Working with people experiencing enduring mental health problems
The purpose of this assignment is to select a client with the diagnosis of enduring mental illness and carry out an assessment based on the presenting problem of the chosen patient and the psychosocial intervention during his treatment. From the assessment process, the problem identified will be considered along with patient coping strategy, stress, medication compliance and family intervention. The author will also identify intervention that aim to promote recovery with the patient. Gibbs (1988) Model of Reflection cited in Burns and Bulman (2000) will be utilised to evaluate the care of the patient.
To maintain confidentiality and protect anonymity, a pseudonym of John will be given to the patient; this is in compliance to Nursing and Midwifery Council (NMC) Code of Professional Conduct (2008). John is a 40 year old man of Africa Caribbean origin, living independently in the community. John experiences unpleasant and hostile auditory hallucinations mainly describing his actions and his thoughts. This normally happens when he is out of the house, in public places and at shops. He claims that he also hears these voices when alone and inactive at home usually in the evenings and at night. These experiences make him feel angry and frightened.
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John also experiences that other people can read his mind, this is particularly true of some teenagers in his neighbourhood whom he thinks are out to get him. He receives six hours support from the support workers every week to help maintain his mental health and independence as it is the organisation's philosophy to provide this support in order to allow patients to continually work towards an ordinary life. John is diagnosed with paranoid schizophrenia because he suffers from stable delusions, usually accompanied by hearing voices and disturbance of perceptions (The Diagnostic and Statistical Manual IV, 1994). The DSM IV, of Mental Health criteria for schizophrenia states that two or more of the above must be present for a significant period of time during one month period for a diagnosis to be made. John was previously admitted onto a psychiatric ward for eight months. Schizophrenia is a common disorder and has a devastating effect on sufferers and their families - patients typically hear voices in their heads and hold bizarre beliefs. On discharge from the ward, John was offered accommodation where he could live independently with the support he wants in the community.
John is the second of three children born from one father. Pregnancy and delivery were normal, and developmental milestones were accomplished on time. History of the patient's father is unknown. John's elder brother is in prison for robbery and the other has had a number of admissions to psychiatric hospital with diagnosis of schizophrenia. During assessment, John was described by his mother as a shy boy and reports never having any close friends and knew primarily the street boys he hung around with. He has had a sexual relationship with a neighbourhood girl in the past but never had a steady girl friend. John reports that he never liked school and dropped out in his early age. He has never worked and lived at home until his first admission into mental health hospital three years ago. His mother who has her own mental health problem (Depression) is his primary source of emotional support and his main carer. His medical history and examination proved him healthy as there was no record to show that he has suffered any serious aliment, however he admitted to poly drug use including alcohol, cannabis and crack cocaine. He currently smokes a pack of twenty cigarettes a day. His general health is good at this moment.
Through observation and talking with John, it became apparent that he suffers from anxiety and low mood. Davis et al. (2007) stated that anxiety plays an important role in producing and maintaining dysfunction in schizophrenia but these symptoms are often overlooked or viewed as less important than the positive and negative symptoms. At present, John does not appear to be experiencing any symptoms of schizophrenia although his low mood and anxiety are something he expresses as hurdles he has to battle with on a daily basis. The medication he receives for anxiety and low mood seem not to be eliminating the symptoms he suffers, although the medications are being reviewed to determine the correct therapeutic dose he requires (Lieberman and Tasman, 2006). He lacks motivation and self esteem, and due to his level of anxiety he finds it difficult to enjoy the amenities within his local community.
Full assessment to determine John's mental health needs with specific assessments for his anxiety and low mood, where he can be supported to develop coping strategies which may assist his daily activities and engagement in activities where carried out. Assessment is an ongoing process which allows for all records and interventions to be current and up to date. Following an accurate and comprehensive assessment other elements of the nursing process such as planning, implementation and evaluation can be applied (Callaghan and Waldock, 2006). To carry out John's care, the author carried out Krawiecka, Goldberg and Vanghu (KGV) assessment and one to one session in partnership with John and his main carer.
The KGV Manchester Symptom Scale modified version 6.2 by Stuartand Lancashire (1998) is a global assessment tool that allow nurses to carry out an assessment of the service user to ascertain symptoms severity and incidence, and further to identify further ways forward in care delivery (Barker et al. 2003).By adopting this tool, the author was able to carry through the nursing process and assess to identify a broad overview of John's needs, which aim to specific specifically clarify his problems, and assist in the nursing intervention aim to promote and enable recovery. Keke and Blashki (2006)state that mental health assessment includes symptoms, characteristics and psychological state as well as psychosocial factors applicable to the patient; consequently, the KGV is seen as an integral part of mental health assessment.
