# 20220107 My current understanding of treatment rationale and theories Related [[20220107 Thoughts about EMA EMI uses in HOPE system]] #hope-s [[What's our conceptual framework]] ## Who are the patients? Patients come to us through the following pathways, (1) self-referral via GP/Polyclinic and an appointment to the hospital, (2) through a visit to the Emergency Department. They could visit the Emergency department by themselves, brought in my their caregivers, by the police, or a transfer from another hospital. Once they are in The Hospital, they will be seen by psychiatrists and ultimately a referral will be made to Our Service if they fall into the acceptance criteria for the service. ## Why do they come to Hospital, or see a doctor? (1) Patients who are aware that they are not feeling well. They feel different from before. They feel depressed, anxious, or have abnormal experiences such as hallucinations. They want to feel better. They seek help. (2) The other group of patients are encouraged by their caregivers/friends to seek help. They may have been observed that they are not their usual self; they seems more depressed, withdrawn, unhappy, anxious. They could also be seen to have odd behaviors such as talking to themselves, smiling to themselves. They may not be able to continue with work or studies. So their loves one encourage them to seek help. ## What are problems? So the patients came through the healthcare system and ultimately arrived to Service, and the psychiatrist and the case manager meet them for the first time. We have to take note that how the patient define his/her problems will be different from how a healthcare professional (say a psychiatrist) define the problem: We may start with the question "what brings you here today?" From the patient's perspective: their problems could be "I can't sleep", "I worry alot for my son", "I feel hopeless", "Others are making my difficult", "I hear many voices", "I am a prophet of God on earth", "My parents are the problem!", "I don't go to school." From the professional's point of view: We look out for signs and symptoms that can help us form a diagnosis. (the DSM etc). It could be depression, anxiety disorders, psychosis etc. [[why is there mental illness]] ? The medical approach/model takes precedence in hospitals. A Diagnosis is made by interviewing the patient and their caregivers The aim is to form an understanding of the patient's longitudinal history and to form an impression of how this patient functioned before (the change) and after (the onset of this change). We want to know, "Who is this person?" "What has happened in their life" "What might have caused these symptoms/illness now?" ^d5d8ca ## What is the goal of treatment in Our Service? The treatment goal is related firstly to how one explains the problems. Because problems are seen, explained through a particular theoretical lens/assumptions/beliefs. [[why is there mental illness]] From each different approach, there will be different treatment goals. Generally, the goal of treatment, is of course, to reduce patient's problem. If we can reduce patient's problem, then they become less problematic to us (healthcare system), utilizes less of the resource. The important thing to note is that; how patients see their problems and how treating team sees the problem may still be different, thus we need to bridge this gap. Patients need to see what we are recommending to them is going to help them with their problems. For example, for a patient who think that there is a conspiracy against him, he will not see why he need to take medication. Therapeutic Rapport is vital for a good outcome. There must be trust between patients and treating team. Understanding and to see the patients as whole human beings with past, present and future. Empathy to understand how come patients experiences the whole this way at this moment. Most of the challenge arises when the interventions given mismatch with what patient's wants. Not going to cover the acutely unwell crisis patients here, because we give them what they need, not what they want at that point to restore their mental capacity to think for themselves again. The goal of treatment for us; reduce patient's symptoms and their distress. Help them go back to their level of functioning, go back to school/work. Reduce risks to self, reduce crisis. The goal of treatment for patient: Most of them will say "i want to be normal again", "..go back to work/school", "...stop taking medicine." *- That is interesting, because they came to us in the first place for help, when we are helping them, they want to stop receiving our help?* ## What does recovery mean? It means different thing to different people. - The patient may say they want to stop using medicine, go back to school/work - Another may say, as long as they can function, they are fine with continue medications. - Once they stop experiencing symptoms (no more voices), mood improve.. etc - Caregivers think as long as their love one is "not relapsing", can work and get on with life. - Clinicians have the clinical definitions. PANSS score? - What about my view? Does it matter what i think? ## What are the interventions rendered and why? This really is related to a the earlier explanation on "what are problems?" and the fundamental question of, [[why is there mental illness]]. Thus each approach will focus on different outcome. We formulate each patients through a BioPsychosocial Formulation process [[C20200327 Why do we formulate cases]] https://www.evernote.com/shard/s5/nl/463671/4dd4b42e-e71b-4cf0-a21e-c6da4ff27fc4?title=The%20Biopsychosocial%20Formulation%20Manual #stress_vulnerability_model What principles do we hold with regards to interventions or case management? The principles of interventions. https://www.evernote.com/shard/s5/nl/463671/44953f84-e012-4dd1-9bdb-6ecaa78344ff?title=An%20introduction%20to%20the%20practice%20of%20case%20management%20in%20Social%20services. 