Serious Mental Illness

Person-Centered Approaches

Abraham Rudnick, David Roe

• Publisher: CRC Press
• Year: 2018
• eBook ISBN: 9781315346717
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Practical and evidence-based, this unique book is the first comprehensive text focused on person-centered approaches to people with serious mental illness such as schizophrenia and bipolar disorder. It reflects a range of views and findings regarding assessment, treatment, rehabilitation, self-help, policy-making, education and research. It is highly recommended for all healthcare professionals, students, researchers and educators involved in general practice, psychiatry, nursing, social work, clinical psychology and therapy. Healthcare service providers, and policy makers and shapers, will find the book's wide-ranging, multi-professional approach enlightening. 'Serious Mental Illness reflects a continued distancing from the outmoded and unsubstantiated belief that people with severe mental illnesses could not recover, and that they would respond positively only to goals and treatment plans chosen, designed and implemented by providers in order to prevent their further deterioration. Anyone with an interest in the concept of person-centered approaches will discover new ideas in this book. Indeed, anyone with an interest in person-centered approaches has to read this book. Not only is it the first such book on person-centered approaches, but it will serve as the gold standard in this topic area for years to come.' William A Anthony, in the Foreword

CHAPTER 1

Framework

This (first) chapter of the book addresses foundational or conceptual, as well as ethical and historical, underpinnings of PCC for people with SMI. Such a framework is helpful in order to try to understand the pertinent driving principles and fundamental challenges, as well as how and from what PCC for people with SMI developed, so that a deep and broad understanding of PCC for people with SMI can emerge. This chapter grounds the latter parts of the book in such an attempted understanding and prepares the way for a discussion of different aspects of PCC for people with SMI in the other chapters of the book. These chapters are structured according to the structure of the Patient-Centered Clinical Method (PCCM), which is the backbone of the book series to which this book belongs. The PCCM is briefly described in Section 1.1, Foundations and Ethics of Person-Centered Approaches to Individuals with Serious Mental Illness, as are some other person-centered approaches. As in other sections and chapters of this book, the aim is to present a pluralistic yet critically minded discussion of PCC for people with SMI.

Section 1.1 presents PCC as a multi-dimensional construct. The section argues that not all dimensions or aspects of PCC for people with SMI have to be present in order for care to be person-centered and outlines ethical principles and ethical challenges of PCC for individuals with SMI. Section 1.2.1, Moral Treatment in the Eighteenth and Nineteenth Centuries, presents moral treatment as a form of humane “psychological” therapy - and hence perhaps the closest at that time to PCC - that emerged towards the latter half of the eighteenth century and which enjoyed a golden age until the first quarter of the nineteenth century; it then gradually fell into disrepute as it was forced to abandon its person-centered ideals due to increasingly large difficult-to-treat populations. Section 1.2.2, Rogerian and Related Psychotherapies in the Twentieth Century, argues that PCC has roots within psychological care, dating back to the 1940s to humanistic psychologist Carl Rogers, and that Rogers applied the core concepts of PCC when providing psychological care to a wide variety of service users, including those with SMI.

1.1 Foundations and Ethics of Person-Centered Approaches to Individuals with Serious Mental Illness

Abraham Rudnick and David Roe

INTRODUCTION

PCC is widely considered a cornerstone of contemporary mental health services for people with SMI such as schizophrenia. This is clearly illustrated in psychiatric rehabilitation, which focuses on assisting individuals with SMI to enhance and maintain their living skills and supports so as to achieve their goals,¹ using evidence-based clinical and social interventions such as social skills training, supported employment (SE) and family psychoeducation.² Recovery-oriented services are part of a new vision of mental health care,³ which is first and foremost person-centered. Recovery is viewed in this vision as both an outcome, which refers to reduction in symptom severity and increase in role functioning,⁴ as well as a process, which refers to seeking and having a personally meaningful life and valued social roles.^5,6

The foundational underpinnings of PCC and other person-centered approaches (such as self-help) for individuals with SMI have not been sufficiently analyzed in a systematic manner, e.g. in relation to the dimensions of PCC as a construct. Yet foundational understandings are arguably important for maturation of mental health care practice and research.⁷ In addition, ethical aspects of PCC, including associated challenges such as legal issues, are still under considerable debate, e.g. in relation to individuals whose capacity to make decisions about their lives is impaired due to their mental illness. In this section, we conduct a conceptual analysis of foundations and ethics of PCC for individuals with SMI, based on writings about PCC in other populations and on writings about individuals with SMI. Conceptual analysis may be said to address the internal consistency within a concept and the mutual coherence between concepts.⁸ As such, it is suitable for study of the concept and of the derived construct of PCC.

