Social Inclusion in Schizophrenia Care

This essay will explore the issues of social inclusion for a service user, diagnosed with schizophrenia, as observed during a placement undertaken at a London Trust in-patient adult mental health rehabilitation unit. It will explore how the medical model on its own is not sufficient in practice and discuss the importance of a holistic approach to recovery. The Social model of Disability will be reviewed and critically appraised as will the International Classification of Functioning Disability and Health (ICF) model. In addition to this, this essay explores how the Model of Human Occupation Screening Tool (MOHOST) considers how therapists can improve participation and facilitate recovery for an individual suffering from schizophrenia by using MOHOST, which is used widely amongst OT rehabilitation. Furthermore, some of the strategies used in mental health care to facilitate the recovery process will be discussed and evaluated. The World Health Organisation (WHO, 2001) defines social exclusion as “the dynamic, multi-dimensional processes driven by unequal power relationships interacting across four main dimensions - economic, political, social, and cultural - and at different levels including individual, household, group, community, country and global levels.” Occupational therapy has helped treat and rehabilitate people with serious mental health conditions ever since its establishment in the United States at the start of the 20th century (Duncan, 2006) and was officially founded in 1920 (Haworth, 1933). The therapy focuses on the evolving field of occupational science, which acknowledges that participation in productive and fulfilling occupations leads to enhanced well-being, social inclusion, and to improved functioning and respect for oneself (Wilcock, 2005).

The service user that will be discussed in this essay will be referred to as Saj, a male of Asian origin in his mid-twenties. He had his first psychotic episode in his late teens. His parents became increasingly concerned over his increasingly erratic and aggressive behaviour and called the police, leading to forced hospital admission and, as a result, a diagnosis of schizophrenia.

Schizophrenia is a mental health problem that affects the way one perceives and interprets reality, most of which is the result of factors such as illusions, hallucinations and thinking that can be considered extremely disordered (National Institute of National Health (NIMH, 2020)). This can result in impaired daily functioning. During diagnosis, Saj exhibited patterns of low mood, depression, and anxiety, which are typical of Schizophrenia. Other behaviours portrayed by Saj include substance misuse, self-harming tendencies and suicide attempts, and reports that he hears voices, he has difficulties forming and maintaining relationships. During admission, Saj preferred spending time in solitude in his room mostly watching television and doing puzzles. The (bio) medical model views the person's disability as an attribute that is directed by disease trauma that requires the provision of individual medical treatment by professionals. According to the model, disability is an attribute linked to an individual resulting from illness or trauma that limits functioning normally, and to ‘fix’ the problem medical treatment is required (Farre and Rapley, 2017). In the case of saj, he was given anti-psychotic medication to alleviate the symptoms of schizophrenia but this on its own would not be sufficient in delivering effective therapy for recovery (Vita, 2018). Alternatively, the Social Model (Oliver, 2013) perceives disability as construction of society. The model considers disability as a socially and culturally constructed problem, and not down to an individual alone. Individuals living with schizophrenia frequently feel stigmatised within society this is often significant barrier to full participation, they are also challenged by the stereotypes, the lack of knowledge, and the discrimination that result from misconceptions about schizophrenia (Rössler, 2016). Stigma can be internalised leading to self-stigma (Brohan et al., 2012) which in turn can negatively affect patient engagement, which can hinder recovery (Fung, Tsang and Corrigan, 2008). This was a key issue in the case study that will be discussed. Consequently, as a result, this group are often deprived of opportunities that define a good quality of life: employment, safe and comfortable housing, access to good health care and opportunities to mix with a diverse group of people (Thornicroft, 2019). This stigma can be internalised leading to self-stigma (Brohan et al., 2012) which in turn can negatively affect patient engagement. This can significantly hinder recovery (Fung, Tsang, and Corrigan, 2008).

After conversations with Saj, who is a practising catholic, it became apparent that he had experienced stigma from his social environment. Due to this, he was reluctant to visit the church or see people in that social network for fear of being rejected and socially isolated due to his history of violence and mental illness. For saj, discrimination and stigma could exacerbate his mental health issues causing lower self-esteem, poor social and vocational function, increased avoidant coping, and poor adherence to medical treatment plan. Stigma and discrimination can therefore trap someone with mental problems in a cycle that may deter him/her from accessing support, which could impede recovery (young et al, 2019). Therefore, in this case the therapist will need to acknowledge, Saj could be faced with prejudicial attitudes, biases, and self-stigma, which could interfere and impact on his performance and look at ways to address this (Schrank, 2013). Engel (1977) recognised that neither of the two models discussed are adequate on their own when treating a disability. Engel (1977) claimed that a more holistic approach was required that incorporate the social, psychological, and, physical aspects. As a result, a biopsychosocial approach known as the International Classification of Functioning, Disability, and Health (ICF) (WHO 2001) was introduced. Selb et al. (2015) illustrated that ICF model considers useful aspects of both social and the medical model in a manner that explores social interaction, occupation, and environment that is fitting with a multidisciplinary approach and currently a common approach taken by mental health rehabilitation settings. According to Danermark et al. (2013), the ICF model enables addressing the complexity of the mental health while also communicating the dynamicity of participation, restrictions, and opportunities for an individual. However, there has been a considerable amount of criticism on the ICF model such as, assumption that every mental disorder classified under biopsychosocial classification increases the stigma attached to these disorders, instead of reducing it.

