FROM FIGHTING TO DETACHING

Rehabilitation focussed working in complex care situations in a psychiatric hospital

Bart Giebels Ton Gofers, Dirk den Hollander and Jean Pierre Wilken

Published: Passage, magazine for rehabilitation: December 2002.

An important starting point of the Comprehensive Rehabilitation Approach developed in the Netherlands, is that rehabilitation should be also applicable for those patients who depend on intensive care for a long period (Wilken and Den Hollander, 1999). This article reports of a rehabilitation process of a client with complex problems. In our opinion this process illustrates the effort it takes from professionals to switch to the rehabilitation approach. At the same time it shows that, if this switch can be made, it results in a higher quality of care, which benefits both clients and professionals.

Rehabilitation in the psychiatric hospital

At clinical intensive care wards, where long term treatment and stay go together

the implementation of a rehabilitation approach is often very difficult. There are several reasons for this. At first, long time and intensive care professionals often have clients that have no wishes at all, or wishes that are considered impossible to realize by the professionals (this is what we call apparent unreal wishes).

Apart from that the severeness of the disease plays a part. When a client suffers from severe cognitive function disorders, this makes communication difficult and often practical and social abilities are severely diminished. Concerning this Petry and Nuy (1997) mention the hard core = psychiatric patients who need long term, perhaps life long intensive care, inside or outside an institute for mental health care. Secondly, there is the issue of hospitalization, with clients and professionals. They are both imprisoned in a since long existing culture that is focussed on control rather than development.

The Comprehensive Rehabilitation Approach targets integration of development-problem- and environment-focussed working. In this approach the emphasis shifts from problem focussed to development focussed working, for professionals themselves and in their work with clients and family members. The environment itself too, in this case the clinical ward and the team that works there, is part of the change process. The ward environment itself often needs to go through a process of shifting from problem- and control focussed to development- and support focussed (Pols a.o., 2001). This means that a reversal has to be made from a power household to a cooperation household in the way their clients are treated.

This article has been built around the life story, the rehabilitation and recovery process of Els.

Els is a young woman, who is staying at a closed unit for long term and complex care treatment of Mental Health Care Eastern Brabant, location Padua House in Boekel, at the time of implementation of the Comprehensive Rehabilitation Approach. This process report describes what happened, which difficulties had to be conquered, what was successful and what failed. The story has been made anonymous and will be published with the consent of client and her family.

Starting points of Systematical Rehabilitation focussed Action

The method that goes with the comprehensvie rehabilitation approach is the Systematical Rehabilitation focussed Action. For a better under-standing of its application in the article, a short list of some important starting points:

1. Quality of life.

Rehabilitation focussed processes start with exploring together with the client what he considers important within the various domains of life: housing, working, learning and recreating, as well as within the personal domains: health, self care, purpose & meaning and social relationships. In this way the quality of life that client wishes to achieve becomes clear and fitting forms of support can be found.

2. Working in three dimensions. Professional care always takes place in three dimensions: a relationship dimension, an activity- or action dimension and a time dimension.

Within the relationship dimension it is about building a workable relationship, with sufficient trust to go on with each other. Standing beside the client, acquires a strong personal motivation: a motivation to really get to know the client and his life context and wanting to connect closely to this in the supportive action. Within the action dimension concrete supportive activities are carried out. The time dimension runs right through the relationship- and action dimension.

3. Working from three wish- and need steered principles:

the client’s wish concerning improving or maintaining the quality of life within the life domains housing, working, learning and recreating;

the client’s vulnerability in relation with his quality of life;

the environment’s quality (social environment/network)

The importance of working from these steering principles is that various points of view are possible and that a one-sided way of working is being avoided.

History

When Els is 1 year old her parents are getting a divorce. Because her mother finds it hard to raise Els on her own and because she wants to focus on her studies, Els is sent to live with relatives abroad for one year when she is 4 years old. When she comes back to the Netherlands she goes to an elementary school for children with learning disorders. At the age of seven she shows the first behavioral problems for which she gets help from the RIAGG (ambulatory mental health care). In the meantime her mother has remarried and Els’ two stepsisters has been born.

Then there is a period in which Els is isolating herself more and more and she is anxious and defensive in contact. This has been emphasized by aggressive reactions, rooted mainly in the suspicion towards others. At the age of 12 there is a crucial incident. Because Els was very persistent her mother gave her the address of her biological fathter. Els contacts him and goes on a trip abroad with her father, a travelling salesman. Her father introduces her during this week to the world of alcohol and gambling. Els thinks it all wonderful and hopes there will be another interesting and fantastic trip. Despite her father’s promise to pick her up again some time soon, she never hears from him again.

