This assignment is a critical evaluation of the engagement and psychosocial assessment of a client living with psychosis in the community. It provides a critical and analytical account which encapsulates assessments, psycho-education, problem solving, implementation and evaluation of strategies used. I will also use Gibbs (1988) model of reflection to reflect on my assessment process and how learning can be taken forward in terms of my own practice development and that of the service setting.
My client l shall call Emily a pseudo name used to maintain confidentiality in accordance with the Nursing and Midwifery Council (NMC) 2002 Code of Professional Conduct that outlines guidelines of confidentiality. Emily was initially on the acute ward where l started the process of engagement with her before she was discharged under our team in the community to facilitate early discharge. Emily was suitable for psychosocial based interventions (PSI) and this was identified as part of her care plan in order to provide support in adapting to the demands of community living and managing her illness.
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PSI should be an indispensable part of treatment and options of treatment should be made available for clients and their families in an effort to promote recovery. Those with the best evidence of effectiveness are Cognitive Behavioural Therapy (CBT) and family intervention. They should be used to prevent relapse, to reduce symptoms, increase insight and promote adherence to medication, (NICE 2005). Emily is 33 year old woman with a diagnosis of schizophrenia. She was referred to my team to facilitate early discharge from the ward as part of her discharge.
She lives in supported housing and had had several hospital admissions and some under the mental health act. Emily was being maintained in the community on medication but it was felt that there was still an amount of distress in her life and that her social functioning was suffering as a result. Emily presented with both delusional and hallucinatory symptoms and as part of her treatment cognitive approaches were considered to help alleviate the distress and modify the symptoms. Emily was brought up in a highly dysfunctional family.
Both her parents had problems with drugs and the law. Emily had been introduced to drugs at an early age but due to her illness she had stopped using them at the age of 30 when she went into supported accommodation. There was family history of schizophrenia as her grandfather had it and he had killed himself. Emily identified that her problems started in 2007 when her grandfather passed away as she was close to him and had lived most of her life with her grandparents. I completed a time line to look back at while she talked about her life history .
It is vital that the client is allowed to tell their story with the minimum intervention from the practitioner and the timeline can be used to examine if there are any links to their relapses and psychotic episodes (Grant et al 2004). In the community setting we have a variety of patients with different diagnosis of mental health problems. The rationale for choosing this patient is that she had had various interventions such as medication changes and a lot of experience with the mental health professionals including compulsory treatment under the mental health act (1983).
All these factors are likely to have an impact on the individual’s degree of willingness to engage in psychological interventions (Nathan et al, 2003). Hence initially it was a challenge to engage Emily and establish a relationship and build rapport. (Nelson 1997) states rapport is built by showing interest and concern and be particularly careful not to express any doubts about what the patient tells you. The development of a therapeutic relationship is critically important in work with persons with schizophrenia, which maybe difficult with patients struggling with mistrust, suspicion and denial (Mhyr, 2004).
Rapport took some time to develop and was established by core conditions of genuineness, respect and accurate empathy (Bradshaw 1995). I met with Emily to set the agenda and explained to her that she was free to terminate the session anytime should she feel it necessary. It was also vital to ensure that the sessions were neither confrontational and totally compliant with Emily’s view of the world ( Kingdom & Turkington, 1995) I encouraged Emily to describe her current problems and to give a detailed description of the problems and concentrate on a more recent problem.
l was directive, active, riendly and used constructive feedback, containment of feelings to develop the relationship(Tarrier et al,1998). l used her interest in Christianity to engage her and because l showed an interest this became a regular point of conversation and strengthened the connection. I also demonstrated some flexibility in response to Emily’s needs and requirements at different stages of the treatment and intervention. It is not possible to maintain a sound collaborative therapeutic relationship without constant attention to the changing situation and requirements of a patient (Gamble and Brennan, 2006).
Since the development of antipsychotic medication and dominance of biomedical models during the 1950`s mental health care has changed and evolved. The dependency on the sole use of medication was found to have left patients with residual symptoms and social disability, including difficulty with interpersonal skills and limitation with coping (Sanford&Gournay, 1986). This prompted the return of PSI to be used in conjunction with medication management.
The aim was to reduce residual disability and to include in the treatment process social skills and training rehabilitation (Wykes et al, 1998). As part of my assessment process l carried out a comprehensive assessment using CPA 1, 2, and 4 in conjunction with the Trust Policy. This was to establish what her problems were and formulate a clear plan. A process of structured, comprehensive assessment can be very useful in developing an in-depth understanding of issues surrounding resistance to services (Grant et al 2004).
