Paranoid schizophrenia is a type of psychological disorder characterized by patient expressing somewhat delusional behaviors coupled with hallucinations. Patients may also exhibit relative stability in terms of behaviors, hallucinating and being disturbed perceptions. Regarded as the most prominent form of schizophrenia globally, paranoid schizophrenia is also arguably the most pathological stage in the paranoid process (Williams & Dalby 1989, p.101).
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It is widely accepted that psychological rehabilitation should be based on the principle of recovery. Although initial perception was that schizophrenia was a terminal disease, the recent evidences suggest that those who suffer from this disorder can be treated and eventually lead a healthy lifestyle. Studies also show that cultural, social, and psychological perceptions spearheaded by clinicians have played bigger roles in perpetuating the pathological nature of the disorder more than disease factors (Andresen, Oades & Caputi 2003, p.587). However, clinicians have mistakenly concentrated on those in critical states of the disease, while ignoring the recovering patients. This kind of reality has set precedence in the development and preference of recovery-oriented rehabilitation process. The aim of this case study is to review and assess the recovery-oriented collaborative approach to psychological rehabilitation as applied by Shellharbour Hospital Mental Health Rehab Unit.
Brief descriptions of client and context, and the facility
Chris is a 25-year old male client who was admitted to the facility on 8th March 2010. Historical assessment indicates that he was diagnosed with paranoid schizophrenia in October 200. To date, he continues to have low grade paranoid symptoms and florid psychotic features have settled. The social aspect of the assessment illustrate that some aspeges features exist. That is, he has always been social loner, with some aspergers features. At the time of admission, however, he was florid psychotic, hearing voices and believing that unknown voices were attempting to kill him. He had been using marijuana for some time but the paranoid ideas had apparently pre-dated the use of this drug. Since admission he remained on regular anti psychotic and has not been using marijuana, has remained socially isolated, sleeping in until 11 to 12 o’clock in the morning and then spending most of his time on the computer. It is only with great difficulty that his family has been able to get him out to attend any social activities.
Shellharbour Hospital Mental Health Rehab Unit is comprised of various components including an integrated team of 21 nurses (12 register nurse and 9 enrolled nurses), 3 doctors (1 psychiatrist intern), 3 clinical psychologists, 2 social workers. The unit consists of 20 rooms for 20 patients, nursing stations, small interview room, laundry room, kitchen, small canteen, large dining room ( library , 2 TV), 4 back yard, BBQ Place, reception, and large room for activity. A patient is only allowed a short stay of up to 6 months in hospital (3 to 6 months).
Assessment of motivation
Chris’ lack of participation in outdoor activities is imminent. In particular, he operates within his room 24hours, sleeping and playing on a computer. The behavior of being a social loner is reinforced by the indoor equipments that motivate his stay in the house. While it is acknowledged that behavior can be changed through particular systems of rewards as well as punishments, self- behavioral change as exhibited by Chris is a clear indication of lacking motivation to proceed and do some outdoor activities that would improve his social life.
According to behavioral theorists, behaviors can be changed and an individual can improve his or her life through behavioral therapy. Behaviorism as a theory emerged from the school of psychology that concentrates on the external behaviors of individuals and what one can do to change the external habits (Anthony 1994). In the program, every client is placed in his or her fully equipped room, thus restricting their social interaction by each other.
The realization by the client that there is need for change is what will lead to the successful psychological therapy initiative. According to Miller & Rollnick (2002), there are three critical components of motivation namely: i) the perceived value of change, ii) the confidence practice change initiatives and iii) the real readiness to change by the client. However, from the observation it is clear that Chris has not realized the value of change- he lacks the knowledge that change has some importance. In other words, there is the component of lack of change desire in him, evidently showed by him being forced to go out by his family. Barhof et al. (2006, p.207), explains that recognition of the value or importance of change is wholly dependent on the realization by the client that there is discrepancy between his or her present state and the future goal. It therefore follows that if this particular discrepancy is low; the motivation for one to change the behavior becomes low too (p.207). It is therefore prudent to argue that Chris’ present state is due to low discrepancy in the motivation to change.