Els is very hurt and can no longer hold on to the image of the “idealized father”. The growing suspicion towards her father seems to generalize to all others that are important in her life. This expresses itself in the first year of secundary school, that will turn out to be her last year at school.

In 1992, when Els is 17, she is admitted for the first time in a children’s psychiatric institute. From then onward she is almost continiously in clinical care, most of the time voluntarily, but there are also some forced admittances.

Diagnostics vary from an autistic disorder to a borderline personality disorder and finally result in a schizophrenic disorder in combination with moderate mental ability. The periods when Els is not in hospital are characterized by homelessness, alcohol and drugs abuse. A few times this results in contact with the police. When she is not admitted by judicial force she tries to use the wards where she is staying as a pigeon house. Els’ social network is limited. Apart from the weekly contacts with her mother there are hardly any other contacts. She visits a friend sporadically. The contacts with her fellow patients are mainly superficially.

The last two years Els has been staying in a closed ward. Her relationship with psychiatrists and nurses can be characterized as a fight-relationschip.

The many conflicts are allways about the fact that Els claims not to be ill and that she is capable of functioning normally in society.

At the same time the team is doing their very best to convince her that she really is very ill and that she overestimates herself.

Because Els thinks she is not ill, there is also a constant fight about the medication. She attributes the fact that she is less psychotic with medication to other factors.

Her most important wish is: I want to live on my own. Later on she expresses other wishes too like getting her drivers licence. The team considers these unreal goals, that should not be pursued. The policy is focussed on Els’ attachement to the ward. The hypothesis is that in time she can reach a more peaceful pattern

in which can be worked at goals that the team considers more real.

Start of the rehabilitation approach

A new perspective arises after the team has been trained in the principles of the Comprehensive Rehabilitation Approach and the CARe methodology. The investigation of Els’ wishes within the various domains of life starts. Gradually the quality of life that Els wants becomes clear.

Within the life domain housing Els says: I would like to live on my own outside the institute. Within the domain learning: I would like to take driving lessons and get a drivers licence. Research into the personal domains ( purpose and meaning, helath, self care and social relationships) produces information about their meaning for the client, her personal criteria.

For Els living on her own and getting a drivers licence are mainly connected to what it means to her: I want to live like any other normal person, because I am not sick, I do not belong here. The domain self care is also very important to Els: I am an indepent, autonomous woman and I want to be treated like one. I also want to learn to cook better.

It is very difficult for the nurses and practitioners to connect to Els’ wishes. The main problem is that opinions within the team are very diverse. While someone plees to go along with her all the way, someone else plees for sharpening the policy and more control on medication.

In other words: a part ot the team thinks strongly from the life domain housing and the personal domain purpose and meaning, with as main steering principle the client’s wish. The other part of the team strongly thinks from the personal domain health, with as main steering principle Els’ vulnerability.

As an illustration: sometimes the expression itself of wishes in life domains such as housing is considered a sign of being ill.

It appears from the nursing reports that the wishes to live independently and getting a drivers licence are not considered a normal healthy wish for a 22-year old woman by everybody: when Els starts talking about this it is remarked in the reports that she still has very poor sickness insight. Because there is no consensus and a few team members fear to enter new paths they find themselves in an impasse. Leaving everything the way it is seems to be the safest, but as it is nobody is satisfied with the current situation. In fact there has been a lot of fighting and very little attachment for two years.

Els sticks consequently to her great wish; which is full autonomy and living independently. The professionals are not very happy with this. They are afraid Els will relapse in her old behavior of being homeless, eating out of garbage cans, alcohol and drugs abuse, in short total neglect. Els’ mother also fears this will happen.

The relations with team members gradually deteroriate. In the end Els has contact with only a limited number of people. Things that are important to her she only talks about with Ton, psychologist and Bart, team manager. However Bart has little to do with direct patient care and does not function as a key worker.

At Els’ request he takes her wishes again to the Multidisciplinar Meeting. It is decided not to change the policy: no active support to Els’ wishes regarding living independently and getting a drivers licence. The approach stays problem- and offer focussed. Els focusses more and more on the team manager who is a good listener.

She shows him housing advertisements and tries to make him see how important it is to her to live on her own. In order to connect as closely as possible to the client’s personal preference it is decided in the end that the team manager will take on the role of key worker.

Building a cooperation relationship: from fighting to attachment

The team manager in his role as key worker pays a lot of attention to the relationship dimension: the building of a workable cooperation relationship.