I carried out a Case Formulation (CS) using the 5W`s What? , Where? , When? , With Whom and Why, and Frequency, Intensity, Duration and Onset ( FIDO) model to explore and get a detailed explanation of the problem and explore the `Five aspects of your life experiences` (Greenberger and Padesky 1995) (see Appendix 3). CS maps out the relationship on how the environment impacts on your thoughts, emotion, behaviour, physical reactions (Greenberger and Padesky,1995).
While the assessment helped to form a picture of Emily’s suitability for PSI it also provided a scope for further work on her coping skills. Given the assumption that a person may feel reluctant to give a particular way of coping as this maybe the only means of control (Gamble & Brennan, 2006), the exploration was collaborative. From the assessment and case formulation Emily’s goal was to go out more and reduce the frequency and intensity of her voices or even have them disappear. l explained to Emily that we had to be realistic about her set goals and having voices disappear was unlikely.
Kingdom (2002) states that though patients desire to make voices disappear are unlikely since voices are, as far as reasonably established, attributions of thoughts as if they were external perceptions. Goals are positive, based in the future and specific (Morrison et al 2004) and the golden rule in goal setting is to be SMART, Specific, Measurable, Achievable, Realistic and Time Limited. Emily then rephrased her goal statement to that she wanted to reduce the intensity of her voices in the next few weeks by using distraction techniques that she had not tried before.
I used the KGVM Symptom Scale version 7. 0 (Krawieka, Goldberg and Vaughn,1977) to assess Emily’s symptoms which focuses on six areas including anxiety, depression, suicidal thoughts and behaviour, elevated mood, hallucinations and delusions. A KGV assessment provides a global measure of common psychiatric symptoms (feelings and thoughts) experienced with psychosis. The framework ensures that important questions are asked and a consistent measure of symptoms is provided. The KGV is a valid tool with a considered level of high reliability (Gamble and Brennan, 2006).
Assessment is a process that elicits the presence of disease or vulnerability and a level of severity in symptoms (Birchwood & Tarrier, 1996). This gathering of information provides the bases to develop a plan of suitability of treatment, identifies problems and strengths and agree upon priorities and goals (Gamble & Brennan,2006). l also used the Social Functioning Scale (SFS appendix 6) (Birchwood et al,1990) which examined Emily’s social capability and highlighted any areas of concern.
Emily was a loner and though living in supported accommodation she was hardly involved with the other residents or joined in with community activities. She expressed that she was afraid people could hear her voices and were judging her at all times and used avoidance as a coping strategy. On using the KGV assessment and from the results (see Appendix 2) Emily scored highly in four sections hallucinations, delusions, depression and anxiety. It appeared during assessment that her affective symptoms were econdary to her delusions and hallucinations, which were initiated and exacerbated by mostly stressful events in her life. Her hallucinations were noted to be evident at certain times and were followed by sleep deprivation. Emily expressed fleeting suicidal thoughts but denied having any plans or intentions. She also experienced sporadic moments of elation which appeared to be linked to stress. It was important for Emily to understand how life events had an impact on her difficulties and the use of the Stress Vulnerability Model SVM (Zubin and Spring 1977) demonstrated this (see Appendix 4).
Practical measures arising from an assessment of stress and vulnerability factors seek to reduce individual vulnerability, decrease unnecessary life stressors and increase personal resistance to the effects of stress. One of Emily’s highlighted problems was a lack of sleep and this could be linked to the stress vulnerability and her psychotic symptoms. Normalisation was used to illustrate this to Emily. Her increase in psychotic symptoms could then be normalised through discussing about the effects of sleep deprivation on her mental state and reduction of the associated anxiety.
Emily was able to recognise how stress impacted on her psychosis. Emily identified the voices as a problem from the initial assessment. She was keen to talk about them but listened to suggestions l made to tackle the voices. The assumption of continuity between normality and psychosis has important clinical implications. It opens the way for a group of therapeutic techniques that focus on reducing the stigma and anxiety often associated with the experience of psychotic symptoms and with diagnostic labelling.
Kingdom and Turkington(2002) have described such approaches as normalising strategies, which involve explaining and demystifying the psychotic experience. They may involve suggesting to patients that their experiences are not strange and no one can understand, but are common to many people and even found amongst people who are relatively normal and healthy. Normalising strategies can help instil hope and decrease the stigma and anxiety which can be associated with the experience of psychotic symptoms.
