Paranoid Schizophrenia - Essay Example

Case Study; Paranoid Schizophrenia The very first item which the treatment team must have in their arsenal, is the sensitivity which will engender trust. Smith (2003) has offered the opinion that the determining factor of the therapy may very well rest upon the chemistry which is created between the care giver and the client. It is his contention that this fit may carry an even greater weight than that of the modality.(p.61) The client and family members must be convinced that the caregiver is earnestly concerned about their overall well being. While the caregiver is ostensibly in charge, it is incumbent upon the care giver to strive to make the daily sessions into client centered happenings. The care giver should make a concerted effort to include all family members in all aspects of the therapy. By empowering the client and educating the family members to become proactive, everyone in Jims’ immediate environment will become an active contributor to his therapy. They will not only become acclimated with the when, but also develop an understanding and appreciation for the why, and how. He is entering a new situation and it is imperative that one make a concerted effort to mitigate the stress, which accompanies new circumstances. Family members who are empowered, can be invaluable links during the short term orientation, and the long term therapy.Pinker (1997) has put forth the argument that there are instances when someone is introduced to new and highly stressful situations, this can represent the onset of acute paranoia. In Rogers (1951) he maintains that there are three qualities which the care giver must possess if they are going to be successful in creating a therapeutic relationship: (1) Congruence or authenticity (being real, no pretense), (2) Empathy, or empathic listening (not sympathy, the client feels heard and understood), and (3) unconditional positive regard towards the client.  The Rogerian formula appears to be very simple, and above all else, it is relatively easy to comprehend. The challenge is for the care giver to remain focused during the practical application of the formula during daily interaction with the client and family members.. It is the contention of Rogers, that if the care giver is successful in applying the precepts of the formula, it is a given that the therapy will be successful. Moreover, proper application by the care giver will also lead to significant personal enhancement.The point can not be made enough on the importance of proper application of the modality.; If for any reason that it is not appropriately applied, then the therapy will not be a success. Additionally, It is critical to sustain continuity in all aspects of the therapy. This is especially relevant when it relates to the personnel compliment. Once the client gets to know, trust, and relate to specific individuals, it is disruptive, and could very well represent a deleterious impact on progress, whenever established and accepted routines are compromised. The building of client relationships is a time consuming undertaking, some of the characteristics and skills which are needed by personnel to affect a good fit, can not be taught. The team leader, psychiatrist and nurse should attend the meeting to negotiate a plan.The thrust of this meeting should be placed on comprehensive assessment and individualized treatment planning. The objective is to gather as much information as can be collected in the face-to-face meeting with the client and the client’s family. All of the information which is gathered in this and subsequent meetings will serve as the basis for the work which will be done by the team for the client, as such, the plan will evolve from those services which the client is in need of.The information which was collected from Jim lead to a diagnosis of acute paranoid schizophrenia. This information should have been recorded in the first progress note and is termed, the initial assessment. The plan negotiated for Jim was Zuclopenthixol 100 mg intramuscularly (once a week) Olanzapine 10 mg twice per day and Benztropine 2 mg PRN, which is deemed as the initial treatment plan. It has been estimated that perhaps 65% of adult patients who have been placed on placebo will experience a relapse of their acute psychotic phase within 1 year, this is contrasted with 30% on neuroleptics (APA, 1997). Over an extended period of 5 years, close to 80 percent of adult patients have at least one relapse (Robinson et al., 1999). The risk of relapse was appreciably decreased by maintaing the drug treatment in clients. In view of the data presented, the caregiver for Jim is encouraged to continue long term drug treatment for Jim. It is of course important to periodically reassess Jim’s dosage to assure that the lowest effective dose is being administered. At this juncture in his care, it is prudent to anticipate that a review at six and twelve months for adjustments of the medication. This time line will be adhered too, unless Jim’s symptoms worsen, or unless adverse affects dictate more direct actions.The care giver should maintain contact with the physician on at least a 30 day cycle.Thsi monthly contact will be affected to sustained as a mechanism to adequately monitor Jim’s side-effects, symptom course, and compliance. This is also necessary to seek counsel for the direction of any needed psychosocial interventions.The information in its entirety; things which the team learned during the initial interview, and the medications or actions commenced, should be taken back and shared with the entire team, it should also be shared during the daily organizational meeting Information about the client is gathered through interviews, with families and other sources and from accessible medical histories. Collecting this information and putting it together is the initial step. Staff must take this information one step further to analyze and make sense of it, with the assistance of the clients family, this will provide the basis for treatment planning. The process of developing the psychiatric and social functioning history timeline will be conducted by staff members, in that these individuals have close proximity and familiarity with Jim’s case, these individuals should be assigned as members of Jim’s Individual treatment Team.Within the bodies of literature, there does not appear any evidence which points to psychological or social factors being the cause of schizophrenia. However, there are indicators which point to environmental factors and the potential interaction with biological risk factors which contribute to the onset, course and the seriousness of the illness. Expressions of emotion within the family setting, are considered to be psychological stressors, which contribute to the onset or severity of acute episodes and relapse rates.