This essay will focus upon an appraisal of the "package of therapeutic
care" which is experienced by a selected client. The intention is to
consider the rational for and the relationship between care, treatment and other
therapeutic interventions in effectively meeting the clients needs. Within this
essay, the author will present a profile of a client, followed by the
identification of the client's needs. The author will then identify the
therapeutic interventions that the client has been prescribed by the care team.
The therapeutic interventions identified will then be analysed and
recommendations made following that analysis. The client will be given the
pseudonym Joan, to comply with the UKCC Code of Conduct (1992), clause 10. Joan
is a seventy-nine year old lady with an extended history of depression that has
been treated in the community by her allocated keyworker since Joan's initial
admission to hospital. Thompson, (1989) states that it is important to remember
that the word depression can describe anything from low mood to a life
threatening disorder, or even fluctuations between the two. According to Wood,
(1992) women are twice as likely as men to suffer from a serious depressive
episode at sometime in their life. Seligman, (1992) goes on to say that women
are ten times as likely to suffer from depression as their grandmothers. Joan
was originally referred to the psychiatric services by her GP after an overdose
following the death of her husband. Joan's presenting symptoms were, loss of
appetite, sleep, and concentration, and thoughts of suicide. She lives alone in
her own house as Joan's family has immigrated to America. Joan expresses a lot
of love for her estranged family, especially her numerous grandchildren who she
sees maybe once or twice in a year. McFarlane, (1992) states that a poor family
situation has been proved in several studies to be the cause of disorders and
also contributes to relapse, he goes on to say that the individual may be more
vulnerable to other stresses that exist within everyday society. In addition
Joan has only her two neighbours that she can call friends. Physically Joan has
difficulties with mobility due to a previous hip operation and being overweight
caused by the anti-depressant medication. Joan also has arthritis which often
compounds the mobility problems, however Joan says that the pain killers and
anti-inflammatory medication alleviates most of the arthritic symptoms. Joan's
needs are assessed on a regular basis using a systematic approach derived from
Ropers Model, (1986). This approach has also assimilated some of Neuman's,
(1989) theories of stressors in the clients environment and self. Neuman, (1989)
identifies three types of stressors, these are intrapersonal that is related to
the person, interpersonal which is related to others, and extrapersonal that is
related to a wider context, for example the environment, or society. In relation
to Joan, her intrapersonal stressors are her mobility difficulties, arthritis
and compliance with medication. The interpersonal stressors present are
concerning her distance from and communication with her family, as well as lack
of social contact with friends. Joan's extrapersonal stressors are access to
facilities in order to allow her to benefit socially. Joan's keyworker will take
all of this into account when assessing Joan's needs and how they will be met by
the care team. Joan's allocated keyworker has been with Joan for two years and
has been able to build a good therapeutic relationship between them. Joan is
usually visited in her home due to her mobility difficulties, this helps the
relationship as Joan is familiar with the surroundings and feels relaxed and at
ease. The assessment meetings are conducted in the style of a friendly chat
rather than like an interview. The keyworker chats with Joan but keeps control
of the conversation enabling the keyworker to extract the required information
at a pace and manner that is comfortable to Joan. Lyttle, (1994) states that
being approachable develops an attitude of tolerance and acceptance. Rogers,
(1951) suggests that the interviewer allow for questioning and offers feedback
and reassurance to the client, the interviewer should speak calmly and clearly
in order to build trust, as it is only through trust that the assessment can be
successful. When asked Joan identified her need as "needing friends,
company, and getting out of the house to stop the isolation and loneliness that
she feels". Her keyworker assessed Joan's needs and concluded that
"Joan had got to the stage in life where she feels isolated and alone. Her
husband has died, most of her friends have died, and her family lives away and
rarely visits. She needs to be encouraged to go out, develop new friends, and
meet others in similar circumstances. Joan also needs to be encouraged to comply
with taking the medication to lift the depression". Joan's self-assessment
supports the assessment carried out by the support worker, this indicates to the
care team that the assessment tools and method of assessment were effective in
this situation. In order to continue to improve on the client's package of
therapeutic care it is also necessary to complete a risk assessment the outcome
of which will have a bearing on what the package will contain. Joan stated that
she had lost all motivation and feels nothing is worthwhile. Her keyworker feels
that if the medication does not relieve the symptoms of depression and Joan does
not begin to meet new people and start to socialise, she will be in danger of
neglecting herself, or attempting suicide. Joan's keyworker after consultation
with the care team has derived a package of care consisting of short and long
term goals. The short-term goal is to lift the symptoms of the depression with
medication and to continue with regular visits from her keyworker so that the
effectiveness of the medication can be assessed on a regular basis. Regular
visits from the keyworker will also act as a support for Joan, having an
allocated keyworker means that at any time Joan can contact her keyworker or
someone from the team if she feels especially low. McKeon, (1992) states that a
therapeutic relationship between carer and the depressive client is of crucial
importance if the client is engulfed by low self esteem, as the client will then
benefit from some affirming positive regard, a listening ear, and effective
supervision to ensure safety. This will also allow the keyworker to assess the
effectiveness of the medication and any side effects that may occur. The long
term goal is to encourage and facilitate Joan's attendance of the Therapeutic
Day Services (TDS) run by the Community Mental Health Team (CMHT) on a regular
basis. These services consist of various groups such as art therapy groups,
music therapy groups, anxiety management, and depression groups. This service
also has a canteen and recreational meeting area, which is run and staffed by
some of the long term clients as well as clients that no longer use the service
but wish to continue to offer support to others. This will allow Joan to meet
other people of a similar age group and circumstance to herself as well as
benefiting from some of the therapeutic groups that are available. To help
relieve the symptoms of Joan's depression she is prescribed two Lofepramine 70mg
at night. Breggin, (1993) states that the aim and justification for psychiatric
drug treatment is to relieve a person who is tormented and preoccupied with
their mental experiences whilst neglecting most other parts of their life.