This rationale emphasises the biological vulnerability to stress of individuals with schizophrenia and the importance of identifying stresses and improving methods of coping with stress in order to minimise disabilities associated with schizophrenia (Yusupuff & Tarrier, 1996). (Grant et al 2004). The problem l encountered when applying and using this model with Emily was that she realised and understood that she was not the only one experiencing voices but she wanted to find out why she experienced the voices.
I used the belief about voices questionnaire (BAVQ-R appendix 5) which assesses malevolent and benevolent beliefs about voices, and emotional and behavioural responses to voices such as engagement and resistance (Morrison et al 2004). We identified the common triggers of her voices such as anxiety, depression and social isolation. During my engagement with Emily l emphasized enhancing existing coping strategies (Birchwood& Tarrier, 1994); (Romme &Escher 2000). The idea was to build on Emily’s existing coping methods and introduce an alternative. We agreed upon distraction as a coping strategy.
The plan was for Emily to listen to music or carryout breathing exercises when the disturbing voices appear and to start interacting with them by telling them to go away rather than shout at them. Emily used this plan with good effect at most times as it appeared to reduce the psychological arousal and helped her gain maximum usage of these strategies in controlling the symptom (Tarrier et al, 1990). To tackle Emily’s social functioning we identified activities that she enjoyed doing and she enjoyed going to church but had stopped due to her fears that people could hear her thoughts and found her weird.
I suggested that she could start with small exposure, like sitting in the lounge with her fellow residence and going on group outings in the home as these were people she felt comfortable with as she knew them. This would then hopefully lead to Emily increasing her social functioning and enable her to attend church. Emily expressed that she felt more in control of her voices . My work with Emily was made easy as she agreed to work with me although l did face some reluctance initially. As my intervention and engagement with Emily started while she was on the ward this made it easier for me to engage her in the community.
We developed good rapport and she felt she could trust me, which made the process of engagement easier. Through my engagement and assessment process l improved on my questioning and listening skills. Emily was clearly delusional at times and working with the voices present proved a challenge at times, but l realised that l had to work collaboratively with her and gain her trust and not question her beliefs. At times though l felt l was interrogating her and did not follow a format and also because of the constraints on time l did not allow much time to recap and reflect and could never properly agree the time of next meeting.
I also worked at her existing strengths and coping strategies that she had adapted throughout her life and this empowered her and made her feel like she was contributing. At times though l felt we deviated from the set goals and l lost control of sessions. On reflection this is an area that l will need to develop and improve on and be able to deviate but bring back the focus to the agreed plan. My interventions were aimed at Emily’s voices and increasing her social functioning. This l discovered was my target areas and not necessarily Emily’s. n future l will aim at concentrating more on what the client perceives as their major problem as this will show client involvement in their care. This will also help me have a clear and rational judgement and appreciate every improvement the client makes no matter how small. I did not focus much on Emily’s family which l realised was a topic that she wanted to explore but l felt l was not equipped in exploring this part of her life in relation to her illness. The other difficulties l faced was because of my working pattern l had to cancel some of our meeting appointments.
As part of the set agenda l had to reintroduce myself and the plan and goals that we had set out in the initial stages and this always proved to bridge the gap. It was also difficult for continuity in the team that l work in as one did not carry a personal caseload so delivering interventions was not always easy and there was not always continuity as some of my colleagues were not familiar with some applications of PSI. This highlighted as a service that there was a need for us as nurses in the team to have PSI training in order to continue with the work if the main practitioner was away and also as a team we hardly ever sed assessment tools and were therefore not confident and competent in their use. l also had difficulties in completing assessment in time due to constricted time frames. l could not always spend as much time with Emily because l had other clients to see in a space of time. In future l will have to negotiate my time and improve on my time management. In this assignment l had to carry out a critical evaluation of the engagement and psychosocial assessment of a client living with psychosis and carry out a critical self reflection on the assessment process and how this could be improved on.
From my case study l deduced that use of some applications of PSI remains highly experimental and requires considerable research and more theoretical models. Furthermore discussion is also lacking on the details as to ways in which symptoms improved or social functioning enhanced in behavioural terms in relation to social context. However the interventions used in this case study highlighted considerable strength in supporting claims that PSI can work and does help reduce symptoms of psychosis.
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