Assessment of cognition
The Shellharbour Hospital Mental Health Rehab Unit is fully equipped with every physical requirement for what one would call a complete modern home. However, the cognitive rehabilitation program for Chris and presumably his colleagues is based on various components of rehabilitation. With the support of the multidisciplinary team, the hospital applies what is known as cognitive drilling, where the team gets to identify cognitive gap within the client. This is then followed by remediation effort. However, critical observation indicates that the process is not formal but rather applied haphazardly with no clear pattern. Moreover, Wilson (1997), through her study entitled, “Cognitive Rehabilitation: How it is and how it might be”, states that this type of cognitive rehabilitation is not exhaustive and may not lead to satisfactory result. She therefore recommends the holistic approach that holds the belief that “cognitive functions cannot be divorced from emotion, motivation, or other non-cognitive functions” (Wilson 1997, p. 489). Basically, the holistic approach will address all areas concerning rehabilitation program and at the same time helps develop a formal program to follow in the entire program.
With proper and formal cognition assessment criteria for clients, the facility will be in a position to identify clients who still exhibit more cognitive impairment from those with less cognitive impairment. The difference between the two types of clients will help design higher vocational assistance for those with more cognitive impairment, while reducing that which is given to those with less cognitive impairment (Rosdahl & Kowalski 2008).
Assessment of Need
The hospital unit uses certain tools to meet the definition of client needs. The most generic definition of need of a client in psychiatric rehabilitation revolve around the client in question recognizing or identifying the residential, health, educational and social goals they intend to accomplish through built skills and supportive significant others that would make them achieve the intended goal. According to CR adoption of needs, it is a negotiated approach to assessment, where multiple definitions associated with feelings, expression, negotiations between the client, clinical practitioners and the significant others. The hospital unit therefore uses normative, objective, comparative and action-based approach to identify the needs of the clients. The hospital unit has developed The Camberwell Assessment of Need (CAN) and Camberwell Assessment of Need Short Appraisal Schedule (CANSAS) to carry out structured interview with clients, medical practitioners, and the significant others including family members tasked with the caring of the patient.
American psychologist Abraham Maslow (1921-1970) developed what he called “hierarchy of needs” after carrying out a study on needs and motivation of individuals (Mosher & Burti 1992, p.11). In fact, Maslow had presented a different view of what needs are by focusing mainly on the total person, and not just one dimension of an individual such as illness and problems. Through his findings, he emphasized the need to focus more on individual health. Through the hierarchy of needs, the basic needs that motivate individuals are very basic components that people tend to assume such as “water, sleep, food, water, sexual expression, sexual expression, and freedom from pain must be met and satisfied first (Kopelowicz, Liberman & Wallace 2003, p. 284). The level of the hierarchy involve the need for safety and security, which will also mean freedom from being hurt or deprived of any important need highlighted above. The third involve being shown love and enduring intimacy, being befriended and accepted. The fourth level of the hierarchy involves the need to boost self-esteem and individual self-respect. At the top of the hierarchy is the need for self-actualization, the need to have a feeling of beauty, feeling of truthfulness, and believing that justice is being done.
The hypothesis put forward by Maslow is that the client’s basic needs at the bottom of the pyramid would be the dominant theme in his or her life until those specific needs are met adequately, after which the second hierarchy of needs will become dominant (Mosher & Burti, 1992, p. 23). In other words, if the client misses food which is a basic need at the bottom of the pyramid, the fear for starvation overrides every other need in the second hierarchy until this need is met. The self-actualization concept is used to illustrate a client who has achieved all needs of the hierarchy and has eventually developed full potential for a normal life (Lasalvia, Bonetto, Tansella et al. 2008). That is, it is noted that a client’s life may not be stable throughout his or her life even after recovery. If a traumatic life circumstance that affects health occurs, he or she is likely to regress to lower hierarchy of need. For Chris’ case, even though he has reached a level where he no longer uses marijuana, the possibility of regressing if the life of isolation continues is still imminent.
The role of a rehabilitation worker in this case is to develop the client-centered approach, where he or she becomes supportive rather than being directive or playing an expert role. Rogers (1961), cited in Oades, Crowe & Nguyen 2009, p.21), believes that the client is the expert of his or her own life hence should be given time to develop self-awareness and subsequently progress into self-actualization stage of life.
Negotiation of goals
The rehabilitation team of the unit often meets regularly in several organized internal conferences so as to set common goals for all members. In the conference, the only participants are rehabilitation team comprised of 21 nurses (12 register nurse and 9 enrolled nurses), 3 doctors (1 psychiatrist intern), 3 clinical psychologists, 2 social workers. Once a common goal has been set, the patients are presented with certain regulations follow, with the encouragement of the caretaker (mostly a member of his family) and a psychiatric nurse charged with the role to monitor the situation. From the regulations, always set in accordance with the client’s mental status, the client is expected to accept his or her status as it is and work towards setting their goals of moving to the next level.
