Analyse the care given the patient in your case study from biological, psychological and sociological perspectives.
Mr X a 26 year old gentleman diagnosed with paranoid schizophrenia; he lives at home with his family, episodes of unpredictable and violent and threatening behaviour directed at family. Newly diagnosed.
Jack Dwight (not his real name), aged 26 was diagnosed with paranoid schizophrenia in October 2004. In August 2004 Jack’s best friend was killed by a group of youths who were terrorising their neighbourhood. Before the diagnosis Jack’s family was concerned about his constant complaints of headache and tummy ache. He suffered from a severe lack of appetite. He lost a lot of weight in a short time – from 120 to 108 kg in just two months. Jack no longer paid attention to his personal hygiene – his body odour was unbearable. Around September 2004 Jack developed an uncontrollable fear that he was going to be run over by a vehicle. He would not be persuaded to venture into the street, even going to his favourite store to get cigarettes for himself. He became extremely anti-social, keeping to himself in his locked bedroom most of the time. His family could not cope with his anger outbursts, which sometimes became violent. Thus it was that in October Jack was diagnosed with paranoid schizophrenia. Jack’s behaviour proved that Pinker (1997) is right when he states that sometimes, when thrust into a new and highly stressful situation, people suffer acute paranoia.
For six weeks Jack was admitted to a psychiatric hospital where a team of specialists worked with him. It was on the 14th December 2004 that Jack was sent back home, and I became a part of his home staff of care providers. The medical staff prescribed pain killers – Paracetamol or Codeine for his headache, and antacids like Gaviscon for the tummy. It was agreed that care givers should try to redirect him whenever possible when he complained about head or tummy aches. It was suggested that since Jack enjoyed tea, he should first be offered calming tea when he complained of pain. He was also given Multi vitamins and Risperdal to take in the morning and evening. Jack is now happy to ask for a cup of Camomile tea whenever he has a headache. He understands that if his headache persists, he is allowed to take pain killers. He enjoys receiving positive feedback when he does not ask for painkillers all the time. He has even suggested that I serve him a cup of Camomile tea once every hour because he has realized that this controls his headaches. He has not made this request to my colleague who takes care of him when I am off duty. Instead, he gets the usual headache during this care giver’s shift. At this point one wonders whether this is similar to what Sorensen, Paul, and Mariotto (1988) refer to when they say in some cases the paranoia diminishes for psychological reasons rather than because of the drug’s action. I argue this because Jack’s headaches seem to surface when he is taken care of by some, and not other care givers. To this effect Smith (2003) is of the opinion that the outcome of therapy may be determined by the ‘chemistry’ or fit between the therapist and the client than the specific modality being employed. (p.61)
In order to improve his appetite, Jack’s nutritionist suggested that Jack should be involved in the planning of a healthy menu. His opinion was to be sought and he was encouraged to plan his meals, choosing from a wide range of foods in the refrigerator. Care givers were advised to invite him to participate in the cooking and preparation of his meals, if he so wished. That plan worked very well because he felt a sense of ownership and was very proud to be serving his care givers the food that he himself has prepared. He started to enjoy meals that he had planned himself. This also made him to take an interest in reading the labels on all food packages, and he was proud to tell staff about the nutritional value of foodstuffs. The advantages of Jack’s involvement in the kitchen were enormous. Apart from improving his appetite, Jack also took an interest in going grocery shopping – something he had previously refused to do. He realized that he had to bathe and dress in clean clothes before going shopping. So his state of personal hygiene improved. He enjoyed watching his reflection in the mirror before going out. We now turn the trips to the grocery store into special excursions. I have noticed that even his need for a cup of Camomile tea disappears when we prepare to go shopping. It is not uncommon for him to compile the shopping list before going out. Jack recently invited his case manager to join us for shopping because he wanted to show her how well he was managing the shopping exercise.
Before Jack’s friend was killed, they both worked as shop assistants in the local supermarket. During his illness Jack did not want to see any of his former work mates. He believed that they had plotted against his friend, and that they would do the same against him. This behaviour is in line with what Smith (2003) says, paranoid persons have a highly developed aptitude for fabricating stories – making connections is like seeing shapes in clouds. (p.39) In January 2005 the case manager helped Jack to sign up for membership at the local Clubhouse where care providers accompany him to attend meetings at least three times a week. Jack has met and talked to other individuals who have had a similar illness to his. The counselling they receive at the Clubhouse has helped Jack to want to renew his membership of his former workplace’s bowling club. From March 2005 Jack has been accepting invitations from former work mates to go bowling with them. The local Clubhouse operates on a slightly psychoanalytical manner in the sense that it serves all of Smith’s (2003) purposes in one integrated package. At the Clubhouse psychological problems are addressed in a comprehensive interdisciplinary method. Clients are given vocational training so that they can attain some basic skills of concentration and reasoning that would enable them to fit in the job world again. In May 2005 Jack was invited, through the help of the case manager, by his former employer to work some shifts. At the moment his job is in the cafeteria section where he works three hours for four days in a week. He cleans tables and makes sure the dining area is generally clean. Jack seems to enjoy going to work. His job coach, a qualified rehabilitation specialist reports that Jack is an asset at work, the cafeteria manager is pleased and speaks highly of Jack.
