Case management Outcomes Improvement

Introduction

Mental health nursing is a complex healthcare practice, because it aims to meet the needs of clients with mental health needs, which are usually also complex and require more than a single therapeutic approach. Mental health nurses usually provide supportive and therapeutic care adhering to nursing and healthcare principles of beneficence and non-maleficence, and adhere to the principles published in the national guidance, of client-centred care focused on service user need, as enshrined in the National Service Framework for Mental Health (Department of Health, 1999). Mental health nursing usually involves the provision of ongoing, supportive therapeutic interventions and ‘talking’ therapies, which can include counselling based on established principles. This role of the mental health nurse involves the formation of a therapeutic relationship with the client, in order to support the client to development self-management and coping strategies for the ongoing control of their condition and its symptoms, in conjunction with pharmacological treatments.

This critical essay will explore the mental health nursing care of a particular, identified patient encountered in clinical practice, in whose care the author was directly involved. It explores the provision of Cognitive Behavioural Therapy (CBT) to a single client who had complex health needs and challenging symptoms, reviewing the usefulness and appropriateness of the therapy, the effects or projected effects on the client’s wellbeing and symptoms, and the issues surrounding such care for the client in relation to rehabilitation and recovery as part of their mental health journey.

The essay will focus on the care of one client with depression and suicidal ideation, looking not at the acute phase of mental health care, but the rehabilitation phase where the client is being supported into ways of managing symptoms and returning to a useful, active social life where they can function effectively within society. The essay focuses on the goals and principles enshrined in the NSF for Mental Health (DoH, 1999), that of achieving the best possible standards of health and wellbeing for the client and the best possible control of their symptoms. It will explore the rationales and process of the therapeutic intervention, and use this intervention within a person-centred model of counselling, support and care.

Client Background and History

The client, who for the purposes of this essay will be called Lisa (this being a pseudonym used to ensure client confidentiality), is a 19 year old young woman with a history of depression and suicidal ideation. Lisa first presented to the local mental health services at the age of 16, after an acute episode of physical self harm and attempted suicide. Lisa’s self-harming behaviour takes the form of cutting, usually to the arms, legs and abdomen, although she has been known at times to also cut her face and neck. During her first admission, Lisa was diagnosed as having Depression with Psychotic symptoms. She has been managed with a combination of Fluoexetine and a range of other medications, but is known to have frequent relapse due to medication non-compliance.

Lisa has a complex personal and social history which goes some way to explaining her current state of mental ill health. She was abandoned by her single parent mother at the age of 11, from which time until the age of 16 she spent in local authority care, a mixture of foster homes and care facilities. At age 16 she left care and went on the streets, but at 17 after her third hospital admission was able to get into a social support programme, secure accommodation for herself, and start to attend college. Lisa is still at college, studying beauty therapy. She has a history of sexual abuse, but for the past year and a half has been living a relatively stable life, with a good social life and a busy college life.

Lisa has presented this time with a relapse in her Depression, and has demonstrated a strong suicidal ideation, low mood and being very withdrawn and apathetic. She has, this time, attempted suicide through overdose of a friend’s prescribed medication accompanied by severe cutting to the arms, legs and breasts. After being medically stabilised, she was admitted to the mental health ward, and after two weeks on the ward, fully compliant with her medication, was making some progress towards rehabilitation.

Discussion

Norman and Ryrie (2004) describe mental health nursing as a process of working with clients to allow them to develop the skills to regain control over their lives through managing their mental health. Ultimately, mental health nursing supports clients into a phase of recovery (Tschudin, 1995), which means that they are not overwhelmed by their symptoms and can manage them through a combination of medication, personal supportive therapies, and other support, in order to lead ‘normal’ lives within society and achieve personal goals. Mental health nursing is based upon a range of principles, some of which are scientific, some of which are more holistic (Norman and Ryrie, 2004). Mental health nursing supports clients through the acute phases of their illness, via crisis management, and through the chronic stages of their illness, through longer-term processes of rehabilitation (Perkins and Repper, 2004). Quite often, mental health service users are viewed in terms of their disease and its treatment, but the provision of true client-centred care should start off with a good understanding of the client and their condition, their particular needs, and then be followed by a judgement about how best to help them towards recovery along the spectrum of mental health and illness (Perkins and Repper, 2004; Foreyt and Poston, 1999). Recovery cannot be considered as a finite point in time, but as an ongoing balance between the client and their illness, wherein the client aims to achieve the ability to function at the level they desire, through accessing appropriate support (Perkins and Repper, 2004; Greenberger and Padesky, 1995)). The judgement about what kind of support is best is based upon a number of factors, but most often, the decision about which of the many approaches to supportive therapies and counselling will be used is based upon both the client need, and the mental health nurse’s own knowledge about, experience of, and preference for, a particular form of therapy (Puentes, 2004).

