Janet, a service user at the Priory Hospital Cheadle Royal

Janet* is a 50 year old lady, with a longstanding history of chronic paranoid schizophrenia dating back to her early 20s.  She was born overseas and raised by her Grandmother whilst her parents moved to UK. At the age of 15 years she moved over to the UK to live with her parents. At the age of 16 she became pregnant with her first child and within the next five years she had four  further children all from different relationships. All of these children were later taken into care.

Her first admission to a psychiatric hospital was in her early 20s and up until her admission to the Priory Hospital Cheadle Royal she had 22 admissions mostly as a detained patient.

Following her last discharge from a psychiatric unit in 2006 Janet disengaged from the mental health services and became non-compliant with her medication. Her mental health deteriorated and she became verbally hostile, abusive and threatened physical violence. A mental health assessment was completed and she was reported to be exhibiting paranoia and lacking in insight. Subsequently she was detained under section 3 of the Mental Health Act and admitted to an open ward.

During her stay there, Janet became increasingly verbally and physically hostile. It has been reported that there were thirty seven incidents of violence to staff and hospital property by her. Floridly psychotic symptoms were evident as she reported thought broadcast and was observed responded to unseen stimuli by talking to herself. Whilst out on section 17 leave, Janet regularly consumed excessive amounts of alcohol and abused illicit substances mainly cannabis.

It was felt by the team that they could no longer safely manage Janet risks and she was therefore transferred to a low secure unit in her home area. However Janet became very irritable and made unprovoked attacks on patients. She also refused to engage in her rehab program. Her home team felt Janet had not made sufficient progress and arranged for her to be transferred to the low secure services at the Priory Hospital Cheadle Royal.  She remained within the low secures for approximately six months, after which she was transferred to Roselea unit (an open rehabilitation unit).

Initially Janet was unhappy with her transfer to Roselea, as she felt that she no longer required inpatient support.  Janet presented as hostile and challenging and she was unwilling to engage in any rehabilitation program.   During a multidisciplinary team meeting it was agreed that a low key graded approach would be the best option for Janet in order to establish a therapeutic working relationship.   This approach was taken for approx one month with good results.  Once the therapeutic working relationship was established with Janet, the following rehabilitation plan was developed.

A gradual introduction into therapeutic activities both ward and community based.

1:1 key worker session to explore relapse prevention issues and to complete a Wellness Recovery Action Plan. (These sessions were facilitated by the key worker under the supervision of the Psychologist, as Janet declined to engage in any sessions with the Psychologist).
Janet identified that she would like to develop her educational skills, as she had missed out on schooling during the early years of her life.  Janet independently engaged in three education sessions per week and established an excellent relationship with the Adult Education Tutor.

Activities of daily (ADL) living skills.  Janet had lost confidence in her abilities to complete basis ADL skills and initially stated that she did not want any support from staff in this area.  We eventually encouraged Janet to engage through her teaching the Occupational Therapy staff and fellow patients how to prepare traditional meals from her own country.  This provided Janet with a sense of independence and led to increase in confidence and self esteem.

Janet always strongly denied any past abuse of either alcohol or illicit substances.  The Occupational Therapist and Janet’s key worker encouraged her to attend the weekly substance awareness group.  Initially Janet remained reluctant and continued to state that it wasn’t relevant to her, although one day Janet attended the group under her own volition.  Staff did not challenge Janet as to why she had decided to attend the group, but each week after this Janet would participate and speak about substance misuse issues using the third person.  During the final group session (seven weeks) Janet completed a feedback questionnaire giving positive and encouraging feedback.

Following the intensive rehabilitation plan staff observed a marked improvement in Janet’s mental state, confidence and self esteem. Through the CPA process it was identified that a placement back in her home area should be sought.   During this time in discussion with her key worker Janet spoke about her grown up children and her feelings of loss.  The team managed to re-establish links with her oldest child and eventually this resulted in her spending Christmas with him and his family.  Janet also went to visit her youngest child and her family, who she had yet to meet.  During these visits she was supported by the staff on Roselea.  A community based placement was eventually found and with support from the staff on Roselea Janet commenced a graded transfer plan.  Upon discharge Janet had spent a total of 10 months on Roselea.

*  Please note, where necessary, the names used within case studies have been changed to protect confidentiality.