FOUNDATIONS OF PERSON-CENTERED CARE

Person-Centered Care as a Multi-Dimensional Construct

There is still much controversy about what PCC means; indeed, the related notion of (the personal process of) recovery of individuals with SMI, as described above, is currently so rife with diverse meanings that it is at risk of becoming meaningless if not clarified.⁹ The meaning of PCC appears clearer when applied to other clinical populations. For instance, the PCCM approach, which was originally designed for a primary health care population, includes six interactive components of the person-centered process: 1. exploring both the disease and the illness experience (history, physical, lab and dimensions of illness - feelings, ideas, effects on function and expectations); 2. understanding the whole person (the person, the proximal context such as family, and the distal context such as culture); 3. finding common ground (problems and priorities, goals of treatment and/or management, and roles of service user and provider (physician); 4. incorporating prevention and health promotion (health enhancement, risk avoidance, risk reduction, early identification, and complication reduction); 5. enhancing the service user - provider relationship (compassion, power, healing, self-awareness, and transference and countertransference); 6. being realistic (time and timing, teambuilding and teamwork, and wise stewardship of resources).¹⁰

A thematic analysis of relevant centeredness (person-centeredness, patient-centeredness, client-centeredness, family-centeredness and relationship-centeredness) across health care contexts revealed 10 common themes: 1. respect for individuality and values; 2. meaning; 3. therapeutic alliance; 4. social context and relationships; 5. inclusive model of health and well-being; 6. expert lay knowledge; 7. shared responsibility; 8. communication; 9. autonomy; 10. professional as a person.¹¹ Analysis of PCC with particular focus on elderly populations has demonstrated four components (the VIPS model): 1. the absolute Value of all human lives; 2. an Individualized approach, recognizing uniqueness; 3. an understanding of the world from the Perspective of the service user; 4. a Social environment that encourages well-being.¹²

PCC for individuals with SMI can be argued to be: person-focused, i.e. the person is the (intended) beneficiary of care; person-driven, i.e. the person decides on his or her care; person-sensitive, i.e. the person’s particular needs are addressed; and person-contextualized, i.e. the person’s history and current circumstances are considered in providing care. We suggest that these are different dimensions of the construct of PCC, which under some conditions may be complementary, yet under other conditions may be in conflict. In what follows, we elaborate on each dimension of PCC and note potential conflicts between these dimensions, in preparation for the discussion on ethics of PCC for individuals with SMI near the end of this section.

Person-Centered Care as Person-Focused

The person-focused dimension of PCC refers to the person as the (intended) beneficiary of care. PCC is explicitly aimed at the person with the health problem. More specifically, it is aimed at that person’s benefit, such as alleviating a health problem, e.g. treating and hence curing pneumonia with antibiotics, or reducing a persistent health problem’s disruptive impact, e.g. managing and hence stabilizing diabetes mellitus with a healthy lifestyle (in addition to medications if needed). In relation to people with SMI, PCC may sometimes alleviate the problem, such as in treatment for an acute episode of major depressive disorder, and at other times it may reduce the problem’s disruptive impact, such as in management of schizophrenia.¹³ Note that SMI sometimes defies the distinction between a problem that can be alleviated and a persistent problem that has disruptive impact which can be reduced. The clinical manifestations of SMI commonly recur, with remitting-relapsing and exacerbation patterns such as recurrent depressive or manic episodes in major mood disorders¹⁴ and psychotic relapses in schizophrenia,¹⁵ in addition to ongoing manifestations such as residual negative symptoms and neurocognitive impairments in schizophrenia.^16,17

It may be considered a given that care aims at benefiting the individual with an SMI. Yet this is not always so, as in some cases care is provided to individuals with SMI in order to benefit others. This is particularly so in cases of involuntary commitment of individuals with SMI who pose an aggressive threat to others due to their SMI, such as in manic or psychotic episodes where an individual’s delusions or hallucinations may lead him or her to act aggressively toward others. In such cases, the benefit of the individual with the SMI is considered of secondary importance, and although that individual commonly benefits by being protected from legal and other normative social consequences of his or her own aggression, in some cases such individuals are not thankful for such protection even after the fact. This characteristic of care for some individuals with SMI qualifies PCC in such cases, as will be discussed later in relation to ethics of PCC. Note that if person-focus is viewed as a continuous dimension, the question of health care benefit to the individual with the SMI versus to others (particularly those directly impacted by that individual’s life and care, or lack of care), can be viewed as a matter of balance, i.e. more or less benefit to the individual with the SMI versus more or less benefit to others.¹⁸ This matter of balance is not unique to SMI, as it is relevant to some other health conditions such as infectious diseases (particularly respiratory and sexually transmitted diseases, which are commonly reportable to public health authorities even without the infected individual’s consent), but it may be more prominent and common in relation to SMI.

Person-Centered Care as Person-Driven

The person-driven dimension of PCC refers to the person as the decision-maker about his or her care. According to health care legislation in Western countries and in some other jurisdictions, indi...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Series Editors’ Introduction
• Foreword
• About the Editors
• List of Contributors
• Acknowledgments
• List of Abbreviations
• Introduction: background and overview
• 1 Framework
• 2 Magnitude of the Problem
• 3 The Person’s Experience of the Illness
• 4 Understanding the Context of the Individual
• 5 The Person/Patient-Provider/Clinician Relationship
• 6 Management and Finding Common Ground
• 7 Prevention and Health Promotion
• 8 Constraints
• 9 Academic Activities
• 10 Conclusion
• Index