Registered Psychiatric Nurses, Partnering with People
Schizophrenia is the most disabling of all the major mental disorders. Schizophrenia is an illness that interferes with an individual’s ability to think, feel and to receive and understand sensory information. An individual’s behavior may also be disturbed. The most noticeable of symptoms include hallucinations, delusions, thought disorder and behavior considered unusual for the person. Fortunately, such schizophrenic symptoms can be controlled with medication. The less obvious symptoms such as loss of interest, energy, warmth and humor do not presently respond well to medications. These latter symptoms cause considerable obstacles for the schizophrenia sufferer and their families.
Schizophrenia rehabilitation attempts to increase an individual’s level of functioning. The aim is to build upon strengths and assets while reducing deficits. “The goal of rehabilitation is to nurture the strengths and life skills that the patient with schizophrenia requires to live as independently as possible in the community” (Lalonde, 1995, p. 71). The ability to enjoy a quality of life comparable to that of others is also foremost in rehabilitation. This paper will focus on the wide range of interventions that are implemented in rehabilitation. In order for these interventions to be effective, they must be comprehensive, continuous, coordinated and all encompassing.
Anti-psychotics, also known as neuroleptics, are the mainstays of treatment for schizophrenia (Jeffries, 1995; Keltner, Schwecke, Bostrom, 1991; Modrow, 1995; Thornton & Seeman, 1993). Thornton & Seeman (1993) state that anti-psychotics act on a number of neurotransmitter systems in the brain to produce a variety of effects. It is through the use of these neuroleptics that schizophrenia symptoms such as hallucinations, delusions, thought disorder and bizarre behavior can be controlled. Once these symptoms are controlled, a major source of preoccupation for the patients is removed and this allows sufferers to focus attention on other aspects of their life. Despite the importance of medication, it is far from the only form of treatment for schizophrenia sufferers.
Medical follow-up is also a vital part of the rehabilitation process. Follow-up has two major purposes. First to monitor medicinal compliance and, second, to adjust the therapeutic level of medications. “Studies consistently show that without medication, people with schizophrenia relapse at a rate of 60% to 70% within the first years of diagnosis” (Stuart & Sundeen, 1995, p.504). Stuart & Sundeen (1995) also state that for those who are faithful with their medication regimen, the relapse rate is approximately 40%. Hospitalizations, mainly in the form of crisis intervention, are also important for the rehabilitation program. Clients, families, and caregivers must have a ready knowledge and access to emergency wards, mobile crisis units, in-patient or occasionally, in times of extreme relapse, long term hospital stays. Knowing that these options are available may decrease anxiety and make their use less necessary.
Psychotherapy is a major building block in the rehabilitation program. A schizophrenia sufferer may meet with his or her therapist to discuss a myriad of topics ranging from medications, vocational issues, finances, family interactions and quality of life. Keltner et al (1991) states that the ultimate goal of psychotherapeutic management is to help the client to become stronger than his or her symptoms. Many schizophrenics that go on for years fighting and struggling alone without anyone to help them get stronger than their symptoms need the aid that psychotherapy provides. Carson & Arnold (1996) state that schizophrenics respond best to psychotherapy that is supportive and focuses on “strengths, increasing coping and problem-solving skills and offering affirmation, long-term concern, hopefulness, and commitment” (p. 748).
Interventions for alcohol and drug abuse are also an important component to rehabilitation. Norris & Neagle (1990) state that between 20% and 25% of clients admitted with a diagnosis of schizophrenia report recent substance abuse. Jones (1995) states that exacerbation of symptoms during the recovery and maintenance phase is the complication of drug and alcohol abuse. Keltner et al (1991) observed that 88% of the drugs abused were alcohol, marijuana and cocaine. The problem of drug abuse among schizophrenics must be addressed and confronted by exploration, education, supervision, monitoring and peer discussions. Behavioral techniques, supportive therapy and family involvement will also be effective. The possible referral to special drug and alcohol rehabilitation programs may also be utilized.
In the best of all conceivable worlds, each individual with schizophrenia would be granted unconditional access to continuous, comprehensive and co-ordinated care as well as consistent financial stability. Finances are an important need in order to meet basic needs such as shelter, food, clothing and spending money. Personal needs such as hygiene, personal safety and medical care also need attention. Interpersonal relationships, emotional support, recreational and vocational activities and community involvement are not often thought of as entitlements, and need to be looked at as well. As important as medical management of symptoms, these needs must be met before a person can develop a sense of well being. It is the responsibility of those charged with the rehabilitation to educate the schizophrenic and families about these entitlements and to assist them with accessing them as fully as possible.