Mental health nurses, therefore, must have a good understanding of themselves, their philosophical orientation in relation to counselling, and the therapies on offer, and are most likely to provide those with which they have the most familiarity. In this case, the author is describing their own philosophical approach as matching that of their clinical practice mentor, who, as an experienced mental health nurse, is a strong advocate of client centred approaches to counselling. Gamble and Curthouys (2004) describe these approaches as being founded on Rogerian principles that include empathy, genuineness and unconditional positive regard. Rogers (1957 in Gamble and Curthouys, 2004) suggest that within a therapeutic relationship, which is a supportive relationship between client and nurse, with the express goal of attaining rehabilitation or recovery, there should be certain features which support the client towards ‘functionality’. Thus, there needs to be contact between two people, nurse and client, in which the client is in a condition of incongruence, and the nurse a state of congruence, and in which the nurse displays unconditional positive regard, and empathetic understanding, towards the client (Rogers, 1957 in Gamble and Curthouys, 2004). The nurse must be able to communicate these factors to the client, within the client’s frame of reference (Rogers, 1957 in Gamble and Curthouys, 2004

Bryant-Jefferies (2006) argues that the therapeutic relationship must be founded on empathy, and that in order to achieve empathy the nurse must employ active listening, and must attend to all the signs and the kinds of communication which the client displays, providing a sense of being ‘present’ with the client in whatever experience they are retelling or currently experiencing. One of the more challenging aspects of developing such a relationship with the client is the provision of unconditional positive regard, which Bozarth and Wilkins (2001 in Bryant-Jefferies, 2006) describe as an ongoing, unceasing and unflagging ‘warm acceptance’ of the individual, regardless of what they might say. Some authors describe this as the element of the therapeutic relationship that is most likely to support the client towards recovery (Bozarth and Wilkins, 2001 in Bryant-Jefferies, 2006). In this case, the mental health nurse (the author’s mentor) who was the primary support person for the client, fully aspired to such principles and to the concept of developing the best possible therapeutic relationship with the client. The literature consistently demonstrates that the quality of the therapeutic relationship is fundamental to the client achieving a state of mental health and wellbeing (DoH, 2001; DoH, 2006; Nice, 2004). The author agreed with this and felt that their own therapeutic philosophy was founded upon similar principles, making it appropriate to get involved in the case. The client was also happy to have the author present, as they were involved in there are from admission, and had spent some time observing the client during the acute phase to prevent further self harm.

Depression is a surprisingly common, yet often serious mental illness, which can present in a variety of ways, with features such as “low mood, lack of enjoyment and interest, reduced energy, sleep disturbance,appetite disturbance, reduced confidence and self-esteem, and pessimistic thinking” (Embling, 2002; p 33). According to Embling (2002), these symptoms can have a significant effect on people’s ability to take part in normal daily life or social activities, and in particular, the low mood and predisposition towards pessimistic thoughts can have a negative impact on thought processes, leading to suicidal ideation (Rollman et al, 2003)..

There are a number of individual and social issues which have been shown to have an association with depression, including physical illness (acute and chronic), poverty or low socioeconomic status and deprivation, divorce, bereavement or relationship breakdown, loss of a job or sudden, negative change in circumstances, ethnic minority status, and concomitant mental illness (Embling, 2002). It is a chronic condition which can manifest in acute episodes which are often successfully managed with pharmacological and non-pharmacological support, but the relapse rate is high for many patients (Embling, 2002). It can range from mild depression to severe depression or anywhere along a spectrum in between (Rollman et al, 2003). A wide variety of therapeutic approaches have been used in treating this illness, and in Lisa’s case, she had had some success previously with solution-focused brief therapy, but had found herself relapsing once regular, close contact with a mental health nurse had lapsed. Lisa admitted that she felt the time was right to take control of her life and find ways of coping with her illness more independently, and was keen for strategies which would allow her to avoid having such serious relapses, because they themselves had a negative effect on her life and potential career. Therefore, it was agreed that CBT might be the optimal approach. Luty et al (2007) argue that CBT is not always the most efficacious therapeutic choice for severe depression, but in Lisa’s case, it seemed worth trying, particularly as her worst symptoms were related to not maintaining her medication, and once she was on her medication, the focus had to be on keeping her well enough to keep taking the tablets. Other literature suggests that CBT is effective in patients who have had a history of sexual abuse (Price et al, 2001) This seemed to imply that the focused approach to support that CBT offered would the right way, particularly as it is so focused on relapse prevention.

According to NACBT (2007) cognitive behavioural therapy is the term used to describe a variety of therapeutic or interpersonal interventions, all of which are characterised by a focus on the importance of how clients think, and how this thinking impacts upon their feelings, their responses to stimuli and stressors, and their actions. Its value lies in the fact that it is structured, directive, and also time-limited, strong focusing client and nurse on the current problem, on how the client feels and thinks at the single point in time that therapy is taking place (Embling, 2002). CBT is based on “the theory that the way an individual behaves is determined by his or her idiosyncratic view of a particular situation, thus the way we think determines the way we feel and behave ‘”(Embling, 2002p 34).