The biopsychosocial model considers the effects of society on an individual, including his or her beliefs, social interactions, employment history and so on. However, when planning interventions, it can become impractical to take so many social factors into consideration when trying to explore a service users’ difficulties. Furthermore, it can be challenging to determine which social, psychological, or biological factors should be considered. Thus, this could result in delays in treatment due to considering so many factors. However, despite of this the biopsychosocial approach is seen to be the most appropriate approach for people living with schizophrenia. Individuals with schizophrenia have medical as well as non-medical symptoms which significantly impact their daily living and the quality of life which are important in rehabilitation and vocational therapy. Schizophrenia leaves a significant impact on patients, their families, and society and there is need for biopsychosocial approach to ensure the best possible understanding and outcomes of the illness [National Institute for Clinical Excellence, 2010]. The National Health Service (NHS) long-term plan (2019) outlines the need incorporate the recovery-based approach in addition to care and services focusing primarily on treating illness. As pointed by Leamy et al. (2011), in mental health, recovery is a process built around vision, perspective, and guiding principle to gaining and retaining hope, acquiring personal autonomy, developing purpose in life, engage in an active life, and understanding one’s abilities and disabilities. In context of schizophrenia, the recovery model can be used to help people with mental illness look beyond mere survival and existence to living actively and having purpose in life (Warner, 2010; Mueser et al., 2013). The recovery model supports the view that the service users can recover from mental illness and the most effective pathway to recovery is allowing the service user to make informed choices about their recovery (Jacob, 2015). The Multi-disciplinary Team (MDT) had referred Saj to the rehabilitation unit at the acute mental health ward following an admission of just over a year. Rehabilitation services are provided to patients who do not recover adequately following acute admission to a mental health unit and are unable to be discharged safely into the community. The MDT at the rehabilitation unit consisted of occupational therapists, psychiatric doctors, psychiatric nurses, support workers, and activity coordinators.

The aim of rehabilitation is to help people with severe mental illness develop the social, emotional and intellectual skills required to live, learn and work with minimal amount of medical support in the community (Royal College of Psychiatrists, 2020). Enabling individuals with schizophrenia to live a normal life in the community causes a shift away from the medical model to a more functional approach (Vita, 2018). An initial assessment was carried out using The Interest Checklist (Kielhofner & Neville,1983) this was used to engage Saj in examining areas of past interests’ prehospital admission and look at ways to re-engage in these. As such, it was evident that he had some interests but that these were limited to his existing situation. The Interest Checklist helps to identify the individuals’ interests that the OT can use to engage an individual in therapeutic activities that evoke and support motivation throughout the intervention. The therapist took a client centred approach with Saj, actively listening to him, taking on board his values and aspirations. The relationship was formed built on trust, support, and mutual understanding. The therapist found the best time of day for Saj’s mood to be settled and at his calmest state was the after midday so this was set as the time to meet, as a result Saj was able to better engage with the therapist. The assessment assisted in identifying Sajs past, present, and hope for future roles. He also expressed an interest in the cooking group, art, and gardening. This gave the OT an overview of what he valued and what areas of responsibility, roles needed further exploration. It became evident while talking with Saj that his routine was not seen as constructive, and it became apparent that Saj had taken on the role of a patient, and his long admission in the acute ward had allowed him to become institutionalised (Johnstone and Owens, 1981). A Care Programme Approach Meeting (CPA) was held to determine a package of care for Saj, where his goals, treatment plans were discussed by the MDT and reviewed fortnightly to prepare for suitable accommodation and safe discharge. This involved putting together an individualised recovery care plan and was achieved in collaboration with psychiatric nurses, OTs’, social workers, care co-ordinators and psychiatrists at (MDT) meetings. This involvement of many health professionals enabled a holistic approach to recovery and considered the biopsychosocial approach incorporating medical, social, psychological elements required to formulate a personalised care plan. The goals and aspirations that Saj identified as important to him were included in his Care Plan and a written copy was provided to him in a clear simple English format so that he could understand and review if necessary. It is a legal requirement for service users and their carers to be involved in decisions relating to their care (Health and Social Care Act, 2012).

