Essay: Schizophrenia / self-harm (lenses, life course perspective, biological/sociological/psychological perspectives)

This essay I will identify a case study from my current practice and explain how each of the lenses helps to understand my own healthcare practice in relation to the needs of the service user. The first four lenses will explore the life course perspective, and how working alongside the biological, sociological and psychological perspectives provide a detailed and complex view of health and illness. The final lens relates to multidisciplinary team working, this will explore the involvement of the team and how it operated, identifying good practice and possible areas for improvement. Multidisciplinary teams are composed of different professionals, possessing various skills and experiences, working together to achieve a common goal (Charlesworth, 2013, cited in Rogers, 2018). The perspectives will each explore, what they look at, how they look at it and the responses they trigger people to make, which will help to understand the needs and experiences of the service user.
The case study is based on a 43-year-old female, named Claire, whom I have anonymised, to uphold confidentiality and to respect her privacy (NMC, 2015). Claire is diagnosed with schizophrenia and has a history of self-harm from her early teenage years, as well as substance misuse in the form of smoking cannabis. She has also experienced childhood sexual abuse and exposed to domestic violence in her family home setting. Schizophrenia is considered as a mental health illness, which can affect how you think, feel and behave, with symptoms described as ‘negative’ or ‘positive’ (RCPSYCH, 2015a). Positive symptoms are unusual experiences, which can be intense and distressing, such as hallucinations and delusions. While negative symptoms lack emotional responses and thought processes, which can inhibit daily functioning and lead to social isolation (RCPSYCH, 2015a). To understand the biological lens in relation to Claire, I will explore the genetic predisposition, neurochemistry, physiological responses and effects of medications. Watson (2018) defines the biological perspective as only focused on the physiological functions of the body and restoring the body’s equilibrium, by curing illness and disease and arguing ‘nature’ is paramount to ‘nurture’. Claire was diagnosed with schizophrenia in her late twenties and upon gathering information from her social history, disclosed both her parents had a diagnosis of schizophrenia. Genetics play a role in susceptibility of schizophrenia, with an increased risk of the illness, if both parents (46%) or an identical twin (50%) has schizophrenia (Castle and Buckley, 2008). Schizophrenia is associated with structural brain abnormalities, such as reduced overall grey matter volume, enlarged third ventral and lateral ventricles, extensive cortical and cerebellar atrophy, including frontal and temporal lobes deficits, especially with individuals experiencing negative symptoms (Castle and Buckley, 2008). Claire has experienced negative symptoms, where she isolated herself from social situations, neglected her activities of daily living (unkempt, poor hygiene), reduced motivation and reduced range of emotions. Claire found these symptoms difficult to overcome, as these symptoms lasted longer and affected her cognitive functioning, where she reported poor decision making and poor concentration. Castle and Buckley (2008) suggest the dopamine hypothesis offers a neurochemical explanation for schizophrenia, with the overactivity of dopaminergic agents in the mesolimbic pathway, attributing to positive symptoms of schizophrenia. Positive symptoms are disorganised thinking (rapid or slow talking, chaotic speech), hallucinations (experiences that are not real and can affect your senses) and delusions (a fixed belief that others don’t see), (RCPSYCH, 2015a). Claire experienced hallucinations, where she heard voices telling her ‘she was worthless’, ‘she be better dead’ and ‘kill herself’. This was a distressing time for her and her family, she reports she was suicidal when experiencing these symptoms. Claire was prescribed anti-psychotic medication to help stabilise her symptoms, the anti-psychotic medication blocks D2 receptors (Castle and Buckley, 2008). The biological approach contributes to understanding the biological brain functions and physiological responses, through scientific research, consequently progressing developments in care and treatments. However, the psychological perspective studies people’s behaviour, reactions and interactions, this offers insight for health practitioners to predict when a behaviour is likely to occur and control an aspect of the behaviour by manipulation (Clark, 2018). It’s paramount in healthcare to be aware of emotions, attitudes, perceptions and beliefs when interacting with individuals and not to make assumptions (Clark, 2018). Claire experienced intrusive thoughts and participated in Cognitive Behavioural Therapy (CBT). This therapy is effective in reducing positive symptoms and aims for the individual to understand their thoughts, emotions and actions (Garety, 2012). Although Hazell et al., (2016) found CBT was successful in reducing symptoms of schizophrenia which remained successfully after a period of 3–18 months, though Claire initially found CBT beneficial, but further interventions was required after non-compliance of medication. Claire required specific psychological interventions to target substance misuse, medication compliance and social anxiety, which is effective in reducing the distress of symptoms and supporting empowerment (Castle and Buckley, 2008). Additionally, the sociological lens interlinks with the psychological lens. The sociological perspective looks at human societies and the interaction between health and society, whilst objectively exploring social determinants, such as gender, ethnicity, socio economic status, interpersonal relationships and the effects for healthcare practice (Hickman, 2018). Although, gender, age and ethnicity (biological basis) may account for an individual risk to schizophrenia, environmental factors may also trigger the onset of schizophrenia, such as misuse of cannabis, life events, abuse, neglect and deprivation (RCPYSCH, 2015a). Claire had a traumatic childhood, witnessing domestic violence and victim to childhood abuse. Mistreatment and abuse in childhood is undeniably a contributing factor associated with mental illness in later life (Browne., et al 1986 cited in Datta 2010). The stress diathesis model offers an explanation to why a person is more susceptible to schizophrenia than others, as it considers the genetic vulnerability and resilience to mental illness (Datta, 2010). According to Royal College of Psychiatrists, (2015) intense use of cannabis can double the risk of developing schizophrenia and if smoked in the teenage years, it increases the chances of developing schizophrenia, by six times. Claire uses cannabis as a coping mechanism to lift her mood and when she experiences stress, although she has increased her vulnerability to schizophrenia by smoking cannabis and from an early age. Claire is an only child and her parents separated when she was ten years old, whilst she maintains a good relationship with her mother, she has become socially isolated since her diagnoses of schizophrenia. National Institute for Health and Care Excellence (2014) notes after an acute episode, this can lead to social isolation, inhibiting forming relationships and work opportunities, with an increased risk to suicide in the first few years. Claire has attempted suicide on several occasions, by overdosing on her prescribed medication and cutting her arms. Self-harm usually occurs when someone is in a high state of emotion, distress and intolerable instability (RCPSYCH, 2016). Claire has a negative view of schizophrenia, she was concerned people would see her as a ‘crazy woman’ and who would be violent. NICE (2014) notes schizophrenia is associated with negative beliefs, ideas and stigma and Hickman (2018) states the media has portrayed someone with schizophrenia is most likely to be violent. In addition to the three perspectives of biological, psychological and sociological, the life course considers the connection of social and historical contexts across the lifespan to help understands health and well-being (Bengtson et al., 2005 cited in Rogers, 2018). Bengtson et al., (2005) cited in Rogers (2018) identifies five principles that are essential to the life course perspective, these include linked lives, historical time and place, transitions and their timings, agency and planfulness and biographical process. Claire’s childhood was ‘linked’ with both parents having schizophrenia and the impact of a difficult childhood, has influenced her attitude and behaviour. She has difficulty forming new relationships and poor self-esteem. Historical time and place interrelates to the stigma of both parents having schizophrenia and relying on the benefit system to support them as a family. However, Claire said her mother was a very strong person, with good coping skills which helped her through
her illness of schizophrenia, similar to Enid developing her mother’s resilience (Roger’s, 2018). Claire married in her early twenties, which was cultural expected, although she experienced a biographical disruption of divorce a few years later, leaving her a single parent, like Enid experienced the early death of husband in her fifties (Roger’s, 2018). Claire’s choices and actions have resulted with her smoking cannabis and self-harming, due to the impact of past life events and relation to agency and planfulness. Lastly, the biographical process, such as Claire’s early divorce and childhood trauma, has impacted on subsequent life events.