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This KGV tool is noted to be a global assessment tool that is used to assess an array of mental health problems, including intensity, severity and duration of symptoms within few weeks. It comprises fourteen items; the first six sections aimed at determining depression, anxiety, hallucinations, delusions, suicide and elevated mood and are based on a subjective description of their condition over the past few weeks. The other eight sections are based on the behaviour of the patient during assessment. This was fundamentally utilised as a starting point in assessing John's mental health problems. The author was already aware of the issues relating to anxiety and depression although it was thought that at this point of the assessment, all aspect of John's mental health needed to be reviewed; hence the use of KGV was an ideal tool to accomplish the task. With this tool, the author was able to recognise what symptoms John was experiencing and identify specific area of need which the author need to undertake to clarify the extent of the client's distress and symptoms. The KGV assessment tool does come with some limitation which is time consuming, though this time was spent in forming a therapeutic relationship with the patient, this is something that should be done over a series of interviews, taking in to consideration individuality of the patient and how long he can sustain interest and attention to the questions being asked.
Engagement with a patient experiencing psychotic episode can extremely be problematic during assessment, like experiencing disturbances of thought, perception, mood and behaviour (Rigby, 2008). After completing a comprehensive assessment, screening tools were used to evaluate and measure severity of the identified symptoms (Stein, 2002).It was found that John was reporting issues of anxiety and depression; the author therefore decided to utilise the Beck Anxiety Inventory [BAI] by Beck (1987), to measure both psychological and cognitive component of anxiety (University of Pennsylvania, 2008), and also used the Beck Depression Inventory (BDI -1) Beck (1961) to determine the severity of depression. The BDI-1 and BAI are both self rating scale consisting of 21 items, in which patients rates the existence and severity of their presenting symptoms (Norman and Ryrie, 2005). The patient rates from 0-3, how best describes the way they have been feeling over the past few weeks and later summed up between 0-63. The author decided to use these scales on John to identify the severity of his anxiety and depression and was completed by him; it aims at promoting him as partner in his own care (NMC, 2008). It was also felt that both tools would enable the author to discuss problematic areas of John's life rather than just engage in general conservation and additionally giving scope for appropriate intervention (Barker, 2003). Going through these assessment tools after the appropriate time scale will give him and the whole nursing team a report of the progress that has been achieved or any changes that can be worked on.
The outcome of the screening tools used shows an indication of moderate anxiety and depression. During time spent with John, it was believed that his immediate needs in connection with these concerns were being met by the involvement of the staff and the support he receives from his mother (carer). Negative attitude by his carer about John's diagnosis may be linked to lack of knowledge, skill or judgement (Duffin, 2003). This was not an issue for the staff providing him with professional support as all performed to a high standard offering him empowerment and informed choice, ensuring best practice in care delivery in John's life (Department of Health, 2006). Psychosis has an enormous impact on the sufferers' family and carers particularly in the first episode (Reed, 2008). Families are often distressed, confused, anxious and fearful of the patient's behaviour, and what the future may hold for them as a family.
The author's observation is that John was distressed and stigmatisedby his family, their member's presentation and behaviour and other people's judgement about him and the family as a whole. The physical and emotional burden of care always falls on the family which may adds stress and anxiety, and attempt to come to terms with their own feelings of mental illness (Patterson et al, 2005). Families may often tackle the guilt for not recognising their beloved family member's symptoms and distress earlier, while also recognising that the illness itself might procure financial burdens to the entire family. They also feel the burden of stigma of mental illness to deal with and Patterson (2005) hypothesises that families often perceive the patient as displaying odd behaviours deliberately and therefore become less empathetic, and feel that they have less control over the situation.
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The Department of Health (1999) recognised the importance of caring for carers and the National Strategy aimed to support people who chose to be carers, and the National Service Framework (NSF) for mental health reported levels of services to involve service users and their carers in planning and delivery of care. By considering this patient in his own terms during the care planning process, he came to terms with his psychotic experience by promising to accept his medications and keeping to appointments with the professionals, began to understand it and acknowledge ways of coping with it. This is in - line with evidence based practice which sees the patient as central to all care packages with individualise care plans and multidisciplinary teamwork at the heart of care delivery (DoH, 1999 and NICE, 2002). The National Institute of Clinical Excellent (NICE, 2002) further emphasise the need for family intervention to be available to the families of patients diagnosed as being schizophrenic. Norman and Ryrie (2005) recognise families as a valuable resource for individuals that have symptoms; however if the family reacts to symptoms by being critical or by doing too much for the patient, this can equally have a negative effect on the individual.
Education regarding his illness and medication was given to both John and his carer. This was undertaken in his homein an interactive, question and answer format and took several days to complete. Updates and recaps of information were given at regular intervals and they were encouraged to introduce difficulties, questions and queries as they arose. It was an interactive session as it enabled John to give consent for treatment and he contributed his own version.
Educating the families / carers of a schizophrenic patient is aimed to lower the expectation of patients and may reduce the presenting symptoms. Leff (1994) and McDonagh (2005) note that one of the main contributions of stress in psychological disorder is expressed emotion from families. Having a mental illness may place limitations on patients' lives; in any case, it is the negative attitudes of the other people that may help disable people with mental illness and not the mental illness itself (Seggie, 2007). The expressed emotion from formal carers such as the support workers and nurses can equally have an effect on patient as high and low expressed emotion can be present in the relationship between the nursing staff and patients resulting in possible negative effects on patient's outcome (Tattan and Tainer, 2000). Expressed emotion is the critical, hostile and emotionally over involved attitude that carers have towards patients. The carer may influence the outcome of the diagnosis through negative comments and nonverbal actions. This negative attitude from carers does not always help the patient to improve the state of his health.
