RCLS 450 Assessment Techniques for Therapeutic Recreation

Case Study

Molly McDonald

10/21/17
1) Client information: Tim; 28 year old White Male.

2) Diagnosis: Social and Acute Anxiety and Schizophrenia with Auditory and Visual

Hallucinations and Delusions. (Unexplained Psychosis, Depression, suicidal thoughts/

tendencies.)

3) Medical History: Paternal Grandfather died of cancer. Father has heart disease,

mental disorders, depression, and anxiety. Mother addicted to and using

Methamphetamines during pregnancy. Client born with Methamphetamine addiction.

Diagnosed with Social Anxiety at age 15, recommended Therapy Animal for coping.

In process of Schizophrenia diagnosis confirmation/ Second opinion. Taking

Antidepressants and may begin antipsychotics. Sleep Apnea due to excessive weight

(currently untreated). Smoking (cigarettes and cannabis) since age 11. Recreational

drug use since age 13. Bilaterally knee injuries at age 24 (not treated).

4) Functional Abilities/Limitations/ Adaptations: Client maintains a sedentary lifestyle,

client has poor cardiovascular health. Requires low impact exercises due to Knee

injuries. Poor posture due to occupation requiring standing for over 9 hours at a time.

Cant go into public without service animal or well-known companion. Client states

hallucinations; I cant do shit when I see something, my body goes stiff, its

debilitating.

5) Social History: Parents and Step parents addicted to various drugs and alcohol

(mainly Meth), Client endured 11 years of physical, verbal and mental abuse and

neglect by parents, step- parents and older siblings. Client recalls having a bodyguard

assigned by his mother after client was stabbed with a pencil twice in the back, at

school because of his mothers criminal/ gang affiliations. Mother was a gangster,
 pimp, and stripper. Client recalls prostitutes around his home growing up. Clients

home was a target for gang and family violence. Client moved in with his

grandmother intermittently during childhood (summers and for a few months at a

time as parents were in and out of jail). Never experienced abuse while in

grandmothers care. Grandmother lived in Montana. Client experiences sense of calm

and associates nature and outdoors with safety and security felt while in

grandmothers care. Graduated high school, went on to gain two culinary degrees

from Le Cordon Bleu. Client currently lives with father who is on the verge of relapse

every day but has been clean from Meth for 10 years.

6) Scoring according to Leisure Attitude Measurement on page 236 of the Redbook.

Cognitive score 2.9, Affective Score 4.5, Behavioral Score 4.3. While none of these

scores are considered low; it is clear that this client needs some work on their

leisure attitudes. Leisure is an important piece of mental health and for this client

could relieve stress from delusions or hallucinations as well as build real world

connections with peers.

7) Client needs coping mechanisms to deal with stress associated with social anxiety,

delusions and hallucinations. Client also needs low pressure activities to increase

socialization without triggering social anxiety. Client could also benefit from

moderate cardiovascular exercise to ease symptoms of Sleep apnea which is

aggravated by clients excess weight.

8) Goal: Client will increase social interaction

Objective:
 Client will organize at least one activity per week with a friend or coworker

with 100% accuracy

Client will talk to a friend at least once per week on the phone or in person

with 100% accuracy.

Client will attend one community event per month with or without a friend

9) Client agrees with interventions and would like to invite friends to go to the dog park,

come over to work on dirt bikes/ motorcycles, or go kayaking once per week. Client

wills also attend dirt bike races/ demolition derby events once per month.

10) Client wants to learn new coping mechanisms for social anxiety and delusions so that

he can expand his leisure activities. His comfort animal becomes uncomfortable at

loud events such as demolition derbies, motocross races, and car shows.

11) Client will continue to explore leisure interests and will explore interests of friends to

strengthen relationships.

12) I learned that depending on the person, a deeper explanation of the assessment I am

giving may be required. If I were giving the assessment in a professional setting I

would have to note on the back side of the assessment that my client became

increasingly irritable with each question, asking how any of these questions had

anything to do with him, the assessment was stupid and none of this information will

be something that could help him. I may have chosen the wrong assessment but I

discovered that he doesnt realize how isolated he is, and drawing this to his attention

has increased his socialization. He has reached out to a different friend each day (text

messaging is a start). He has gone to the dog park with a coworker, the dog park

allows him breaks from intense eye contact or conversation and also exposes him to
small talk with strangers. He just had a group of high school friends over tonight and

was able to effectively communicate to three people that he had been up since 3am

and was ready to go to bed.