Within the action dimension he uses the steering principle: the client’s wish and the support needs that go with it.

Due to this the discussion- and action space improves. Whereas professionals and Els used to tell only their own stories (I want to live independently and We will not support this yet) there is now space for negotiation.

Bart claims that he is willing to support Els actively in her wishes but that there are restrictions: I want you to keep taking your medication, which includes having your bloodsamples taken.

I also want you to stay in contact with someone from Padua once you live on your own. As a negotiation stake Els asked for a meeting once a week with the psychologist.

Furthermore Els and her mother thought it important that the team manager would finish his support, so he would finally be working ambulatory too.

This was a difficult issue for the team. There was the risk that the relationship between Els and the team manger would become too exclusive. It was decided to start from this point anyway and to refine the work within the relationship dimension in the long term to the introduction of other professionals.

Housing agencies and private letters in the area were contacted. This phase appeared to be mainly important to the reinforcement of the relationship.

It was often obvious beforehand that an action would not be successful, but was carried through anyway because it was important to Els.

In the beginning of the process the emphasis was on reinforcing the relationship between Els and the team manager, without letting out of sight that this relationship could not stay too exclusive. The psychologist and the team manager set up a meeting with Els’ mother.

She was very sceptical at first but became more understanding when she was assured that Els would have constant support during this process. In this way they could work on an alliance (triade) between client, her mother and the professionals (Petry and Nuy, 1997). There was also a meeting with the trustee.

This made the financial limits clear so the looking for a house could begin.

In connection with living independently there was also the issue of medication. Els is taking an anti-psychotic medicine. Taking the medication is extremely problematic. Problably she takes her medication irregularly, proven by her much too low blood levels. It is discussed within the team what to do about this.

There are several suggestions: increasing the medication, starting depot medication, offering it in ground or in fluid form. Finally it is decided that Bart will talk about this with Els and will ask her if she has a clue why her blood levels are so low.

When he asks Els, she says: I take my medication always the way it should be done, maybe my body is not reacting well to it.

Her explanation for the low blood levels is the fact that her body may not react to the medication. This is not argued because it is thought important to connect with Els’ perception. It is proposed that she will take her medication for a few weeks under supervision, so that they can come to an objective judgement together.

When the blood levels are determined, Els claims that she actually does not want to take medication at all. This gives occasion to discuss again the necessity of her medication and her illness schizophrenia (timing!).

What happens if she does not take her medication (experience from the past)? This approach proves to be effective because gradually the discussion space becomes bigger.

Els promises to take her medication, but says that she will definitely not be doing this all her life. The first few months she is offered her medication every day. If the blood levels are good, this will change in a weekly issue that she can take on her own.

It is agreed that there will be no more supervision on taking the medication, the blood levels only will be decisive. Els is enthusiastic about this plan, she goes to the lab independenty to have her blood sampled and comes in repeatedly to find out if the bloodresults are there yet. This commitment is new!

This leads to a situation in which the blood levels stay within the reference values, even when she takes her medication on her own. Until this day her medication taking goes well and her behavior shows no signs of an increase in psychotic symptoms.

Getting a drivers licence.

In the search for a place to live the team manager’s car was used at first. It was decided together to buy a bicycle, in order to take short trips by bike. A second-hand bike was bought in a bicycle shop. After some time of biking Els expresses the wish to get her drivers licence.

Her father was a travelling agent and travelled a lot by car. Her motivation: every girl of 18 wants to drive a car, be independent and mobile. At the question if she sees any disadvantages she answers: her use of medication. It is said that her arguments are to be understood, but that there are more disadvantages than she might see at this time such as her slowness of reaction, concentration weakness and financial limitations.

There are obvious differences in opinion. The larger part of the team estimates that this is an absolute unachievable goal, but at the same time the question is asked whether it is sensible to put the wish aside.

Because going along with her wish can also mean: getting insight in the limitations and the feeling that you are taken seriously.

Finally it is decided to take her wish seriously and together with Els an action plan is set up. A driving instructor who shows understanding for Els’ situation is found. The theoretical part of the training is started to find out how Els is handling this. When she does well the practice lessons start. It was fun to hear the first reactions: A learner car at a closed ward: it has to be at the wrong place.

The result: an enormous motivation; every week 3 hours of continuous theory lessons, not once did she not show up. At the first exam Els scored 37 wrong answers out of 75 and failed finally with 11 wrong answers. After 12 lessons the practical lessons appear to be problematic. At Els’ request there is a meeting with Els, the driving instructor and the team manager. Els asks: what are my changes to get a drivers licence?