Claire presented to mental health services following an overdose of her prescribed medication, and an Emergency Mental Health Assessment was carried out with Claire, a Community Psychiatric Nurse and myself. Trust A (2016) states an Emergency Mental Health Assessment is to gather detailed information to build an accurate picture of the patient’s needs. Prior to the assessment Claire consented to collateral history being gathered, this was to obtain and share information from a relative, which was Claire’s mother and confidentiality was explained and recorded. NMC (2015) states confidentiality is to be respected to those receiving care and the information shared appropriately, however confidentiality can be breached if the person is at risk to self, others, or experiencing or at risk of abuse (Mental Health, Equality and Disability Division, 2014). The information gained from Claire gave insight into her past history of childhood sexual abuse, witnessing domestic violence, both her parents diagnosed with schizophrenia, relationships, substance misuse, symptoms experienced past and present, premorbid personality, psychiatric history including prescribed medications, treatments, and the mental state examination which comprised of appearance, behaviour and emotional functioning. After the information was gathered an Immediate Management Plan was formulated specifying actions and referrals to be taken, the management plan was shared with Claire, and Claire consented to share the relevant information to the appropriate organisations. Valid consent is crucial in healthcare, as patients have a fundamental legal and ethical right to determine what happens to them, advocating informed choices about patient care and treatment (Trust A, 2015). Claire consented for referrals to a ‘self-harm intervention programme’ which provides counselling to prevent or minimise self-harm/suicide, ‘community addiction programme’ to reduce or prevent cannabis misuse and ‘Lifeline check-in calls’ which provides telephone calls to offer help and support over a 72-hour period from the point of referral. Also, Claire agreed for me to update her General Practitioner (GP) of the misuse of prescribed medication and the Gateway team would be notified as she has a child under the age of 18 under her care. Further safety advice was given regarding alcohol, as Claire had consumed a substantial alcohol amount when she took the overdose. Consuming alcohol in excess releases a high amount of dopamine, which blocks negative emotion, fear, stress, and anxiety and leads people to engage in risky behaviours (Trust A, 2017). Claire was also informed of the process following the assessment, that her case will be discussed at a multi-disciplinary team meeting with the consultant psychiatrist, team leader, CPNs and social worker and if the management plan changes, the information will be shared with her and consent gained. Multi-disciplinary teams are a range of professionals with different training and backgrounds working together (Rogers, 2018). Claire’s case was discussed within a team meeting, with the consultant psychiatrist, CPNs, social worker and myself. The roles vary within the community mental health team, usually the CPNs are the main point of contact in an emergency situation, where they assess people and give advice and support and then the team leader, manages the CPNs and offers guidance and support within the team. Although the social worker offers emotional support and practical help with housing, money, benefits and family support, however the psychiatrist consults with the CPNs after each assessment to ensure the management plan is comprehensive and appropriate actions taken, to ensure patient safety (Trust A, 2016). The CPN and I discussed Claire’s assessment at the meeting, with regards to her presenting complaint. Claire stated she has a poor appetite and recently lost weight, persistent low mood and energy, disturbed sleep and thoughts of life not worth living. The psychiatrist examined the assessment and discussed further with myself and my mentor, regarding Claire’s mental state examination and her biological symptoms, particularly in relation to her mood and affect. Mood refers to the patient’s emotional state and affect is the display of emotional expression (Trezpacz and Baker, 1993). Following further discussion, the psychiatrist advised to contact Claire for a medical review, to further investigate the possibility of Claire having depression, as she has encountered these symptoms for the past two months. The assessment of depression is based on the Diagnostic Statistical Manual (DSM) – IV and includes the number and severity of symptoms, duration of the current episode and course of illness (NICE, 2018). The social worker discussed a Gateway referral, as Claire has a child under the age of 18. A referral is deemed appropriate according to Department of Health and Social Services (2016) ‘a child or young person should be safe from harm in circumstances where a parent or carer is not meeting their needs’. Claire was informed a Gateway referral is standard practice and social services will offer advice and support to both herself and her child, however through discussion with the social worker present at the meeting, assessed the situation as low risk. The factors considered was the age of the young person, being age 17 and the nature of the overdose, as Claire was alone and not in the presence of her son. A further recommendation from the psychiatrist was to inform Claire’s GP of the misuse of prescribed medication and to recommend weekly prescriptions, to reduce the amount the prescription medication at any given time. The final outcome discussed at the meeting was Claire’s cannabis use. Claire states she is willing to engage in a community addiction programme, as she has insight into the negative effects of smoking cannabis has on mood. Though there was some debate, if the community addiction referral should be a routine or urgent referral, however an urgent referral for the self-harm programme was to be prioritised, as Claire took a significant overdose of a month’s supply of prescribed medication.