1. reduce crisis 2. Improve safety 3. Giving knowledge 4. Collaborative ## How do i know what interventions is needed? Based on each patients individual formulations, diagnosis, and the area of interventions are planned with the patients. According to the different biopsychosocial perspectives, incorperating the varies theories and perspectives. The patients need to understand why we do what we do, and we have the "buy in" from the patients. Thus a certain level of trusts and rapport is needed. ## How do patients know what help they need? Before even coming to seek help from professionals, patients in their own ways have their attempted solutions. For example, spiritual beliefs, their unique way of coping with problems. They have tried their own ways to solve their own problems. We need to process whether those attempted solutions have been helpful, through conversations with the patients. Related back to the "view of the problems" by patients. ## Do all patients want help? What kind of help? They may want us to "collude" with them, to agree with their views. They want us to believe them, their views, their delusions/beliefs. What if the kind of help they seek, is not what we can give? And their attempted solutions actually causes more problems, to themselves and the people around them (that is the social interaction perspective) [[What's our conceptual framework]] ## What are the challenges faced by me? ### Alignment of views. To form this collaborative approach Patients view of their problems, do they view it as a medical problem, a spiritual problem? or other attributions? ### Expectations Related to that first point, we work not just with the individual patients but with their systems (caregivers), the multidisplinary team, each professions comes with a certain angle/assumptions/views; Psychiatrist by training may emphasis on medical model, Occupational Therapists, Social Workers, Psychologists.. all have own training. All have a different view of "problems" and thus "interventions" needed. How as Case managers, we have to broker, and manage these stakeholders, to form an integrative approach. ### Time and Energy for each patients The challenge is to spend the time and energy in working out the individual formulations plan, that comes from spending time (emotionally) to understand the personhood of patients. Not a reductionist view. With so many patients under our care, sometimes that is a challenge to give enough attention to each cases, when others demands our attentions due to crisis, relapses etc. ## What informed me that the patient is progressing or not progressing? Going back to the individual management plan, and the formulations. Whether we are able to reduce perpetuating factors. ### Through patient's subjective experience Patients giving us direct feedback about their symptoms, distress levels. Whether it is reducing or increasing. Patient's subjective views of themselves. Any new development of more problems? Any improvement in level of functioning? - Medically - Any reduction of symptoms, side effects. - Cognitive deficient - Is there a reduction of abilities/functioning - Psychologically - Psychologically, do the patients experience more "power", more "space". Do they feel that they are freer to make choices. - Greater ability to manage their life stressors? - Less "stuck", "tightness" in views about problems. i.e They can entertain more possibilities of explaining why things happen. - Do they have more understanding, differentiation of self. Integration of selves. Acceptance. - Related to the ![[why is there mental illness#^0064cb]] those themes of mental illness, any improvement in those areas? - Psychosocial / Occupational - Is there a reduction of abilities/functioning. Do they need rehabilitation? ### Caregivers observations, of how patients are doing in the natural environment. - Social - The general level of crisis, distress of the cases. Generally as we move from the acute, to stablisation phase, things should become less chaotic and fluid. (But stablisation does not necessary means improvement, it could just mean they return to how things were. Related to the systemic perspective. The system adjusted.) THUS interventions should be able (Maybe EMA/EMI should be doing the following.) 1. Giving information about illness, explanations "Why is this happening to me?" 2. Pertube patient's mental models, to help "loosen the knots" through the use of [[Interventive Interviewing]], questions (Could be #solution-focus ) that are design to help patient reflect - To reflect on different levels, individually themselves, their systems, cause and effects. Whether to accept or reject beliefs (Cognitive models) - related to #CBT 3. Giving information and guidance to caregivers. Systemic. Expressed emotions, Expectations. Circularity interaction pattern. 4. Empowerment. Giving hope. Narrative of their life-story 5. Advocacy on behalf of patients against "systems" - Social perspective. Stigma. Discrimination. Dominant discourses. ## How will these interventions be delivered? Through case management (and there are different models of case management), the case manager is attached to a client to help the patient manage the complexities. Interventions are paced, according to the patient's state, readiness. CMs provide "supportive therapy", counseling techniques. Also referral to different MDT professionals to intervene.