At the Clubhouse clients also receive training in handling their finances. Jack is now capable of balancing his bank balance. He draws a budget, based on what he earns from his employer and his weekly allowance. He compares prices and chooses which hairdresser, restaurant, super market, etc. to visit. Qualified physiotherapists are available to advise clients on the best ways to relax. They teach clients how to breathe, exercise muscles, or meditate when feeling anxious. The Clubhouse staff also organises evening social events during most weekends. Clients are invited to bring friends and / or family along. Jack was reluctant to attend these social events at first, but as soon as he started going out with his ex colleagues, he felt comfortable to attend the Clubhouse events as well. He has recently made friends with a few clients of his age group, and they love to dance and sing. I have lately experienced some difficulty in getting Jack to stop dancing when it is time to go home. The nutritionist has suggested that his high energy levels may be caused by some refreshments that are served during the evening of festivities. The care givers have been advised to encourage Jack to take sugar free drinks. It seems that Jack’s progress causes him to lack the insight to appreciate the full extent of his illness. Pennington et. al. (2003) state that sometimes positive symptoms of schizophrenia distort a person’s ability to perceive his or her own condition. Jack realizes that he has missed out on fun activities, so he might be trying to make up for lost time. It is therefore difficult for him to understand the need to control his excitement levels.
Although a lot of progress is made in Jack’s health one cannot quantify the success. 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 unfortunate that care providers in Jack’s case do not always compile comprehensive reports about our shifts’ proceedings. There is no standard instrument of assessment that can produce measurable results. Reports compiled at the end of a shift may be subjective. With regards to symptoms, for example one care giver might conclude that a particular action points to worse illness while another might not think so. It is also a subjective matter whether a symptom is or not present because what one might regard as a symptom, another might not.
The therapeutic modality may be effective, but if it is applied inappropriately outcomes may be unreliable. It is also disheartening that the care providers do not maintain their positions for long. During the six months that I have been taking care of Jack, three care providers have left. Jack needs stability and consistency in order to regain his sense of trust and confidence in people. I have noted that he becomes very sad when a staff member leaves. He takes it very personally, becomes moody for some time and blames himself when a care provider resigns.
I have also noted that not all family members take part in discussions or attend meetings organised by the medical staff to help Jack, so there is an information gap which slows down progress. One afternoon during the Easter weekend Jack went out with his older brother who lives with the family, in the same house as Jack. They left home around 7pm and did not come home until the early hours of the next morning. They had been to a pub, and Jack argued with some people there. Jack spent the rest of the weekend in a bad mood – using foul language and banging doors. Time out did not really help. Jack later confessed to me that he was disappointed with himself, for having lost his temper and nearly ‘getting himself killed’. Had Jack’s brother attended all family therapy meetings, had he taken the time to find out what needs to be considered when Jack enjoys a night out, Jack would not have had a relapse. Care givers often feel inadequate when confronted by unreasonable family members. When one interrogates the motives behind bullying relatives or irresponsible actions like Jack brother’s, one cannot but agree with theories like Bentall’s (2003) when he asserts that there are many people who suffer from undiagnosed forms of psychoses. Who, if not a psychotic person would expose his / her paranoid brother to a pub full of night revellers? Such questions are bound to remain unanswered for some time because the approach to schizophrenia itself is in need of improvement, so that it does not just assume that there is a distinct line between what is considered mental illness and mental health.
A lot of ground has been covered in the study of paranoid schizophrenia, but a lot more still has to be covered. Studies examining the diagnosis of schizophrenia are not very reliable and consistent. The fact that it was Jack who showed remorse, and not his brother after the incident at the pub proves this assertion. Assessment is also another area that needs extensive research. The anti-psychiatry movement also finds fault with the diagnostic approach to schizophrenia. Bentall (2003) explains how proponents in this field argue for their case – stating that to classify specific thoughts and behaviours as an illness allows social control of people that society finds undesirable but who have committed no crime. Jack had committed no crime, but his loss made him to behave in a manner that is not so acceptable by society. An assessment of Jack’s condition at this point in time might also pose a challenge to psychologists. One care provider who ‘gets on well’ with Jack might assess him as stable, yet another might not. The challenge continues.
Bentall, P.P. (2003) Madness Explained: Psychosis and Human Nature. London:
Pinker, S. (1997) How The Mind Works. London: Penguin.
Smith, D.L. (2003) Psychoanalysis in Focus. London: Sage Publications.
Sorensen, D.J. ; Paul, G.L. ; Mariotto, M.J. (1988) Inconsistences in paranoid functioning, premorbid adjustment and chronicity: Questions of diagnostic criteria. Schizophrenia Bulletin Vol. 25 (4) pp.570-575.