them. At this point, the remaining people who are currently
incarcerated were moved inside the group room with me. The RT had to remain outside to tend
to the code with the correction officers. Instead of standing in silence, the first thing I did was
ask everyone how they were feeling about the seizure. I refrained from calling it a pseudo seizure
to them as they all believed she was having one and that individuals are entitled to their medical
conditions' confidentiality even if they are not real. Together as a group, we began processing
their feelings and moved into what good things happened during the week. When they wanted to
go to negative things, I could redirect them back to good things. We processed mindfulness and
emotions throughout the group as they came up. Everyone was staying engaged, and I was able
to push individuals who were not responding to get in on the actions, which helped to change the
dynamic of the whole group.
For all of the reasons above, I am confident in saying the group was a success and helpful
for the majority of the people who are currently incarcerated. The RT at the prison enjoyed the
group and complimented me on a well-designed and run group. The RT at the prison plans to run
The Exquisite Individual with the males who are currently incarcerated as they believe that it will
be successful in helping them as well again, though there is always room for growth.
Case Study Response to Intervention
The following is a copy of a documentation S.O.A.P. note for Smith following the
intervention. Despite the Utah State Prison using a charting system tied to the DSM-III and just
as outdated, a S.O.A.P. note was made to be in accordance with the National Council for
Therapeutic Recreation Certification (NCTRC) Job Task Analysis regarding documentation. The
current system the Utah State Prison uses does not allow for S.O.A.P. notes as it is driven by an
activities provider scope and not an RT focus.
S: Smith appeared not to be responding to negative internal stimuli AEB her ability to remain
focused on the task of drawing when it was her turn. Smith communicated that she felt "annoyed
and upset when the drawing was taken away and passed along before she was finished." Smith
expressed her enjoyment of the intervention by communicating effectivity to the RT.
O: Smith did not need a cue to remember the prompt to draw something that brings you joy.
Smith was engaged in all aspects of the group AEB her willingness to close her eyes and engage
in a body scan and other mindfulness techniques. Smith processed the emotions of being
annoyed and upset with the group AEB engaging in a group conversation about coping skills.
A: Smith was able to effectively remain present during the entirety of the group by using
mindfulness techniques. She was also able to effectively process emotions of annoyed and upset
AEB her communication of said emotions and group communication about coping skills.
P: Moving forward, Smith needs to continue to engage in mindfulness at least two times a week.
As mindfulness was something she said helped her to remain present. Smith should also engage
in The Exquisite Individual group at least once a month.
Evaluation
Overall, the time spent observing Smith and the other people who are currently
incarcerated was a fantastic experience. Working with these people who are currently
37
incarcerated within the mental health setting was even more rewarding than intentionally
anticipated. With experience as a person who was previously incarcerated, getting back to a
setting that I was familiar with was a slight concern in the beginning. There was some uneasiness
about how I would handle being back inside a corrections facility. However, this time being a
provider was a lot different and incredibly eye-opening. The corrections facilities in California
and Utah can have vast differences. Likewise, there are many similarities.
Having the opportunity to learn from Katie has managed to influence not just my RT
education and career but my life. She goes above and beyond to ensure that the people who are
currently incarcerated are getting the best possible treatment and care. Be advocating for the
earlier release of people with quickly progressing dementia being held in a cell with no mattress
or toilet for 23 hours a day. She is advocating to lower the number of days that a person who is
currently incarcerated can spend in solitary confinement after working with people who are
currently incarcerated and who have spent 2,000 plus days locked in solitary confinement.
Alternatively, she even placed herself on a committee to ensure that a new charting system will
utilize the current version of the DSM. She has been an impeccable example of the advocacy that
is RT. Along with the lessons in advocacy, she was instrumental in teaching me how to build
rapport with individuals I can closely identify with. Katie showed me how to do this without
crossing the lines of professional and friend.
Seeing how Smith responded to an intervention that was designed specifically for people
who are incarcerated was a highlight of the case study experience. A low point of the experience
was learning how to process a suicide of a person who is currently incarcerated. When providing
groups for people who are currently incarcerated, it is painful to learn of one of them taking their
life. This was an important lesson for me to learn. With a long history of suicide, I began to
struggle with how to separate my feelings and help the people who are currently incarcerated.
Katie was critical in showing me how to do that and how to take time for me and process it when
it is okay. The changes that I witnessed in not just in Smith but in all the people who are
currently incarcerated provided proof that mental health is the population I want to work in. The
process of this case study opened the idea of working specifically with people who are currently
incarcerated.
Shane Brooks TRS, CTRS (Licensure, Certification) April 29, 2022

38
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CASE STUDY SCHIZOAFFECTIVE DISORDER

Person Who Is Currently Incarcerated with Schizoaffective Disorder

RECTH 4330 RT and Mental Health Services

Professor Dr. Steven Bell

April 29, 2022

Page 3 of CERT-Psych/R for case study Smith

o Substance abuse of psychoactive drugs such as LSD may worsen the

Traditional pharmacology reports would not be included in a case study. However,

 As an RT, it is crucial to know if the person who is incarcerated is on

the best interest of the person who is currently incarcerated (Haymarket

 For the person who is currently incarcerated, a 9 mg tablet dosage once a

 Geodon can cause an adverse reaction. The person who is currently

Goals and Objectives:

1. Responding to internal stimuli

i. The person who is currently incarcerated will write down three

 General Program Purpose

o Supplies and equipment

o Instruct the people who are currently incarcerated to pick what

 License/National Certification/ Specialty Certification

Case Study Response to Intervention

Shane Brooks TRS, CTRS (Licensure, Certification) April 29, 2022

ALKERMES®. (2022). Aristada initio® (ARIPIPRAZOLE LAUROXIL) and Aristada®

American Therapeutic Recreation Association. (2015). Standards of practice - american

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