According to Embling (2002), Beck et al (1979) introduced CBT , suggesting that “CBT can treat depression as it helps the client to evaluate and modify distorted thought processes and dysfunctional behaviours” (Embling, 2002) p 38). According to NACBT (2007) CBT has expanded within the therapeutic domain to include a range of approaches based upon the sample principles, including, Rational Behaviour Therapy, Rational Emotive Behaviour Therapy , Rational Living Therapy, Cognitive Therapy, and Dialectic Behaviour Therapy, all of which are based on what are described as “cognitive models of social response”. These in turn have been based on philosophical principles derived from Socratic thought, wherein individuals aim to attain a state of calm and tranquillity when challenged by stressful or difficult situations and experiences (NACBT, 2007). Thus the idea is to modulate the responses to life and experiences which precipitate symptoms of mental illness. The counsellor directs the client to use inductive methods combined with principles of rational thinking and educative approaches, to support behavioural self-managed over the longer term , (NACBT, 2007; Sensky et al, 2000) and to prevent relapses (Bruce et al, 1999). Therefore, in CBT, the nurse provides the client with the ability to explore their behaviours, their responses and their typical symptomatic responses in particular in certain situations, and assists them in developing ways of mediating such responses so that they do not relapse into behaviours characteristic of their illness (Sensky et al, 2000; RCP, 2007; BABCP, 2007).

Management of Lisa’s Care

To begin with, it was really important to ensure that Lisa’s counselling and therapy was truly person-centred, in order to develop a good relationship between Lisa, the primary nurse and the author (NELMH, 2007; Moyle, 2003). The author hoped that Lisa would respond well to this approach because it would allow for the demonstration of empathy and a good understanding of how her life, previous mental illness and personal circumstances were contributing to her current illness, and therefore would support congruence in provision of support to meet her needs and address her specific concerns. However, the difficulty in achieving congruence here was that the author could not really claim to fully understand the effects of Lisa’s previous experience of sexual abuse or really relate to her experiences, and in particular, the author found some elements of her history, including the stories she told relating the sexual abuse, as very disturbing. The author discussed this with the nurse mentor prior to the counselling sessions, and discussed how to achieve that true sense of congruence and presence, without communication their own abhorrence of the experiences that Lisa was relating. It was decided that it would be acceptable to tell Lisa that the author was appalled by these experiences, because this would underline the fact that she should not have had to suffer this abuse and that she was right to seek help in dealing with the effects on her mental health. Therefore, the author was able to enter into this counselling in supportive frame of mind, and able to achieve empathy without communicating negative feelings to the client.

The focus of Lisa’s CBT was on the suicidal ideation/self-harming and the low mood and self-abhorrence that were the main manifestations of her depression. Collins and Cutcliffe (2003) show that one of the most common features displayed by mental health service users with suicidal ideation is hopelessness. This was certainly the case for Lisa, who displayed a sever pessimism about life and her ability to achieve anything like lasting recovery. Her goals to become a beauty therapist seemed unobtainable, and she felt she had no hope of making a new life for herself that was not ‘ruined’ by her previous life.

However, Collins and Cutcliffe (2003) recommend CBT for this kind of pessimistic thinking because it focuses the client on establishing ‘hopefulness’ within their thought patterns. Other research shows that suicide risk can be reduced if individuals can experience others showing concern for them (Casey et al, 2006). This was supported by the author’s and the mentor’s firm belief in the efficacy of CBT for clients such as Lisa (Joyce et al, 2007). Thus, it was possible to establish an initial level of trust, and through the therapeutic relationship, the author was able to support Lisa in exploring her conditional assumptions (Curran et al, 2006) which led to the ongoing, spiralling pessimism, and then using CBT, we were able to set goals for each counselling session, set ‘homework’ which focused on self-management, and then reflect on progress as each session followed the previous one (Curran et al, 2006). The sessions focused on relapse prevention through changing cognitive patterns and schema, rehearsing relapse drills, and ensuring ongoing compliance with medication (Papakostas et al, 2003. While some authors argue for the need for inclusion of family or carers in therapeutic interventions such as (Chiocca, 2007), this was not possible with Lisa because she had no family and although she had a number of good friends made through her college course, none of them knew of her mental illness. The focus was therefore on health education, developing personal skills, and helping Lisa to cope with issues such as her current socioeconomic status (Jackson et al, 2006; Cutler et al, 2004).

.

Conclusion

If, as Calloway (2007 p 106) suggests “nursing is defined as a profession that protects, promotes, and restores health and that which prevents illness and injury”, then using such a client-empowering form of therapy, one which is based on the development of realistic coping mechanisms (Salkovskis, 1995; Deakin, 1993), was the right approach with Lisa. Discussion with her revealed that focusing on relapse prevention, within an honest therapeutic relationship which addressed the factors affecting her mental health, and addressed the ways of thinking and behaviours which led to relapse, was the right approach, because these were, fundamentally, her primary needs. The person-centred approach, in particular, seemed to give her the positive, ongoing interpersonal contact she needed, such that she did demonstrate signs of moving into a state of rehabilitation and recovery.