(APA 1997). In very early on-sets of Schizophrenia (VEOS), incidents of communication deficits have been discovered in families, while these are probably genetic rather than etiological agents.(Asarnow,JR, & Ben-Meir,S. 1988). There is a complex relationship which exists between psychological, social and illness related factors which is bi-directional. This is true due to the occasion that the existence of complicated family interactions may not be casual, but instead a reaction to the accumulation of problems the patient contributes to the family setting. There exist an anti-psychiatry movement which presents criticism concerning the diagnostic approach to Schizophernia. Bentall 2003), makes a presentation of how proponents of the diagnosis presents arguments in favor of their position. They purport that in the classification of specific thoughts and behaviors as an illness fosters social control of people which society determines to be undesirable, but these people have not committed any crime.Stigma is thought to be one of the primary problems which intervene in the treatment and management of schizophrenia. The introduction and presence of stigma can result in severe discrimination which unnecessarily represents serious problems for persons with schizophrenia. Stereotypes and ignorance are omnipresent (Robert Wood Johnson Foundation, 1990; Wahl et al., 1995). They lead many people to avoid living, socializing, or working with, renting to, or employing people with severe mental disorders (Levey et al., 1995).In the treatment of Jim, the caregivers must make a concerted effort to hurdle and circumvent these discriminations due to the deleterious affect they present in the access and acquisition of needed resources which may be necessary to treat Jim. In the specific case of Jim, one must be constantly aware and vigilantly monitor his social interactions. One must be cognizant that thru the media, a considerable amount of misinformation is transmitted; the stigma of schizophrenia will not only affect Jim, but it will also take a toll on his family members, caregivers, and other health care professionals as well. The reality that misconceptions abound makes the general public and health professionals, hold stereotyped perceptions of those who have been diagnosed with schizophrenia. For the sake of self awareness and for one to achieve a deeper understanding of the pitfalls associated with the myths, the following list is presented for on-going consciousness; schizophrenia is an illness from which no one ever recovers; schizophrenia as a disease is untreatable; schizophrenia once manifested in people, makes them violent and dangerous; schizophrenia is a communicable illness and the illness can be contracted by others due to contact with the diagnosed; the presence of schizophrenia in a person make them lazy and unreliable; The belief that schizophrenia is a self imposed weakness of will, that if the person who has been diagnosed, can through the initiation of a stronger will in themselves, can reverse the condition.That the person with schizophrenia has completely baseless thoughts, lacking all merit; That the person with schizophrenia is incapable of relating the affects of their treatment which they receive; That the person with schizophrenia does not possess the ability to engage in rational decision making; That an individual with schizophrenia is not predictable; an individual with the illness is not employable; that once an individual has contracted the illness, they will continually digress; The cause of schizophrenia is genetic. We are aware that this general list of myths are not applicable to Jim’s condition, however they must be considered during the course of care because they are misconceptions which the general public harbors. It will be incumbent upon Jim’s caretakers to make the attempt to insulate his well-being, and this can be achieved with varying degrees of success if the caregivers were to work on the basis of the following; 1) through formal and informal means of education and outreach. 2) establishing links with public policy officials and legislators (municipal and state), who can affect the laws which are presently of a discriminatory nature towards those who have the illness. These mythical social stigmas which are in most instances baseless, are nonetheless far reaching, and they could have an affect on Jim’s treatment. Consequently in attempts to mitigate the affect the treatment team will involve themselves in reducing the impact of stigma and discrimination on Jim through (1) education and outreach programs the thrust will be focused on changing public attitudes. (2) provide information to legislators and other public policy personnel to change and amend laws which have the affect of reducing discrimination against persons who have the illness. (3) community education efforts will be geared specifically towards altering attitudes. (4) Involving patients and their families in the improvement of psychoeducation and the manners of living with the illness. (5) dialogue with patients and families