Abstract
The young, chronic, psychiatrically disabled adult characterised by persistent and multiple pathology, unsuccessful contact with services and therapeutic pessimism within conventional programs continues to challenge mental health professionals. Typically, they have high rates of alcohol and/or drug abuse, of suicide attempts and successes, of social isolation and substantial, if not total, financial dependence on welfare. Although they have been previously institutionalised, the past 25 years have shown an increasing commitment to alternatives. Major developments have included brief hospitalisation, community based case management and a treatment focus based on early detection and problem-solving [1–7]. Although these changes are significant, control remains within the health system; that is, decisions concerning management are still determined by the organisation offering those services rather than by the patient.
Emerging from social learning theory [8], an approach that attempted to integrate models of reinforcement with the complexity of situations that individuals had previously experienced has been developed. Specifically, it was postulated that people may approach potentially reinforcing situations on the basis of prior expectancies. It was hypothesised that there may be a continuum where at one end subjects approach the world as agents who believe that they are capable of influencing their environment; that is, they have an internal locus of control. At the other end, there are people who believed they had little control over their lives and that they would be subject to the unpredictability of powerful others, of chance or of fate. While prior experiences may have contributed to a distrust of the hospital system, we wondered whether patients may not have participated in the care offered believing that their own involvement would be inconsequential; that is, they had an external locus of control.
A number of writers have attempted to translate this approach into a model of care that builds on the premise that decision-making is shared with, rather than exclusive to, the patient. A change in locus of control among adolescent drug abusers who had improved was noted [9], others have described the involvement of patients in introducing an open-door policy in an inpatient unit and showed with it a statistically significant reduction in incidents [10], while another group described how they stumbled upon similar factors that enabled them to successfully manage a previously disturbed 136-bed institution [11]. More recently, the theme of patient participation has been described in the relationship management of people with borderline personality disorder [12]. The authors regarded the person as a competent adult capable of making reasoned decisions; that is, the responsibility for care is returned to the person and an internal locus of control is fostered. Should hospitalisation occur, nothing else would change in the management plan as a result of that decision.
These concepts have been articulated as a number of practice guidelines [13]. These include regular, flexible and long-term contact, rather than brief, crisis-based responses which may unwittingly reinforce maladaptive strategies; the use of a team rather than a single community nurse thereby providing psychological space for both patient and staff; and a focus on problem-solving rather than insight-orientated psychotherapy.
This report describes one further refinement to the management of the young, chronically disabled adult. It assumes that it is the complicated person with schizophrenia who has significant comorbid pathology that forms this group. Characteristically, admissions occur only after the situation has peaked for a patient where involuntary recommendation seems the sole available option. In this case, the point of admission is changed so that it occurs within the context of a patient-initiated, voucher-based, brief hospitalisation program; that is, the locus of control has been shifted from an external to an internal position.
Case report
PF was a 31-year-old unemployed man who created considerable disturbance in a small rural community when he arrived from the drug culture of a major metropolitan centre. His loud and aggressive manner with openly and spontaneously voiced threats of violence and self-harm both alarmed and alienated the community as he wandered the streets. His daily medication was complicated and included 2-weekly, intramuscular fluphenazine decanoate 50 mg and daily chlorpromazine 300 mg, benzhexol 5 mg, prothiaden 75 mg, moclobemide 300 mg, bus-pirone 60 mg, and diazepam 12 mg.
His psychiatric history included an uncertain diagnosis of schizophrenia on the basis of fleeting persecutory beliefs and auditory hallucinations and a diagnosis of polysubstance abuse with amphetmaines, opiates, diazepam and benzhexol. In addition, a diagnosis of both borderline and antisocial personality disorders had been made. The criteria for the former included repeated attempts at self-harm, including threats to jump from buildings and the intravenous administration of car battery acid, unstable relationships and affective instability. He had had four admissions to different hospitals in the preceding 6 months with an average length of stay approximating 2 weeks and interstate admissions ranging between 3 and 18 months. When an inpatient, PF's time was characterised by angry outbursts, threats for immediate medication or else he would kill himself and by absconding. He interacted with staff where he suggested that different staff had said different things and was noted to take on the concerns of other patients, particularly women who had similar histories to his own. He was managed in the high dependency areas with repeated seclusion, at other times appearing settled, expressing a wish to change and admitting to feelings of sadness. There were no consistent features of a mood disorder reported or observed and no disturbance in his eating, drinking or sleeping noted.
His medical history included infective endocarditis with cardiac complications and non-compliance to antibiotic prophylaxis and a family history of schizophrenia, with his drug-dependent mother eventually committing suicide. His own developmental history was marked by emotional, physical and sexual abuse, multiple placements in children's homes, conduct disorder and a forensic history including drunk and disorderly behaviour, theft, wilful damage to a police car and a 5-month prison term for assault on the police.
On mental state examination, PF was a powerfully built 31-year-old male wearing black singlet and jeans, knee length cardigan, a leather mitten on one hand, long hair and earrings. There was scarring over the (R) ante cubital fossa consistent with the injection of battery acid. His speech was thought-disordered with an independently reviewed seven-page transcript of a tape-recorded interview that documented clear loosening of associations, PF having agreed to the process. His approach was intrusive, threatening and intimidating as he thrust his head close to ours while shouting, reporting multiple delusions and hallucinations within a clear sensorium.