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Substance use and addictions are on a spectrum that has a depth of impact which fluctuates with each individual. Each person is located on this continuum of use; creating varying levels of addiction, needs, and goals. Leading to a context of different demands and requirement for intervention, as the type of intervention differs between people. In many client-centred treatment ideals the individual who is seeking treatment is the person to determine the level and type of treatment they participate in. As we will see this is true for Harm Reduction (HR) models and relates to abstinence. The momentum towards HR, and the use of HR theoretical ideas presents us with client-centred ideals, that a person should be able to access care and supports no matter their level of substance use. In HR models it is up to the person to determine how much they wish to decrease the use of a substance. In abstinence-based treatments, the goal is always no use of substances at all. This paper will be looking at HR and abstinence-based programming around alcohol use.

HR and abstinence-based treatments are commonly thought of as opposing ideas or in opposition to each other (Kellogg, 2003; Lee, Engstrom, & Petersen, 2011). However, HR and abstinence are not exclusive to each other. Both practices can work together to support individuals ‘where they are’ and aim to help someone in achieving their own personal recovery goals.

A frequent misconception of harm reduction is that it supports, or encourages, illicit substance use and does not consider the role of abstinence in addiction treatment. However, harm reduction approaches do not presume a specific outcome, which means that abstinence-based interventions can also fall within the spectrum of harm reduction goals. Essentially, harm reduction supports the idea that those with addiction or substance use issues should be treated with dignity and respect and have a wide selection of treatment options in order to make an informed decision about their individual needs and what would be the most effective for them, while also reducing the harms (CMHA, 2018).

This paper will discuss HR and abstinence-based treatment programs for alcohol, with individuals who are homeless and how both types of treatments can benefit and/or detract from recovery. A short case study will be provided at the end of this paper in order to highlight the specific impacts and values each type of treatment can have for one person’s recovery.

Harm Reduction

HR is a client-centred, evidence-based, public health approach that pursues a reduction in the social and health harms connected to addiction, substance use, and other high-risk behaviours (CMHA, 2018; Lee, Engstrom, & Petersen, 2011). HR does this without automatically demanding individuals who use substances to abstain from the use of substances and places the priority on decreasing the possible adverse effects of the substance or behaviour (CMHA, 2018; Lee, Engstrom, & Petersen, 2011; Podymow et al., 2006; Riley et al., 1999). An important aspect of an HR approach is that it offers individuals “who use substances a choice of how they will minimize harms through non-judgemental and non-coercive strategies in order to enhance skills and knowledge to live safer and healthier lives” (CMHA, 2018). HR models can include abstinence; however, HR supports are considered low-barrier because abstinence is not needed to use the service and other impediments to access services have been removed as well (Lee, Engstrom, & Petersen, 2011).

As part of the HR movement Housing First (HF) programs have gained in popularity and have become the evidence-based practice preferred within the homelessness sector (Homeless Hub, 2018). HF programs provide permanent, independent housing without a person needing to be sober, abstinent, and engaged in treatment (Adair, et al. 2017; Stefancic & Tsemberis, 2007). This is taking an HR approach to housing as they are low barrier housing programs. HF removes major obstacles to obtaining and maintain housing for people who are chronically homeless and usually living with mental illnesses (Stefancic & Tsemberis, 2007) and the goal of HF is not to just house people but to also promote consumer choices, recovery, and community integration (Stefancic & Tsemberis, 2007). This is what we see with HR and substance use.

The HF model is focused on housing the ‘hardest to house’ populations, those who are not seen to be ‘housing ready’ by Treatment First (TF) programs, which require an individual to be “housing ready” by going to treatment or being abstinent of any substances. Those who are struggling with high levels of alcohol dependency and are homeless often face barriers to gaining accommodations at shelters, transitional housing programs and permanent housing because of their alcohol use (Vallance et. al, 2016).  It is very challenging for people who are not seen as ‘housing ready’ to exit homelessness and those who fit the criteria are then often evicted because of relapse, breaking program rules, or they leave because they want to be independent and self-determined. This population are usually the chronic or episodically homeless, who despite being only 8% of the clients who use the shelter system for long periods of time, “use almost half of available shelter capacity” (Kneebone & Jadidzadeh, 2017, p. 1). It is with this population that the rest of this paper will focus on in relation to HR and abstinence-based programs and how they both can be used during a person’s recovery.

Alcohol Misuse and Homelessness

Severe alcohol use and alcohol dependency is linked with negative and significant health and social cost; sometimes also linked with homelessness and precarious housing or instability (Lehman & Cordray, 1993; Muckle et al., 2012; Vallance et. al, 2016). The Canadian Institute for Health Information (2017) found that in 2015-2016, about 56, 600 Canadians were hospitalized because of a health risk caused by alcohol (Canadian Institute for Health Information, 2017). This report also found that “low income was associated with a lower prevalence of heavy drinking yet significantly higher rates for hospitalizations entirely caused by alcohol” (Canadian Institute for Health Information, 2017, p. 18). Those who are experiencing precarious housing are found to have higher rates of alcohol misuse and have mortality rates that are six times higher from alcohol-related causes than the general population (Crabtree et al., 2018; Palepu et al., 2013; Hwang et al., 2009). This is attributed to social determinants of health and how they link with low income, high-stress levels, few social supports, a lack of resources, poor diet, unsafe drinking settings, beverage choice, and the regularity of binge drinking (Canadian Institute for Health Information, 2017). Because of this “socially marginalized drinkers” use health services at higher rates (Crabtree et al., 2018).