The instructor gives her an honest answer and says: It will take a lot of lessons and a lot of money and then there is still no guarantee that you will pass. If she wants to continue the lessons it is strongly advised to do so in an automatic car. Els’ reaction to this is a bit cold and she decides to stop the lessons. It is obvious that this is her own choice and that it has been made without any conflict. During the period of driving lessons she had to make a choice because of her financial situation: going for a place to live on her own or getting her drivers licence. Now that she stops taking driving lessons she can start working on her most important goal: living independently.

Living independently

Without looking back she hurles herself again completely on the housing market. Journals are being investigated, telephone numbers are written down, agencies are called.

The way of working is that Els engages in all activities herself, but is getting constant support from her key worker. Now Els hits the reality frontier: it is not easy to find a house.

She develops more and more insight in the variety of housing possibilities (environmental sense) and she can place this next to her own ideas (personal criteria). She develops an increasingly clear insight in the course of months. At first she wanted to live anywhere at all (as long as it was not the hospital), going along she can define better where she wants to live.

She can also express better the extent of support she needs. She has developed a much more realistic time perspective and she knows that she (like any other Dutch citizen) has to wait for a house. She is capable of waiting now.

Cooking independently and shopping for groceries

Els expresses regularly that she wants to prepare her own meals and asks whether that implies a financial compensation. When Els’ mother gives her a microwave oven as a present, she wants to start using it rightaway. The first time this results in lots of smoke in her bedroom and a roaring fire alarm.

Els is not taken back by this. Not only does she succeed in getting a meal compensation, but also in preparing her cooked meals. Els shows that she is quite capable of shopping for groceries independently, while staying within her budget.

She even offered to show the receipts to render account, but the team said that they trusted her to handle this in a responsible way. In this phase of the process it is time for another important step: Els moves to an open rehabilitation ward, a lovely old residence outside of the hospital.

Els is very content with her new living situation. It is a considerable improvement. She has a nicer room and starts living with people that she connects better with. It is important to her that this residence is not situated on hospital grounds.

Els handles alcohol and drugs in a controled manner in this new situation. She knows there is a policy of tolerance as long as her habit does not cause problems. She soon feels at home, despite of the fact that she often says that she wants to leave. The fact that she plays the guitar for the whole group of people that live there, proves that she feels happier and more safe.

From attachment to detachment

The one to one relationship between client and professional was very exclusive and it seemed it would be very difficult to transfer this relationship to another professional.

This appeared to be easier than expected. There was a process in which the acting space of Els broadened in a natural way: others appeared on the scene naturally.

The team manager helped her to move to the residence, which meant the end of this supportive relationship. While saying goodbye Bart said that she was welcome to come and visit him whenever she wanted. Els invites him back. In the meantime her range has broadened. She has bought a moped and uses it a lot. She had to give up her ideal of getting a drivers licence, but in the end it appeared that the most attainable alternative could be realized.

As far as she is concerned the residence is not her final station. She keeps on working in the direction of her own place.

Contemplation

Els’ story is not exceptional. She shares her experiences with many other young people with a severe chronical psychiatric disorder. The story illustrates that client and professionals are sometimes imprisoned in apparent insolvable impasses, but also that there can be a breakthrough. Impasses in mental health care often develop as a result of tunnel vision. Professionals and clients can see only one thing and loose sight of the total picture and the other’s perspective completely.

Apart from this tunnel vision there are often (mainly medical orientated) policy frameworks that stagnate rehabilitation processes. For example getting an individual cooking budget has to go through many (bureaucratic) layers.

Experience, in this situation too, shows that real beautiful rehabilitation processes start with committed professionals, and then start to spread through the organisation. By the consequent application of the principles of the rehabilitation approach surprising new ways appear. At the end of this article we emphasize a few remarkable issues.

Wishes and vulnerability

Apparently professionals find it very hard to connect with the life wishes of the most vulnerable group of clients. Yet in general it is about completely normal wishes: a place of your own, a drivers licence, a nice partner. Wishes that most people have and that are utterly understandable.

Els’ wishes can be placed in the perspective of normal needs of young people. Getting a drivers licence stands for being independent. In a narrower sense it meant to Els the possibility to identify with her father who drove a car professionally. This refers to an important personal domain: purpose and meaning. If we as professionals only have eyes for the (severeness of) the psychopathology this often leads to a kind of conversion.