to gain knowledge of and insight into discriminatory practices. Socialization is of course a critical element in Jims treatment, therefore he will be the cornerstone of a client centered endeavor which will encourage him to articulate his feelings, which will lead us into a trusting supportive relationship. He will be encouraged to convey his delusions as he perceives them, free of coaching and proding. To gain insight into Jim’s feelings which are relative to conflicts and troubling events, the caregiver will initiate and be supportive through an emphatic approach. Jim is a young man and as such, he will be encouraged to socialize and participate in group activities. The caregiver must at all times be aware of personal space and remain cognizant that touching is not a recommended activity. Jim’s family members are a vital link to his therapy. Evidence points to the reality that when all other types of interventions are considered, that family interventions diminish the chances of relapse.( Cochrane Collaboration 2003). The therapeutic interventions should specifically address Jim as an individual.He has been prescribed conventional antipsychotics which have been shown to be highly effective both in treating acute symptom episodes and in long-term maintenance and prevention of relapse (Davis, Baxter & Kane, 1989; Kane, 1992). Their common mechanism of action is by blocking dopamine D2 receptors, and their therapeutic effects are presumably due to D2 blockade in the mesolimbic system (Dixon et al., 1995). It will be essential to provide Jim with psychosocial treatments, as a compliment to his medication. This will assist in maximizing Jims functioning and recovery. In the active phase of Jims illness his prescribed medications will assist him to be more amenable to the psychosocial therapy. In the unlikely event that Jim may experience remission, continuance of his maintenance medication should be sustained, the psychosocial treatments will assist him in improving his quality of life.Additionally, it is important to note that in the event that Jim becomes intolerante of continuing his medications, the psychosocial treatment will assume even greater im,portance. Psychotherapy for individuals with schizophrenia have made some contributions, albeit not substantial, however . Overall, it is clear that individual and group therapies that focus on practical life problems associated with schizophrenia (e.g., life skills training) are superior to psychodynamically oriented therapies (Scott & Dixon, 1995a). There are a number of family intervention programs which are designed to assist family members with serious mental disorders (e.g., Hogarty, Anderson & Reiss, 1987; Cazzullo, Bertrando, Clerics, Bressi, De Ponte & Albertini, 1989; Mari & Streiner, 1994; McFarlane, 1997).These family interventions have appreciably demonstrated their capabilities in either preventing or delaying symptoms of relapse and there is every indication that they assist in improving the patients functioning level and the well-being of the family. (Goldstein, Rodnick, Evans, May, & Steinberg 1978; Falloon, Boyd, McGill, Williamson, Razami, Moss, Gilderman, & Simpson 1985; Strachan, 1986; Lam, 1991; Tarrier , Barrowclough, Porceddu, & Gitzpatrick 1994; Goldstein 1995a; Penn & Mueser, 1996).Jim has exhibited some difficulty with articulation, in an effort to correct this malady, an effort will be made to correct this via Psychosocial skills training wherein emphasis will be placed on improving his verbal and non-verbal interpersonal skills and competence, which will empower him to enjoy his community setting.It should be noted that there is an increasing addition of cognitive skill mediation which places considerable emphasis the development of training in social skills. (Bellack, Morrison, & Mueser 1989; Bellack & Mueser, 1993; Scott & Dixon, 1995a).Assertative community treatment with its intensive approach is well suited to the treatment of Jim given the serious nature of his illness, because it has the capability of providing a comprehensive assortment of services within the community. The existence of community assertive treatment was created to accommodate the need for community based services, which brings with it a multi-disciplinary team. The comprehensive nature of this concept is complete until it is commonly referred to as a hospital without walls. The assertative community treatment team will consist of ten professionals; this will enclude a case manager. Several nurses, social workers, a psychiatrist, and a vocational specialist. The coverage will be on a 24/7 basis. Given the fact that the nature of services found in assertative community treatment are so intensive, renders it to be a most cost effective form of treatment.Smith (2003) contends that in order to measure psychological change, one must possess an instrument to do the measuring. The psychological test used must be both valid and reliable. A valid test is one that is adequately underwritten by empirical evidence and able to produce consistent results. (p.61). It is is commonly held contention, that record keeping is usually not consistently accomplished, and that the subjectivity with which shift ending reports are prepared, does not lend itself well to objectively evaluating a clients progress. In an attempt to rectify this shortcoming, a quantifiable form will be prepared by the team leader with the assistance of the psychiatrist, and input from the concerned staff participants, which will enable quantifiable assessment of the various therapies; their schedules and impact on Jim’s well-being and progress. The head nurse shall review the content of Jim’s assessment at the conclusion of each shift. At weeks end, the head nurse and psychiatrist shall evaluate Jim’s progress, or lack thereof; this weekly assessment will serve as the juncture for retrofitting or maintenance of Jim’s treatment plan. 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