Alcohol has been shown to increase a person’s risks for many physical health issues as well as an increased risk for accidental or self-inflicted injury and experiences of violence (Vallance et. al, 2016). Non-beverage alcohol (mouthwash, hand-sanitizer with alcohol, rubbing alcohol, etc.) may be consumed in the place of beverage alcohol because they are lower in cost and more readily available; these sources of alcohol further add to the health risks for a person (Crabtree et al., 2018; Vallance et. al, 2016).

In order to address the negative health impacts and precarious housing, Managed Alcohol Programs (MAP) take the HF models to a next stage with a HR approach by providing beverage alcohol to program participants staying in the shelter, in an attempt to stabilize drinking patterns and decrease the consumption of non-beverage alcohol (Pauly et al., 2016; Podymow et al., 2006; Stockwell et al., 2018; Vallance et. al, 2016). These programs hope to not only lower the harm to the person but also decrease hospital visits and engagement with police and/or the justice system (Podymow et al., 2006; Stockwell et al., 2018; Vallance et. al, 2016).

Podymow et al. (2006) show in their study on a MAP in Ottawa that for those who participated, police encounters decreased by 51% and emergency department visits decreased by 36%. The alcohol markers in the blood tests of the participants remained consistent through the research (Podymow et al., 2006). While participants and case managers stated that there were improvements in the participants’ hygiene, nutrition, and health; especially when related to medical appointments attended and medication compliance (Podymow et al., 2006).  This research, however, did not assess alcohol intake outside of the MAP premises, therefore, it is unknown to what impact, if any, MAP had on the overall alcohol consumption for the individuals but the indicators show there was a positive benefit to the overall health of the participants.

Another MAP study, which was completed in Thunder Bay by Pauly et al. (2016) and Vallance et. al. (2016). In their research, Pauly et al. (2016) found that the MAP program helped participants retain their housing as well as presented an increase in positive experiences around safety and overall quality of life. Once stabilized in the MAP, it was found that the participants regain a sense of self, home, and family (Pauly et al., 2016). All of which are important aspects of one’s recovery from an addiction. With aspects of HR such as respect, trust, and non-judgemental care, with alcohol management, this allowed for the potential of recovery and indicates that HR is an important part of the recovery discourse (Pauly et al., 2016).

For the same database as above, Vallance et. al. (2016) report that the MAP participants consumed non-beverage alcohol on fewer days and had few detoxification episodes than the controls. As well as fewer police contacts and hospital admissions than before the MAP. However, questions still remain around if the quantity of alcohol overall was reduced for participants and further research must be completed (Vallance et. al., 2016).

Stockwell et al. (2018) have shown through their comparison of six managed alcohol programs in Canada that MAP can reduce the harms associated with alcohol. In this study, the long-term MAP residents drank more often than the controls (regular access to alcohol) but they drank fewer standard drinks per drinking day than the controls did; included in this were drinks outside of the program and non-beverage sources of alcohol (Stockwell et al., 2018). The long-term MAP residence also drank less non-beverage alcohols and was less likely to report experiences of social, health, safety, and legal problems in the past 30 days (Stockwell et al., 2018).

Abstinence.

There are many different types of treatment programs and housing options that involve a person being abstinent from drugs and alcohol in order to gain access to supports. There are abstinent-contingent housing programs where testing for alcohol and drugs in a person’s system occurs (Rash et al., 2016). If a person tests positive while living in one of these programs, they are removed from their housing immediately (Rash et al., 2016). These programs are a type of behavioural intervention contingency management (CM) program (Rash et al., 2016). Other types of housing and treatment that are alcohol and drug-free are: sober living homes, half-way houses, recovery homes and centres, and after-care housing (Rash et al., 2016; Polcin, Korcha, Bond, & Galloway, 2010a, 2010b; Wittman, Polcin, & Sheridan, 2017). Within these programs, the frequency and level of drug testing change between programs; as does when, and if, someone would lose their housing due to positive drug and alcohol testing (Rash et al., 2016). For example, sober living homes (SLH) are different than residential treatment and halfway houses because they do not offer formal treatment (Edwards, 2018; Polcin & Henderson, 2008) and the level of structure in each SLH would vary depending on the peers within the house.