The expression of a wish is not viewed as a form of healthy behavior, but as an expression of the illness, or even more specific: as an expression of lack of illness-insight (Den Hollander, 2001). And that makes the circle round: the behavior that professionals find difficult (such as the constant expression of apparent unreal wishes), is immediately blamed on a lack of illness-insight, and then again this lack of illness-insight is part of the illness itself.

This results in strange reasonings such as You must be crazy to want to live on your own. In our opinion the constant expression of apparent unreal wishes has more to do with an (often stagnant) mourning process than with psychopathology in a narrower sense.

Not being able to accept a life that has not worked out the way is was expected to, and in which all kinds of loss experiences play a part.

In Els’ situation it is visible how the recovery process slowly gets started. Els takes steps from the stabilization phase to the reorientation phase: an orientation to a life with an illness. The recovery process is supported which gives Els the feeling (again) that she means something as a person. Hope arises: hope for a better life. And this hope is the fuel for the recovery process.

Personal commitment

Rehabilitation processes are characterized mainly by the fact that the professional connects to the client’s wishes in order to enhance his/her quality of life. Els wants to live on her own. Many professionals foresee great problems along this road. Els’ story illustrates that connecting to the client’s wish is not the same thing as uncritically accepting what the client wants.

The professional has no magic wand to make appear for example a house out of nowhere. In the end Els found support with the one thing that was the most important in her life: getting a more autonomous life. Because she experienced this support a cooperation relationship developed. An it appeared that within this relationship demands could be made and there was space for – equal – negotiation.

There was enough discussion space to talk about the difficult issues, like the use of medication. Difficult discussion subjects can not be on the agenda until the relationship is strong enough. Timing is of extreme importance: over coffee and riding the bike the best discussions took place!

The rehabilitation process with Els illustrates an important principle of rehabilitation focussed working: without a relationship with some attachment between client and professional no development takes place. And without attachment there can be no detachment. Although there is a relatively forced start from a rather exclusive relationship (an allience between client and key worker) gradually space appears for other professionals.

It appeared important that other people who were involved, such as fellow professionals and family members do not stand on the sideline, but stay in the picture as much as possible, in order to come closer again and give support at the right moment. This illustrates the importance of conscious use of the time dimension.

The positive change with Els leads to the disappearance of the last bit of scepsis in the team and to industrious attempts to (by applying the described methodology) get the relationships with other clients that got stuck back on track again.

Learning from experience

Els was given the opportunity to a dosed experience with the tough reality of our society. Getting a drivers permit is not so easy and very expensive. It is not easy to get your own home. She could experience this because she was supported.

She was not alone! The professional that supported her built up a personal relationship with her: a relationship in which the human being behind the patient and the human being behind the professional became visible. This process is called object presenting. In this personal relationship that is characterized by equality demands could be made.

Because of this alliance Els could for the first time in her life take steps that led to independence and adulthood. Handling wishes and reaching goals take place within a concrete social context that differs from the context of a psychiatric hospital.

That is why Klaus Domer (2001) mentions as one of his most important experiences: In a psychiatric hospital one can only learn things that are important there, the real learning takes place at places where one has to live with the things one has learned. This learning is a painful process which confronts the client with his own limitations, as well as the limitations of society. Still these are essential experiences in a recovery process.

Literature

Dörner K. (2001): Het einde van de inrichting. Vermaatschappelijking van de

geestelijke gezondheidszorg. In: Passage nr. 3.

Hollander, D. den (2001): Schaf het begrip ziekte-inzicht af. In: Psy nr. 10.

Nuy, M. 2000 (redactie): Rehabilitatie: een oriëntatie en beschrijving van drie benaderingswijzen. SWP Amsterdam.

Petry D. en M. Nuy (1997): De Ontmaskering. De terugkeer van het eigen gelaat van mensen met chronisch psychische beperkingen. SWP Amsterdam.

Pols J. H. Michon, M. Depla en H. Kroon (2001): Rehabilitatie als Praktijk; een etnografisch onderzoek in twee psychiatrische ziekenhuizen. Trimbos-instituut Utrecht.

Wilken J.P. en D. den Hollander (1999): Psychosociale rehabilitatie, een integrale benadering. SWP Amsterdam.

Author information

Bart Giebels is a nurse. Ton Gofers is a psychologist-psychotherapist. At the time of writing this article both were working with the GGz Oost-Brabant, location Huize Padua in Boekel, as a team manager, respectively psychologist.

Dirk den Hollander is a nurse. Jean Pierre Wilken is andragogist/psychologist. Both work at Storm Rehabilitatie in Bilthoven, national study centre for psychosocial rehabilitation.

Published: Passage, December 2002