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In most cases, the clients are expected to set their own goals in line with laid down procedure in the hospital environment (Oades, Crowe & Nguyen, 2009). In this case, Chris is expected to stay at the facility for a maximum of six month, after which he would be expected to fit in the society in the next three months. However, there is lack of connection in the procedure for setting up the goals. Evidently, the role of patients and significant others are ignored. The two are only expected to ratify the goals set for the client. The monitoring of the goal is achieved through Psychiatric nurse who is expected to report what changes or improvements are needed in the process of treatment. The rehabilitation team therefore holds another successive conference where they discus specific case. Studies have shown that if the client is not motivated to set his or her own goal, there is likelihood of failure in the process as the caregivers and client will be pursuing different goals (Andreasen 1983; Beattie & Stevenson 1984; Carkhuff 2000).
There is a need for health facility to develop an assessment tool, specifically an interview programs where they can investigate and talk with Chris and investigate his level of satisfaction with the current situation as presented by the environment of rehabilitation. This kind of interview will also help them explore Chris’ future needs in relation to his choices. Ones the goals with the present and future needs of the clients are established, the psychiatric team and family members are in a position to establish the dichotomy between the present and future hence set a better reference terms for the client. According to the principle of CR, it will boost the relationship between the psychiatric nurse, client and caretaker; hence the ability to identify the client’s unmet needs.
The care plan at the health facility is based on the provision of environmental support and family intervention. In the perspective of environmental support, Chris and his colleagues are provided with every physical facility they may need in their rehabilitation process. The environment provides them with opportunities to develop certain skills and hence get rewards for such participation. It is through the opportunities that they would be able to outline specific requirements to successfully perform certain learned skills. According to the plan, the rate at which reward is given depends on the people involved in the environment of care. These people’s views on whether the care plan is successful are used to establish a reward scheme.
The care plan at the facility also incorporates family interventions. Several interventions that targets family role have been developed to make Chris and his colleagues adapt to their functional behaviors towards opportunities that come with environmental support. Although the methodology of taking Chris out for social events may be forceful, the environment provides room for family intervention or initiative to ensure they adapt to normal family life. However, it is observable that the facility has only emphasized on the need to increase general family support, while ignoring any attempt to improve the overall integrated care that would incorporate everybody and every facility to enhance interaction.
Monitoring progress towards goals
Monitoring progress toward goals is the final criteria in assessment of the progress of the rehabilitation process. In this particular health facility, there’s a clear indication that they lack a formal monitoring criteria. Basically, the process of monitoring progress is left for the judgment of the psychiatric nurse charged with specific dusty of managing the client. He or she has the full mandate to give full report on the progress of the client.
In fact, with this lack of progress monitoring, it is quite difficult to modify the plan as needed such that critically stubborn issues would be addressed. In other words, it may not be easy to know whether the client is benefiting from the program or not.
According to Barton (1999) even the practitioners may get demoralized if they fail to acquire information about the client’s progress, since they may tend to believe that they are not helping the client in question at all. Sometimes they may also believe that they are helping the patient, while in reality they are not. For the client, the lack of monitoring progress means that the stakeholders (family and healthcare providers) do not view the set goals as important.
Modification of goals
In a compounding impact, the lack of monitoring progress towards goals may lead the client to believe that their set goals are valueless or lead to pessimistic view that the goals are after all not important in the overall rehabilitation plan. Dimsdale, Klerman & Shershow (1979) observes that monitoring these goals on a regular basis and modifying rehabilitation plans as need may arise, helps “reinforce the value of those particular goals as the basis for therapeutic relationships” (p.2)
The process of this evaluation has revealed some compounding issues that need to be addressed in the overall psychiatric rehabilitation of the paranoid schizophrenia case at Shellharbour Hospital Mental Health Rehab Unit. The recovery-oriented collaborative approach to psychological rehabilitation of Chris should rely on some core values. The first is the need for collaboration between the client, rehabilitation team and significant others including family members in the execution his needs. With collaboration, goals of the psychiatric rehabilitation to help client overcome the mental problems and eventually lead a successful and normal life can be achieved. Collaboration also help the rehabilitation team, the client and the significant others improve the possibility of success towards goal achievement by avoiding conflicting working relationships.
There is also the need for shared decision-making. As noted, the conference regularly held by the psychiatric team at the facility is not exclusively designed for rehabilitation team only- neither family members nor client is incorporated. This is an irony of the client- centered approach needed for successful rehabilitation. In this case, the hierarchy of needs can only be identified when all are included in the decision-making process, hence the likelihood of just process in line with the set goals.
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