SLHs have gained in popularity as part of a continuum of services and care for those wishing to be abstinent or in recovery from alcohol addiction; treatment programs will work with SLH to provide housing for those who have completed residential treatment or are taking part in outpatient treatment programs (Wittman, Polcin, & Sheridan, 2017). Lack of housing and a safe place to live has and is been a large issue for those coming out of treatment program or who are in recovery and little attention is often paid to finding suitable housing for the clients (Wittman, Polcin, & Sheridan, 2017). Often “without an alcohol- and drug-free living environment persons receiving treatment services have been vulnerable to relapse and homelessness (Wittman, Polcin, & Sheridan, 2017 p. 160).

Wittman and Polcin’s (2014) research on SLHs found that they were modelled on the “12 step” principles of Alcoholics Anonymous (AA) and were grassroots, peer-based services for those with drug and alcohol disorders. The philosophies of AA promote the inclusion of everyone at all level of alcohol consumption, however, “the 12-step and disease-based approaches generally prioritize abstinence as the goal, and often as a condition, of treatment” (Lee, Engstrom, & Petersen, 2011, p. 1152)which is what we can see in the SLHs housing models.

Polcin et al.’s (2010b) research on SLHs observed that substantial improvements in employment, substance use, mental health symptoms, and arrests during an 18-month period for 245 people. Polcin et al.’s (2010a) research with 55 people living in SLHs, 35 % of whom were recently homeless, had similar results as the above-mentioned study.

Harm Reduction and Abstinence.

As stated above both HR and abstinence-based programs can work together and do not have to be seen in opposition to each other. Both models have strengths, weakness and both work in different ways at different times for individuals. MAPs can aid a far-reaching group of people who are deep in their alcohol use disorders and need HR principles in order to help keep them safe, in order to, lessen the harm they are experiencing. However, once in a later stage of their recovery, it may be difficult for those who have reached abstinence, or have greatly reduced their intake of alcohol, to continue to live in an environment where alcohol is readily available and other individuals are partaking in regular alcohol consumption. There is a sacrifice in the “power of the social environment and the influence of peer support that can enhance the functioning of residents” (Wittman, Polcin, & Sheridan, 2017, p. 160) within MAPs and HF programs.

When an individual has been able to decrease their intake of alcohol, or is abstinent, is when SLHs can be very helpful. Peer support, and the social influences in an SLH, can help to provide support and an environment of recovery with few triggers for the individual. As “sobriety permeates the home environment through daily living among peers” (Wittman, Polcin, & Sheridan, 2017 p. 160). However, if a person does have a “slip”, or begins to engage in alcohol consumption again, they can lose their housing and support system. Becoming once again homeless and in greater harm of injury, violence, hospitalization, engagement with the police and justice system, as well as have a higher risk of death.

Gradualism. Gradualism is an approach that works towards building a bridge between HR and abstinence-based treatments, with the idea of creating a therapeutic continuum that works with the strengths and reduces the shortfalls of both HR and abstinence approaches (Kellogg, 2003). This approach does, however, have abstinence as the end goal and is perhaps better understood as an “abstinence-eventually” model (Kellogg, 2003). As the driving principle is that “the use of substances in an addictive or abusive manner is antithetical to the growth and wellbeing of humans” (Kellogg, 2003). This model, as presented by Kellogg (2003), is contradictory concerning the true understandings of HR, which is to be client-centred. An HR treatment model looks to truly allow the client to determine their recovery goals, not pushing them in either direction of what is “best” for them.

Case study



.

Allan is a 57-year-old man who grew up in low socioeconomic status in rural Ontario. He grew up in an abusive home with his mother, father, and younger brother. Allan came to Toronto at the age of 18 to work. Allan started drinking at the age of 10 with his friends, they also experimented with other drugs such as cannabis, psilocybin mushroom, and LSD, but Allan usually only drank alcohol. By the time Allan was 35 he was drinking heavily every day and had been missing work due to his alcohol consumption. At age 39, Allan was fired from his job. He tried to find stable work but was unable to find something permeant. Allan did, however, get hired for odd jobs through friends and was able to sustain himself for a while with cash jobs. After drinking heavily one-night, Allan slipped outside and hurt his back and broke his ankle. During this time, Allan was unable to work, he lost many of his social connections, and spent most of his time drinking alone in his house. When he was 45, Allan lost his house and went bankrupt. He tried staying with friends and family, however, it always ended up negatively with his friends and family being frustrated with Allan’s drinking. Allan started to bounce between shelters and sleeping on the streets. He did this until he was 54 at which time he was granted a spot in a MAP program. Once in the MAP, Allan was able to stabilize and receive proper and consistent healthcare for the issues he has been having over the past 15 years. Because of MAP, Allan has been able to decrease his involvement with the police, as he has stopped sleeping and consuming alcohol in public, as well as, he is no longer stealing alcohol and rubbing alcohol from stores or getting into fights with shelter residents or people on the streets. Allan has slowly decreased his alcohol intake by working closely with the staff at MAP to determine his goals and how he can reduce his intake safely. All of this together has provided Allan with a sense of control over his life; something he has not felt in a long time. Once Allan was at this point, he was ready to get out of the MAP shelter and live in a more stable location. He was referred to a transitional housing program that was based in HR for older men with substance misuse and addictions issues. After living here for a year Allan’s alcohol use increased as he was around people drinking all of the time and found it difficult to not join them and to not be triggered by the atmosphere. Once he started to notice this, Allan reconnected with his workers at MAP and regained some of the mental stability he had done in that program. He decided he would go into a treatment program. After waiting for 6 months Allan was placed in a 3-month treatment program for alcohol use disorder. He struggled with becoming abstinent in the time leading up to the program, as was required of him and after two tires he was able to go to the treatment program. It was at this treatment program he achieved his goal of long-term abstinence and remained sober for the full 3-months. At the end of the 3-months, Allan moved into an SLH and has continued to work on staying sober.