The treatment plan was structured to encourage Saj to engage in therapy groups, with the view of improving participation in a safe environment with a long-term goal of progressing to acquiring paid employment, as per his request. It was necessary to involve Saj by therapist assess his readiness for change and, as result, enabling putting in place a personalised medical plan that took into consideration Sajs values and culture. Moreover, the involvement enabled him to have a better understanding of his own healthcare needs and his condition. The therapist provided Saj with a range of groups and interventions that were available for him to participate in, to help him make an informed decision. However, when the therapist consulted with Saj he stated that he did not want his parents to be involved. Occupational therapists at the rehabilitation unit offered four type of groups, each with its own therapeutic function and purpose in mental health settings (Lund et al. 2019). This included activity-based groups (task and social) and support based groups (communication and psychotherapy). Task groups' objective is to develop the skills and is end-product focused. Social groups provide an avenue for recreation or fun and are focused on encouraging social interaction. Communication groups emphasize sharing shared experiences, and psychotherapy groups aim to increase insight into individual problems (Fowler et al. 2017). However, the groups were decided by the OTs, and there was little flexibility to change or add additional groups due to the constraints of the environment and staff that were required to run the group. The service users had not input into the groups offered, and generally, the feedback was received verbally and not actioned. Perhaps, the involvement of service users to determine content of the groups would encourage and motivate the service users to participate knowing they had been given a choice to input into the group and the content would be according to what they preferred.

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In addition, the group therapy approach was crucial in encouraging Saj to form therapeutic alliances that enabled him to engage in communication and socialisation among the group, which was a significant incentive towards recovery (Fehr, 2014). The group-based initiative included involving Saj to join a destigmatized group intervention, which was based on Cognitive Behavioural Techniques (CBT) that was effective in reducing self-stigma for people with mental illness. During group therapy, Saj expressed how he often felt bored and isolated and that he wanted to return to work. He further stated that he felt ashamed that he had been given a diagnosis of schizophrenia and felt any future employer would not want to employ him due to his diagnosis. The therapist gave Saj the details on the group and believed it would be beneficial to overcome feelings of stigma. This was achieved by encouraging him to identify and focus on his strengths and develop positive belief in himself (Young, 2018). During the group intervention, individuals shared their thoughts on stigmatised situations during the first two group sessions and then they learnt to manage with these experiences through social skill training and role-play within group sessions and then applying these skills in their everyday situations. Thus, by sharing similar experiences with his peers, emotional support, as well as sharing of skills among the group. Saj learned to cope better with his experiences of public stigma by reducing feelings of helplessness and enhancing his self-efficacy to enable him to manage his feelings of stigma and promote recovery. However, it is unclear if the reduction of self-stigma promotes recovery, as very few research studies have been done in this area. Self-management was also involved in the process, where patients were given opportunities to evaluate and keep a reflective diary of their progress regarding their recovery. OT supported the development of individual goals and helped empower the patient by explaining the options available so that they can make their own informed choices (NICE, 2011). The community employment rehabilitation programme provided Saj with graded steps to encourage entry or re-entry into employment. Saj enjoyed his part time Saturday job in an electrical store a position that he had held prior to hospital admission, he enjoyed the work and the company of colleagues. Therapist assisted and taught Saj how to search for jobs, fill out application forms, and practice with interview technique. A temporary work environment was set up to simulate and teach vocational skills aimed at enhancing his employability. Saj was successful in securing a voluntary post in a charity shop work with the view of moving onto paid employment. However, it worth noting that often the disparities between voluntary work and competitive employment is huge such that only 20% of people with schizophrenia obtain paid employment (Fusar-Poli et al., 2013). Nevertheless, this enabled him to build positive relationships within a community organisation that opened new opportunities for participation in a community group and allow social inclusion.

Conclusion

In conclusion, social inclusion is an essential factor that helps support the comfortable living of people with mental disabilities, especially schizophrenic individuals, should be assessed in terms of their needs to ensure that they are accorded the right mental health assistance where necessary. In the case of Saj, group intervention therapy proved the most suitable approach that gradually enabled social inclusion through a voluntary role in a charity shop. As part of the recommendations to oversee Saj’s full recovery and social inclusion, it was vital to position him in a communal setting where he was able to engage and participate in groups in a safe environment, which gave Saj. confidence to carry out his voluntary role in the community. The OTs used MOHOST to gain a baseline assessment of a Saj’s occupational participation. Such community integration will highly likely boost service users' self-determination. In this case, instead of working with dysfunctions, treatment was looked at holistically in a client-centred way focusing on Saj’s strengths to re-establish new patterns and behaviours to help manage his condition and enable social inclusion in a community setting. Recommendations for further action would be for service involvement in the management and development of services and policies, which may entail inviting service users to meetings and working groups and supporting service user-led initiatives. To avoid being tokenistic and superficial and empower service users in their recovery.

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