It is very important to be sensitive to the financial needs of the individual suffering from schizophrenia. If providing for one’s basic needs goes unmet, unnecessary and unwanted outcomes may result, including, relapses, medical problems, homelessness and trouble with the law. Financial stability becomes a crucial part of the rehabilitation. Thornton & Seeman (1993) state that having some money in one’s pocket is a potent source of self-esteem. To discover how financial aid can be accessed, it is important to consult with a social worker and advocate for the schizophrenic. Social assistance can be a blessing even though assistance programs do not provide much money. Regardless of the situation, every effort should be made to aid the individual in all matters financial and to obtain the maximum financial benefit available.
Some schizophrenics have great difficulty in managing their money. For those who have difficulty, there is a tendency to spend all their money at once, leaving bills and payments unpaid. This in turn can lead to borrowing from friends and relatives as well as begging and theft. Thornton & Seeman (1993) tell of one such example:
Sam receives his monthly cheque on a Friday. He spends most of it entertaining friends, eating out, and going to the movies. On Monday, he arrives at his parents’ home looking despondent. He has not paid his rent and has lost his room. The family has experienced this same series of events several times.(p. 53)
These problems can be dealt with by educating the schizophrenic about budgeting and assisting the person to manage his or her money responsibly. Direction in banking procedures, help with shopping, monthly budget lists, visits with nutritionists and patience would be required. If money mismanagement continues, trustees may be involved on a voluntary basis or on an involuntary basis if the schizophrenic is judged to be financially incompetent.
Where should the schizophrenic live? In the family home, boarding home, group home or own apartment. The ideal place is subject to the individual’s needs and what is available. The schizophrenic’s requirements must first be assessed before housing options can be determined. Carson & Arnold (1996) state:
Ideally the housing placement takes into consideration patients’ strengths and abilities for independent living, their ability to live safely, their ability to make decisions in their own best interest, and their requirement for supervision, and matches them with housing that allows them to be in a safe, healthy environment in which maximum independence is possible. (p. 1136)
Great strides have been made to provide adequate and appropriate housing for the severely mentally ill, but the greatest barrier continues to be community resistance to the placement of mentally ill individuals in residential settings.
Nutrition is an essential part of rehabilitation. Limited and meager nutritional intake is of concern to the client, rehabilitation team and families. Carson & Arnold (1996) state that because psychiatric illnesses affect the whole person, it is not that surprising individuals with a mental health deficiency have poor diet intake. Everyone needs good food and a balanced diet, but in schizophrenics and the mentally ill it is more imperative. Sometimes their diets are lacking in the correct amounts of nutrients, or they don’t eat enough or too much. During client assessment, it is important to assess the schizophrenic’s state of nutrition, and also be prepared to supply a certain amount of client teaching on proper nutrition.
Activities of daily living are a part of everyday life to most people. Activities like daily hygiene, cooking, shopping, cleaning, conversation and transportation issues are second nature to most, but to the schizophrenic, they become uncomfortable, if not difficult. Individuals with schizophrenia may have to learn or relearn many or all of these things in order to return to an optimum level of competent and confident functioning. Stuart & Sundeen (1995) state that a major goal of rehabilitation is to assist the person to develop independent living skills. Initially, an assessment must be made to determine what new skills are needed, and then from there a program could be developed and individualized for that client.
Most schizophrenics are not well off financially and find it hard to know what to do with the spare time on their hands. Leisure time becomes one of the most important areas of rehabilitation focus. Lalonde (1995) states that leisure desires and needs of schizophrenics determine the range of activity. The focus is on assisting the schizophrenic that neither works nor attends school to use his or her time effectively. It is imperative that the rehabilitation team is made aware of local activities that are inexpensive. These activities could be accessed at community centres, libraries, churches, parks and adult education centres. Bigger cities may have specialized drop-in centres for activities and fellowship for the schizophrenic.
Socializing is difficult for the individual with schizophrenia. Keltner et al (1991) state that a client is so focused on internal processes that his external social world collapses. Kalman & Waughfield (1987) state that one of the most important factors in a schizophrenic is the loss of self-esteem. Carson & Arnold (1996) also state that the person who is socially incompetent due to mental illness is unable to function smoothly in society because of feelings of low self-esteem, isolation and anger. Ideally, social skills training would begin in the hospital. This is more important to those who have had extended hospital stays. Upon discharge, schizophrenics can be referred to specialized community based programs such as social-recreational day programs with a focus on group interaction and activity. For example, some groups may use art or music to stimulate clients to interact and encourage socialization.
