TREATMENT A rocky start
At Mr. A’s initial assessment, the clinic psychiatrist increases risperidone to 1 mg twice daily to target aggression. Even after receiving this dosage for 1 month, however, Mr. A continues to display physical aggression toward peers in the group home whenever he becomes angry.
The psychiatrist refers Mr. A to a social worker for supportive therapy to help him cope with worry and chronic sadness. The social worker uses general cognitive-behavioral strategies for anxiety and aggression for 12 sessions over 8 months until scheduling conflicts end therapy. The efficacy of this therapy is minimal; Mr. A remains depressed, anxious, and aggressive. During this time, the psychiatrist increases paroxetine to 40 mg/d, but Mr. A continues to feel depressed after 1 month. Mr. A is cross-tapered to duloxetine, but continues to feel depressed after receiving duloxetine, 60 mg/d, for 1 month.
My first visit with Mr. A occurs 3 months after his last visit with the social worker. He states he does not remember anything from those sessions. Mr. A’s goals for therapy are to reduce anxiety, manage anger, and improve relationship skills.
I begin the first 4 months of Mr. A’s therapy with cognitive-behavioral interventions based on the Treatment of Adolescents Depression Study (TADS) manual.3 Although Mr. A is an adult, I choose a manual that targets adolescents because my clinical impression is that his cognitive developmental level is more like an adolescent’s than an adult’s.
I assign homework such as mood monitoring. I ask him to use a form from the TADS manual to rate his mood on a scale of 0 to 10 every morning, afternoon, and evening, and write down what he is doing that makes him feel that way at the time he rates his mood. Mr. A never completes any homework; during each session he states he “just forgot to do it.”
I discuss concepts such as goal setting, for a novel Mr. A says he wants to write, and relaxation strategies to address anger; in session, I work with him on filling out the “What Helps Me to Relax?” form from the TADS manual. Mr. A lists “play games,” “write my book,” “listen to music,” “go outside,” and “exercise” as strategies to help him relax. We also work on visual handouts—such as “Safety Plan” and “What Can I Do to Relax”—to post in his room.
Mr. A does not show up for 3 sessions. When I call the group home, a staff member tells me they were busy with other patients and forgot about Mr. A. I decide to call the group home the day before each appointment as a reminder. This increases Mr. A’s attendance rate.
During each session, Mr. A complains about the quality of the group home, the staff, and other patients. To get my own perspective of Mr. A’s living environment, I consider visiting his group home, similar to how a geriatric psychiatrist sees patients in a nursing home or an assertive community treatment team psychiatrist sees patients in their home environments. Because I am concerned about boundary crossings/violations, I first discuss this action with 2 psychotherapists not involved in Mr. A’s treatment. They recommend that I limit this action to a one-time visit.
I visit Mr. A’s group home 2 months after my first session with him. Located in front of a dairy farm in a rural part of the state about 1 hour from our clinic, the isolated facility has a secured keypad entry. When I meet Mr. A there, he says he feels as if he is in jail. I meet the staff and find them willing to help with various aspects of Mr. A’s treatment, such as discussing events, reporting behaviors, and helping carry out interventions.
For example, I ask staff to remind Mr. A of his relaxation strategies when he becomes angry. On the “Safety Plan” handout, I had Mr. A identify 5 people he could talk to when he becomes angry; I ask staff to remind him of those people when Mr. A becomes angry. I also ask staff to ask Mr. A every day if he is writing the novel he wants to complete. After my visit, Mr. A starts putting more effort into therapy. When I set a daily goal of working on his novel for 15 minutes, he starts bringing pages of his writings to sessions.
Table 2
Social skills training for patients with Asperger’s disorde