A Critical Evaluation of the Engagement and Psychosocial Asessment of a Client Living with Psychosis in the Health and Social Care Practitioners Work Setting.

INTRODUCTION This assignment is a critical paygrade of the pursuement and psychosocial sagaciousness of a guest lifetime with psychosis in the community. It provides a critical and analytical account which encapsulates judgements, psycho education, problem solving, implementation and evaluation of strategies utilize. I will also use Gibbs (1988) model of reflection to reflect on my assessment operation and how learning can be taken for shield in terms of my own practice ontogeny and that of the service classting.My node l shall call Emily a pseudo name utilise to maintain confidentiality in accordance with the Nursing and Midwifery Council (NMC) 2002 Code of Professional Conduct that out delimits guidelines of confidentiality. Emily was initially on the acute ward where l started the abut of engagement with her before she was discharged under our team in the community to alleviate earliest discharge. Emily was suitable for psychosocial based interventions (PSI) and this was place as part of her c ar intend in hostel to provide support in adapting to the demands of community living and managing her malady.PSI should be an indispensable part of word and options of treatment should be do available for clients and their families in an effort to encourage recovery. Those with the best evidence of military capability are Cognitive behavioural Therapy (CBT) and family intervention. They should be used to pr crimsont relapse, to annul 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 s perpetuallyal hospital admissions and slightly(prenominal) under the cordial wellness act. Emily was being maintained in the community on medication yet it was felt that at that place was still an amount of distress in her conduct a nd that her social function was ache as a result. Emily presented with both neurotic and hallucinatory symptoms and as part of her treatment cognitive approaches were considered to avail iodinself alleviate the distress and modify the symptoms. Emily was brought up in a spunkyly 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 a way as she was close to him and had lived most of her life with her grandparents. I completed a date line to look back at while she talked slightly her life history (see Appendix 1).It is vital that the client is allowed to tell their story with the minimum intervention from the practitioner a nd the timeline can be used to examine if there are either 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 individualistics degree of willingness to engage in psychological interventions (Nathan et al, 2003). Hence initially it was a challenge to engage Emily and pee-pee a kind 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 posement of a cure relationship is critically primary(prenominal) in work with persons with schizophrenia, which m aybe difficult with patients struggling with mistrust, suspicion and defense reaction (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 Emilys view of the world ( Kingdom & Turkington, 1995) I encouraged Emily to let out her current problems and to give a detailed description of the problems and concentrate on a more modern 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 Emilys contracts and requirements at different stages of the treatment and intervention. It is not manageable to maintain a sound collaborative therapeutic relationship without constant attention to the changing status and requirements of a patient (Gamble and Brennan, 2006).Since the development of antipsychotic medication and dominance of biomedical models during the 1950s mental health care has changed and evolved. The dependency on the sole use of medication was found to have left patients with residuum 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, a nd 4 in conjunction with the Trust Policy. This was to establish what her problems were and project a clear plan. A process of structured, comprehensive assessment can be very expedient in developing an in-depth understanding of issues surrounding impedance to services (Grant et al 2004).I carried out a Case Formulation (CS) using the 5Ws 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 Emilys suitability for PSI it also provided a scope for further work on her coping skills. effrontery 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 gaffe aspect Emilys ending was to go out more and reduce the frequency and fanaticism 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 believe to make voices disappear are unlikely since voices are, as far as reasonably established, attributions of thoughts as if they were impertinent 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, Gol dberg and Vaughn,1977) to assess Emilys symptoms which focuses on six areas including anxiety, depression, suicidal thoughts and behaviour, heroic 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 train of high reliability (Gamble and Brennan, 2006).Assessment is a process that elicits the presence of disease or photo 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 train upon priorities and goals (Gamble & Brennan,2006). l also used the Social Functioning Scale (SFS appendix 6) (Birchwood et al,1990) which examined Emilys social capability and highlighted any areas of concern .Emily was a loner and though living in supported accommodation she was hardly involved with the different residents or joined in with community activities. She verbalised that she was afraid tidy sum 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 trying events in her life. Her hallucinations were noted to be evident at certain times and were followed by sleep going. 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 difficulti es and the use of the Stress Vulnerability personate 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 Emilys highlighted problems was a lack of sleep and this could be linked to the stress vulnerability and her psychotic symptoms. Normalisation was used to expatiate 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 tenaciousness between normality and psychosis has im portant clinical implications. It opens the way for a separate 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 & Ta rrier, 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 forceful enhancing existing coping strategies (Birchwood& Tarrier, 1994) (Romme &Escher 2000). The idea was to build on Emilys existing coping methods and introduce an alternative. We concord upon distraction as a coping strategy.The plan was for Emily to listen to music or carryout breathing exercises when the move voices appear and to start interacting with them by tellin g 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 foreplay and helped her gain maximum usage of these strategies in controlling the symptom (Tarrier et al, 1990). To tackle Emilys 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 REFLECTION My work with Emily was made easy as she concord to work with me although l did saying some reluctance initially. As my intervention and engagement w ith 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. with 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 refl ection 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 Emilys voices and increasing her social functioning. This l discovered was my target areas and not necessarily Emilys. n future l will aim at concentrating more on what the client perceives as their major(ip) 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 Emilys 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 alwa ys 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 delay 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 terminate assessment in time due to constricted time frames. l could not always communicate 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 an d 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 system highly experimental and requires considerable research and more theoretical models. Furthermore discussion is also wanting(p) on the details as to ways in which symptoms improved or social functioning enhance 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. REFERENCES Birchwood M and Tarrier N (eds) (1996) Psychological Management of Pschizophrenia.Wiley Publishers Bradshaw T (1995) Psychological interventions with psychotic symptoms a review. 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Romme M and Escher A Eds (1993) Accepting Voices. MIND Publications Sanford T and Gournay K (1996) Perspectives in Mental Health Nursing. Bailliere Tindall.Tarrier, N, Yusupoff, L, Kinney C, McCarthy E, Gledhill A, Haddock G and Morris J (1998) Randomised controlled trial of intensiv e cognitive behaviour therapy for patients with chronic schizophrenia. British Medical Journal 317,303-307. Zubin, J, & Spring, B (1997) Vulnerability A new view on schizophrenia. Journal of Abnormal Psychology, 86, Topic Students will carry out a critical evaluation of the engagement and psychosocial assessment of a client living with psychosis in the health and social care practitioners work setting. Word Count 2826