Ironbar, (1989) however, points out that chemotherapy can have unpleasant and
potentially harmful side effects if not administered and monitored carefully.
Lofepramine is a member of the tricyclic antidepressant group. The most
important point to remember about tricyclic drugs is that they take a number of
weeks to exert their antidepressant effects. As the effect is delayed and as
depressed clients may not comply with medication if it appears ineffective, it
is important that Joan's keyworker informs Joan about the dynamics of the
medication and continues to encourage and monitor Joan's compliance with the
medication. Lofepramine also has a wide range of physical side effects that
Joan's keyworker should monitor for, from dry mouth to gastrointestinal upset.
Joan's keyworker also arranges a regular weekly visit to Joan's home, this is
not only to monitor medication, but also to allow Joan's keyworker to assess her
mental well being and presentation of self. This will allow the keyworker to
monitor for any signs of the depression worsening, and to ensure that Joan does
not neglect herself. To meet Joan's long term goals the care team arrange for
Joan to attend the Therapeutic Day Services initially for one day per week
during the first month, and then to increase this, after an assessment at the
end of the first month, to two or three days per week. The assessment after the
first month will focus upon the effectiveness of the medication, and how Joan
has managed within the day services. Joan will also be present at this
assessment so as to feed back to the carte team her own thought and feeling on
the package of care she is receiving. If Joan and the care team then decide that
Joan will benefit from continuing with the services currently provided, there
will be a monthly assessment focusing upon Joan's progress. In addition to this
there will be continuous monitoring from the keyworker so that the team can take
any action necessary if Joan relapses into crisis. Taking into account the
variables surrounding Joan's situation and the fact that the care package has
only recently been implemented it is difficult to analyse how effective the
package of care will be. However, Joan is a very sensible lady who has no
problems with contacting someone for help, as long as that help is made readily
accessible. Joan's depression stems from poor contact with her family and
gradually increasing isolation from society. Most of Joan's social circle has
died around her leaving a social void in her life, attending the Therapeutic Day
Services is meant primarily to allow Joan to leave her house and meet with new
people on a regular basis. The care team decided Joan's visits to the day centre
should start with one day a week and increase after a month, this is to give the
medication time to become effective, and to allow Joan time to get to know the
layout of the day centre and get to know some of the staff and clients that are
there. Social interaction is a vital part of our mental well being. Smith,
(1990) states that people who experience poor family relations often need a
great deal of social support, social and emotion stress plays a significant role
in the symptoms of serious mental disorders. In addition to the social benefits
of Joan's attendance of the day hospital, it will also give the care team a
chance to meet Joan and to encourage her involvement in some of the therapeutic
groups available. Joan's medication if effective will lift the main symptoms of
her depression which will allow Joan to feel better within herself and so more
able to interact with others. Regular visits from the keyworker will allow Joan
to be monitored for any side effects of the medication, and allow the keyworker
to chat to Joan and listen to her thoughts and feelings. In conclusion the
author feels that the care package that has been put in place by the care team
is the most appropriate for Joan's current circumstances, the regular
assessments will allow for changes in Joan to reflect in the care package. The
medication prescribed to Joan will help relieve the main symptoms of depression
chemically, so that Joan may feel able to work on her depression cognitively
through therapy groups and one to one sessions. This may lead to a lesser
reliance on medication, and leave Joan at less risk from the many side effects
that may occur.

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