Conclusion. It is in the case study of Allan, and the discussion above, that we can see how HR treatment programs and abstinence-based programming can work together to aid in one’s recovery. Both HR and abstinence models can offer individuals different recovery supports at different times in their recovery. For different people, with alternative goals than Allan, abstinence could be their main goal right away, when leaving a detox program, or treatment centre and they may have the resources and support to achieve this goal. As for Allan, his process needed more time, support, and space to heal, both physically and mentally, before he was ready to be rid of the “crutch” or coping mechanism of his alcohol use disorder.

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Introduction

Health, like beauty, lies in the eyes of the beholder and a single definition cannot capture its complexity. To this end, this essay aims to explore what health means to me and how it has been influenced by the experience of coping with my mother’s chronic illness. To me, health transcends the absence of disease to include the physical, psychological and social well-being of a person; it means the empowerment of the individual, and is the foundation of a fulfilling life; it also means caring about the people who care about you and whom you care about.

Describe

For a period of time, my mother has been complaining of pain in her joints, hips and more recently, her back. I always had a bad feeling that there was something sinister about her pain even though our general practitioner could not pinpoint anything serious after several differential diagnoses. However, as she has a family history of joint pains, I chose to be in a state of denial to her pain and attributed it to a ‘genetic’ condition she had that would go away with time.

However, that was not the case. My family observed that my mother was getting more emotionally irritable as time went by, and the nagging pain meant that she often found reasons not to take part in social activities that we organized. It got to the extent that she was constantly lying in bed and could not do her favourite activities, such as going to the market, without considering the amount of movements she would have to go through. The radiating pain also gave her sleepless nights and all these were taking a toll on her quality of life, among many other factors. It was debilitating. And as her daughter, I felt helpless. More so because I was studying medicine, and was plagued with the guilt of not being able to relieve the suffering of the person I loved the most.

The persistent pain worsened and my family decided to consult a specialist for a second opinion. A tumour was suspected. While the specialist made his diagnosis, I was very worried for my mother. I tried to prepare myself mentally to cope with the worst case scenarios, and this affected me emotionally and psychologically. I had no one to turn to as I did not want to worry others, and was at a loss of what to do. The results later revealed that my mother was diagnosed with a benign tumour (spine haemangioma). The specialist said that it was the lesser evil because it was not malignant, but that she would feel chronic pain throughout her life. What provided comfort to my family was the knowledge that there were treatments available to contain the tumour through methods such as radiotherapy and physiotherapy.

Reflect

It pains me to know that the person I love would be put through suffering both from the disease and its treatment, and I wished I could be the one going through it instead. Upon reflection, I realize that I had not been dealing with my emotions effectively. The fear of finding out more and my escapist mentality had prompted me to create an internal barrier, such that I could not provide the care and support for my mother as I would have liked her to have felt.

Health means the holistic wellbeing of a person

Witnessing her chronic suffering has made me realise that health does not merely mean the absence of disease but it requires a more holistic view which encompasses the physical, psychological and social well-being of a person. I used to think of health as merely the absence of physical pain that arose from diseases, and to this extent, the physician’s task of relieving “suffering” was merely to alleviate the immediate physical pain and discomfort. However the literature I was exposed to on the nature of suffering in ill persons made me come to the realisation of my limited understanding of the term “suffering”. Through my research to understand the multi-faceted dimension of a person, and what suffering entails, I hope to be able to better understand what my mother is going through (albeit only the tip of the ice berg).

Health means the empowerment of the individual, and is the foundation for a fulfilling life

As the Catalan proverb goes, “from the bitterness of disease, man learns the sweetness of health”. I have too often taken for granted the gift of health that empowers a healthy individual to pursue things that matter in life – not only one’s aspirations or happiness, but down to the little things that affects our everyday living. For instance, I have seen how the chronic pain influenced my mother’s daily routine, and brought much discomfort when travelling or doing household chores. I have come to appreciate that health enables individuals to use their body as a vessel to fulfil their dreams and satisfy their needs without being tied down or be restricted by suffering. Health is thus the basis which enables people to pursue happiness and wealth, aptly worded by Elbert Hubbard, who said, “If you have health, you probably will be happy, and if you have health and happiness, you have all the wealth you need, even if it is not all you want”. It takes a loss of health to appreciate these words of wisdom.