Physical fitness is also very important to help preserve a sense of well being. “Physical health and mental health are linked” (Keltner et al, 1991, p. 258). As schizophrenics become withdrawn and unsociable, their desire to exercises wanes. An exercise group will do a lot to counter this problem. Another important factor is that exercise and achieving overall physical and mental health can offer a different focus or diversion for those experiencing fear, tension and anxiety. Schizophrenia sufferers should be encouraged to get sufficient amounts of moderate daily exercise. A medical check-up would be advised before starting any exercise program.
Interventions in rehabilitation must also address spiritual and cultural issues. “To treat all clients the same is to treat them poorly” (Hunt & Zurek, 1997, p. 93). Culturally specific care focuses on treatment that is acceptable and reasonable to each client. Care must match each individuals’ beliefs, values, norms and perceptions of the illness they are suffering from. Hunt & Zurek (1997) also state that even though cultural knowledge and sensitivity signify concern for the client, we cannot ignore the influence of spirituality on his or her perspective of health and well-being. Spiritual aspects of care are vital for individuals who have had serious health problems and who continue to lead difficult lives. Meaning in life is crucial to all, perhaps even more so for the mentally ill.
Schizophrenia rehabilitation would not be complete without assistance with job training and job finding. Many rehabilitation programs have a vocational component built in. Stuart & Sundeen (1995) state that aside from the development of work skills, the goal of these programs is to promote good work habits. Most often the problems that interfere with keeping jobs interfere with getting them also. A schizophrenia sufferer may not necessarily seek work for money. Helping others is sometimes a vocation that schizophrenics aspire to. Volunteer work is quite often available. Volunteer work does not usually have financial reward, but it may provide the schizophrenic with a sense of purpose and meaning. A point to keep in mind is to remind families and friends to value whatever the individual spends his or her time at. Work, paid or volunteer, may become monotonous, repetitious or even unchallenging, but for the schizophrenic, it can provide a social or occupational environment that will become familiar and safe. The structured routine that employment offers provides a welcome diversion from unpleasant preoccupations.
Retraining is a significant component of vocational rehabilitation. Schizophrenics sometimes want to go back to school to retrain for something new or to finish something they have already started. Sherman (1998) states schizophrenics that graduate with college certificates have a greater sense of purpose and direction. The Redirection Through Education (RTE) program at Seneca College in Toronto, Ontario is a valuable program to achieve that end. “Developed in 1981, this psychosocial rehabilitation program is unique, as it offers adults with psychiatric disorders an opportunity to focus on reintegration into the community while being located in an educational setting” (Sherman, 1998, p. 22).
Schizophrenics need to learn about their illness and how to deal with it. Education parameters include the illness itself, treatments, medications and side effects and what is available in terms of community programs that can assist in their recovery. With any long-term illness, such as schizophrenia, the client must depend on the support of family, friends and the community at large in order to maintain as normal a life as possible. By educating the schizophrenic about this illness, you empower the individual. To empower is to begin to give control back to the individual. Education is key.
Families and friends are also in need of education about schizophrenia. “Family education has become a primary nursing intervention when providing rehabilitative services to relatives of seriously mentally ill people” (Stuart & Sundeen, 1995, p. 317). Carson & Arnold (1996) state that when the education process is successful, it can lower the emotional climate of the home, while maintaining reasonable expectations from the schizophrenic. With schizophrenia, friends and families can be thrust into the role of primary care giver. Initially, when the illness is first diagnosed, almost no family is equipped to cope. “The diagnosis of schizophrenia is experienced as a destructive force that interrupts and transforms the family life trajectory” (Tuck, duMont, Evans & Shape, 1997, p. 120). Over time, with proper education about schizophrenia, it is hoped that the family will learn how to care for the individual suffering from schizophrenia.
Medication is an initial must for every individual afflicted with schizophrenia, but it is by no means a cure. “Rehabilitation is the tertiary prevention process of helping the person who has a serious mental illness return to the highest possible level of functioning” (Stuart & Sundeen, 1995, p. 321). In order to reach the optimum results with rehabilitation, all aspects of a schizophrenic’s life must be considered. It is ideal to keep expectations open and flexible, in order to accept the schizophrenic at his or her level of functioning. The best rehabilitation plan is individualized and is formulated with the aid of the schizophrenic, the family and all health care providers associated with the schizophrenia sufferer. It is necessary to provide the schizophrenic with courtesy, consideration and most of all respect. This will help achieve self-assurance and autonomy, and to help achieve the single most important aspect of rehabilitation: improving the quality of the schizophrenic’s life.
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