Although Claire’s case was discussed at a multidisciplinary team meeting, the service works in collaboration with other agencies in a comprehensive and varied way to achieve a common goal (Rogers, 2018). Throughout both the assessment and the multidisciplinary meeting the outcome to achieve, was to keep Claire safe and within her environment of home and the community. The immediate response to keep Claire safe, was the referral to lifeline, for check-in calls, then followed with the referrals to the community addiction team and the self-harm intervention programme. Working with multi-agency teams is essential within healthcare to focus on the complexity of problems (Jelphs and Dickinson, 2008 cited in Rogers, 2018). The outcome coincides with ‘Transforming Health and Social Care in Northern Ireland, (2016)’, this aims to develop more effective partnerships and team working across organisations. From the initial assessment to the multidisciplinary meeting, to making the referrals was exemplary in responding to Claire’s needs. The team was proactive in engaging with services to ensure the delivery of safe and effective care for Claire. Charlesworth, (2013) cited in Rogers, (2018) notes, to maintain safe and effective healthcare, it’s necessary for teams to communicate and collaborate. Furthermore, teamwork is fundamental for the future of healthcare delivery, appreciating and respecting the expertise of team members and the differences in experience and knowledge (Royal College of Nursing, 2006 cited in Rogers, 2018). Claire was placed at the centre of her care, where she was informed of the process of the assessment, through to giving informed consent for her management plan or plan of care. The information was communicated to Claire in an effective and appropriate way, respecting her right to accept or refuse treatment (NMC, 2015). In addition, The Royal College of Nursing (RCN), (2006) notes, identifying patients’ needs is paramount to determining the appropriate skills mix within a team and care delivered with competent and expert staff. However, when the team was debating about the priority of the community addiction referral, as a student nurse I had no interactions, including a new member of staff. As a student nurse I have limited knowledge and was new to the team. Challenges within a healthcare team can stem from knowledge and hierarchy, which can impact on the power or influence you have within a team. According to Rogers, (2018) power can vary in integrated working, the position someone holds or their knowledge, communication skills or persuasive ability, including power from experience or gender power, the influence of a man over a woman. However, Rogers, (2018) suggests regular, planned and close working can develop effective partnerships. Furthermore, the RCN, (2006) argues, although healthcare professionals require training and education in their own field, it would be beneficial to understand the contribution each discipline brings to patient care. While there was no contribution from myself regarding prioritising the referral, a team member felt Claire’s addiction to cannabis, required an urgent referral also. However, through discussion the psychiatrist recommended a routine referral was appropriate, as Claire could feel overwhelmed engaging with numerous services, thus reducing the effectiveness of each service. It’s essential for the team to promote a clear understanding of the involvement and the accountability of each team member, this would maximise their potential and ensure high quality patient care (RCN, 2006). However, the multidisciplinary meeting had clear objectives, discussing patient care within a timed meeting and effective team working. Therefore, the meeting placed Claire at the centre of her care, implementing integrated working from both statutory and voluntary services, whilst safeguarding Claire and her son.
Claire’s case study explored the biopsychosocial approach, alongside the lifecourse approach to give an understanding of the complexity of her health and illness. These four lenses provide healthcare professionals, a basis on how to predict, prevent and control mental health disorders and illnesses, by considering the environmental and genetic influences. Gathering Claire’s past and present information was crucial for myself and my mentor to effectively formulate a plan of care. This incorporated, Claire’s past experiences, from childhood and the impact it had on her teenage years and going through her years. Working within a multidisciplinary team and collaborating with multi-agencies, ensures patient safety and provides high quality patient care, although teams can experience challenges, such as communication difficulties and power differences. However, an effective team will have a shared vision, structuring services and using resources available, to deliver safe and high-quality patient care.
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