Health means caring about the people who care about you and whom you care about

I always thought of Health as merely a personal responsibility and a duty that an individual owed only to himself. However, this experience has prompted me to comprehend how the absence of health in individuals will affect the mental, social and physical health of their loved ones as well.

Research, analyse and connect

The academic literature available allows me to gain a deeper insight on what health means to me and allows me to make sense of my experience in a broader context through considering the perspectives of others.

Through examining the concept of human suffering brought about by the absence of good health, I learnt about the distinction between suffering and pain. A person who is in pain may not feel a proportional sense of suffering it is similarly possible for one to suffer even in the absence of pain. (Sanders 2009) In light of my mother’s chronic illness, I was prompted to examine the literature on human suffering which made me realised that my understanding of the word ‘suffering’ was limited at best. While I had always aspired to be a doctor to relieve the “pain and suffering” of people, I was of the view that human suffering was synonymous with physical pain brought upon an ill person due to diseases. However, literature has shown that suffering goes beyond the physical pain, and suffering defined merely as pain, disregards the “broader significance of the suffering” experienced by the ill. (Charmaz 2008)

Suffering includes physical pain, but it is not limited to it. It can be understood by examining the many aspects of a “holistic person” and when any of these aspects is threatened, suffering ensues. These aspects may include a person’s past, his or her role in society, relationships with others, day-to-day behaviour, and perception of the future. (Cassell 2004) The persistent pain my mother experienced affected her ability to do things that she had long associated herself with, such as playing tennis or climbing the stairs. In addition, my mother may have seen herself as being defined by several societal roles, such as being a wife, mother, caregiver to her parents, and a useful member of society. If the pain overwhelms her and restricts her from fulfilling these roles, she may see herself as being less than ‘whole’, and this may contribute to her perpetual suffering.

In considering the “holistic person” and the suffering which impacts upon the many aspects of a person other than physical afflictions, it confirmed my understanding that health should also mean the physical, psychological and social well-being of a person. By understanding the multiple aspects of a personhood, I now better appreciate why medical education is shifting its emphasis from the traditional reductionist biomedical model of medicine to the biopsychosocial model of health. The limitations of the biomedical model is that it treats diseases in terms of abnormal physical mechanisms (Engel 2002) and this is inadequate in relieving sufferings in patients, as we now understand it to transcend the physical mechanisms to also encompass the holistic well-being of a person. The implications of the failure of physicians to understand the nature of sufferings can “lead to medical interventions that (though technically adequate) not only fails to relieve suffering but becomes a source of suffering itself”. (Cassell 2004)

This reflective practice also gives me a timely opportunity to evaluate my emotions and thoughts against that of the wider community. Relevant academic studies have shown that chronic illnesses also has an impact of the lives of caregivers. (Jung-Won & Zebrack 2004) The emotions and thoughts that I felt were validated by researchers that show that receiving news of the chronic illness of a loved one can provoke emotions such as sadness, denial, grief and guilt. This may be due to guilty feelings of not giving adequate support to the ill person or it could be due to the emotional pain of feeling the loss of a loved one’s health. (McIntyre 2005) It is important to attend to the impact of chronic illness on caregivers as research has shown that the holistic health of a caregiver has the potential to influence the health outcomes of persons with chronic illness. (WE 1999) Suggested methods of coping with these emotions include talking to someone; being informed about the disease as it gives the caregiver a sense of control; and accepting that there is a limit to the relief that a caregiver can provide. (familydoctor.org 2010)

Decide, act and evaluate

In light of the reflective writing and the academic literature reviewed, I hope that this will help me to come to terms and cope with the negative emotions I felt since receiving news of my mother’s tumour. I can approach this by confiding in someone I am comfortable with, confronting my escapist mentality by finding out more about my mother’s spinal haemangioma, and being aware of the treatments that she is going through. Her treatment is likely to expand over a long period of time, and she would need much emotional support and love from me. I have to be open to discussions about her illness and not evade any conversation on the topic as I did before.

This reflective practice has also helped me to be more understanding and sensitive to the suffering of patients and their families. As a medical student, I have been made aware that the suffering of patients extends beyond physical pain, and that it is necessary for physicians to focus on patient-centred medicine and attend to the biopsychosocial model of health. It is also important to be aware of the impact that caring for a chronic ill patient has on the caregiver. To this end, I can be proactive as a future practitioner in asking caregivers how they are coping, and provide them with support services that they can turn to. I have also realised the important roles that practitioners play in preparing caregivers for the transition of roles to care for the ill, and in helping them anticipate changes that may occur in their lives. This gives caregivers a better sense of control over the situation, and increases their confidence in caring for the patient.

A major takeaway from reflecting on what health means to me has been my understanding of the importance of medical practitioner to focus not only on curing diseases but also to relieve the sufferings of patients, understood holistically. To me, health transcends the absence of disease to include the physical, psychological and social well-being of a person; it means the empowerment of the individual, and is the foundation of a fulfilling life; it also means caring about the people who care about you and whom you care about.

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