Over the next 8 months, PF was seen weekly by a member of the team, although the principal care was provided by a single community psychiatric nurse (DS). The consultant reviewed progress fortnightly and then monthly. The focus of management was on immediate problems, facilitating rather than distancing community contact, rationalising medication and avoiding hospitalisation. Appropriate accommodation was found, welfare benefits transferred, arrangements to join the gymnasium and adult literacy classes which he requested were facilitated, although attendance to the latter was erratic, and with consent, the local police and general practitioners contacted to inform them of the overall management plan and strategy. Opportunities to ventilate understandable anger reduced the intensity and frequency of his threats, specific beliefs and experiences being otherwise ignored. Staff leave was anticipated and discussed with PF in advance. Another team member who had met PF and who was familiar to him continued the same management approach. Modest stability was gained with no admissions and a reduction and rationalisation in his medication. This included the gradual stopping of chlorpromazine and buspirone, reduction of fluphenazine decanoate to 25 mg 2-weekly and diazepam and benztropine to 5 and 4 mg per day, respectively. Moclobemide 300 mg was continued.
However, numerous crises had occurred in the community, one in particular in which the consultant again chose not to admit PF. Although surprised at being able to manage in the community without admission, PF later argued that the team had not appreciated how difficult it had been. As a consequence, a strategy for subsequent crises was collaboratively developed in which PF could choose whether an admission was essential. PF was given, metaphorically, a voucher for 5 inpatient days over the next 12 months. At crisis he would contact the community nurse and alternative community-based strategies would be explored and used. Should he choose to use his voucher, however, he would be admitted the following day. This delay was introduced in order to provide a further opportunity to manage in the community to allow for the practicalities of transportation from a rural setting and to avoid inappropriate reinforcement for crisis admission.
Two months later, PF reported the death of a friend and was again suicidal. He felt unable to manage in the community and sought admission via the voucher system. Although PF has been managed in the community with a similar level of distress previously, the above plan was implemented with the sense that PF may have been testing the process. He was admitted and stayed for 2 days. This coincided with a weekend when there was little organised activity on the ward and during which time a further reduction in his medication occurred including reducing and stopping moclobemide. He was reviewed and discharged home on fluphenazine 25 mg 2 weekly, benztropine 2 mg daily and diazepam 5 mg daily. No subsequent vouchers were used in the next 5 months, at which point PF precipitately moved interstate following the arrival and subsequent departure of a drug-dependent friend who had visited him from the city.
Discussion
Our case history demonstrates that brief hospitalisation under a patient-initiated voucher system was an effective alternative to previous conventional admissions. PF, a man with confirmed dual disability, schizophrenia and polysubstance abuse, and comorbid borderline and antisocial personality disorders, showed a clinically meaningful stabilisation in his presentation and achieved the aims of intervention. In contrast to four volatile admissions in the preceding 6 months, PF had had one uneventful 2-day admission in 13 months. In addition, his medication was rationalised from eight different psychotropics to three, with a 50% reduction in the dosage of the remaining medications. Finally, there was a non-quantified reduction in his verbally threatening behaviour and in the level of community concern and complaint.
In addition, this moderately successful, community based intervention provided the treating team with the experience that seemingly intractable behaviour is capable of change. Further, brief hospitalisation provided psychological space for PF, the team and the community, and demonstrated the effectiveness of a direct, problem-solving approach that focused on the immediate concerns of both the patient and the community. These principles confirmed the treatment guidelines noted above [13].
The person with dual disability is complex and challenging. Engagement is typically difficult. Contact may be seen by patients as having been imposed by a system which has little concern for them as individuals, regarding them instead as the patients that psychiatrists dislike [14]. Changing the orientation and considering people as responsible and competent offered an opportunity for developing a working relationship at least with people with uncomplicated borderline personality disorder [12]. It was from a similar perspective and with a theoretical underpining related to locus of control, that this patient-initiated voucher system was developed. PF's distress was listened to and acknowledged. While a similar level of disturbance in his crisis had been managed in the community previously, PF chose to come in to hospital. He was transported the following day when additional community supports had been tried unsuccessfully. Having chosen the timing of his admission, the duration was discussed and left open with the understanding that he had up to 5 days. Importantly, nothing else changed [12]. The admission occurred at a weekend when there was little in the way of structured activity and PF was managed routinely. PF had been wondering whether moclobemide was useful, the opportunity to further reduce medication was taken and occurred without incident. There were no angry outbursts, no threats of self-harm and no absconding. PF discussed and discharged himself after the weekend and returned to the community where he continued to be managed for the subsequent 5 months as an informal patient in the least restrictive setting.
The case report is, by its nature, anecdotal. As a consequence, results are not generalisable. However, given the theoretical basis underpining the approach, namely of fostering an internal locus of control and meaningfully involving the patient, the above account suggests evidence for a testable assertion that has been derived from the literature. Namely, involving the person as a member of the treatment team, with the use of a patient-initiated voucher system and the flexible use of brief hospitalisation in an otherwise community based model of intervention, resulted in a clinically meaningful change for the patient, the team and the community.
Footnotes
Acknowledgements
Thank you to my family, secretary Lesley Hopkins and to the staff of the Grampians Psychiatric Service.