Carers with “high expressed emotion” are said to cause stress in psychological disorders such as schizophrenia. The stress from negative criticism and pity becomes a burden on the person with a disorder, and may relapse. Expressed emotion may be a direct factor in the relapse of a patient with a diagnosis of schizophrenia (Leff and Vaughn, 1985). Patients are more likely to relapse when there is high expressed emotion present in their living environment as was noted with John (Lopez et al. 1985). When the patient can no longer live with this kind of stress from pity, s/he may fall back into his/her illness using drugs as a way of coping. The stress from the remarks, attitudes and behaviour of the carer maybe over-whelming, because she may feel that she is the cause of the problems. The patient may fall into bad habits and forms a circle of relapse and rehabilitation. One way to escape this circle of behaviour is for the carer to be involved in behaviour family therapy together with the patient it aims to improve the health of the family with less stress and aggravation. The carer is able to learn to accept that John has an illness and may need her help to improve and remain stable hence family therapy. Educating the carer and patient about mental illness is one way that expressed emotion can become lower and no longer be an issue (McDonagh, 2005).
When considering family interventions in the care of John, it was important that this includes many others relevant in his life (Berkeet al., 2002). A multidisciplinary meeting of all those involved in John's care was called, aimed at educating them that crisis can be a turning point and the start of something new. Information about the devastating cause of mental illness can take, and exacerbations of symptoms and remissions to patients and carers were given to them. All aimed at stabilising the family's environment by increasing knowledge, coping skills, and the level of support for the carer and John. Most of the therapeutic interventions offered to John's carer involved communication - training, problem solving skills, and education. The style of therapy emphasises the positive aspects of the family's coping style and avoids judgemental or blaming remarks. The aim is for collaboration between the carer and the nursing team over goals for change and a greater emphasis on the needs of John.
However, Fadden (1998) criticised the narrow focus on relapse prevention at the expense of addressing the carer is widen needs. There have also been strong criticisms noted about family intervention based on beliefs that it blames families for schizophrenia, thus some family therapists have moved away from a position of trying to reduce expressed emotion by offering a message that stress exacerbates psychosis rather than causes it (Harris et al, 2002). There is contradiction that teaching family that reducing criticism lessens the chance of relapse, yet educating families that schizophrenia is an illness not caused by the family. Family intervention has been noted to improve a number of aspects of this patient's social well being such as taking part in activities. John believes that voices from people who were walking closely were planning an imminent attack against him. By getting angry and shouting back at them, he believes that he had prevented a potential attack. In this case, distraction was unlikely to be successful unless this belief is challenged in a calm and friendly way. John and the author agreed to put this belief to a test and he was later convinced that this was part of his illness. John was told to remove his mind from that thinking and belief that people were talking about him.
One of John's main obstacles in life is lack of motivation; he quiet understands that his mood would lift if he spent more time doing activities to occupy his mind. However, he finds it difficult to motivate himself into taking any form of activity but he had accepted going to his carer (mother) most weekends and to pay regular visit to the communal centre. These will enable him to think less about his delusions.
According to Hogston and Simpson (2002) reflection is a process of reviewing an experience of practice in order to better describe, analyse and evaluate, and so inform learning about practice. Wolverson (2000) includes that this is an important process for all nurses wishing to improve their practice. This will be investigated using the Gibbs (1988) model of reflection.
On reflection on the care and interventions that John received, a person centred approach appears to be fore-most. He was at the centre of his care, his personal feelings, beliefs and values were appreciated and he was able to exercise informed choices throughout (Callaghan and Waldock, 2006). Engaging John in discussion about his illness and care, and how it is best dealt with was highly appreciated by him; and this was highly regarded by him and his carer, and it leads to improved ability to cope, improved compliance and better outcomes (Kemp et al., 1996). Relaxation techniques were taught to John as a coping strategy for his anxiety; however, although relaxation can be effective, Frisch and Frisch (1998) recognise that relaxation alone is not beneficial therefore it should be used as complimentary intervention with other therapy.
Kirby et. al. (2004) acknowledge that mixed skills of staff is important, this works in conjunction with the Essence of Care Document (Department of Health, 2006) which states that training programmes and materials should be accessible and used for patients. John was supported by staff with a combination of experience and knowledge with training on Family interventions and cognitive behavioural therapy (CBT). CBT is a short term, problem solving based psychological treatment aimed at finding solutions to problems in every day life (Forsythe, 2008). Standard two of the National Service Framework for Mental Health (1999) specifies that clients should have their mental health needs assessed and be offered effective treatment if they require it. It is hoped that John will benefit from CBT in the future along with continuation of family intervention.
Throughout the care of my chosen patient, the relationship between the author, the patient and the carer was crucial and recognised as an aspect of service effectiveness (DoH, 2001a) and that active collaboration with the family is a requirement rather than an optional extra whilst delivering care to people with enduring mental health problems. John and carer were happy with the sort of help, support and service the author gave to them when they really needed it most.
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