A Critical Reflection of Forensic Practice Placement - Research Paper Example

Running head: A CRITICAL REFLECTION A Critical Reflection of Forensic Practice Placement You're A Critical Reflection of Forensic Practice Placement Introduction This reflective essay explores the various ethical, legal, and professional issues that those working in a mental health care facility encounter on a daily basis. Also, what often takes place is a recommendation for change in a specific practice which could be better suited for the delivery of such care. The main focus within this research is on the knowledge I have gained concerning the client's rationale, coping mechanism, perception, and support, all of which led to the crisis situation of this mental health care client. In this essay the clients name shall be altered, and be referred to as 'Josh' when discussed, in accordance with the confidentiality clause of the code of professional conduct "to protect all confidential information concerning clients obtained in the course of professional practice" (Nursing and Midwifery Council 2002). This current compilation of medical literature is a reflective piece which explores the true underlying meaning of mental health problems for the thousands of clients and significant others in these individual's lives who are diagnosed with a mental health problem. The care experience that has been gained has been acquired through clinical participation with a client who, as was stated will have his name kept confidential in this research. Through personal experience with working with this individual the relevant bio-psychosocial forces which have been found to have adversely impacted this individual patients' life have been detrimental to his care and maintaining a positive influence during treatment. The various theories that have helped me in working with this patient have been consistent in bringing about self-fulfilment and encouragement for him to attempt to pursue an active normal life, despite the mental health problems he has. Since I have personally found that biological psychiatry plays a pertinent role in the scientific research of mental health and in my own educational experience then it will be touched upon in this reflective case. This will be done to the point where my own level of knowledge and comprehension in psychiatry currently lies. I must also say that this patient, 'Josh' has needed a strong humanitarian essence in his treatment regimen but this pretty much goes along with a psychiatrists or psychologists personality when working professionally with others anyway. The psychological treatment and socio-cultural orientation of the client and the environment have also had a strong bearing on this particular case and have widened my own scope of knowledge to the individualism that clients can hold regardless of whether or not the cases are similar. Reflective Clinical Experience, Delivery of Care, Care Management Effectiveness According to the views of the British Medical Association, respect for authority is commiserative with the ability of an individual to decide. However, quite naturally it is more often assumed that treatment is proposed because it will bring benefit to the patient. Within forensic mental health care there exists a precarious edge that medical professionals have to follow in order to stay within the legal framework during the establishment of a treatment regimen for a client. Legally and ethically, to give consent for a therapeutic procedure, the patient need only understand in broad terms what is involved according to the case of Chatterton v Gerson from 1981 (Houlihan 2005). Therefore it could be said that competence judgments serve as a gate keeping role in health care, by distinguishing individuals whose decisions should be solicited or accepted from individuals whose decision need not or should not be solicited or accepted. In addition to this, professional judgment of competence helps in establishing if a guardian is necessary to attend an individual's interest. Abboud (2004) states that often involuntary institutionalization is necessary, because outside of a facilitated environment such as a mental institution, psychiatrists and doctors don't have the necessary tools to properly assist those with more severe mental illnesses such as biopolar or even a manic depression. Also, medicinal Law and to some extent philosophy presumes that the properties possessed by an autonomous individual are also the characteristics of a competent individual, although there are differences in meaning between autonomy and competence, their criteria are strikingly similar. This area has quite a bit to do with what the decisions to institutionalize are, the treatment processes involved with the patients care, and the outcomes that can arise with regard to the patient and even the mental health care givers. With this in mind it should be more easily identifiable why it is felt that an autonomous individual is a competent individual and judgments of an individual's ability to authorize or refuse an intervention should be dependent on whether the individual is autonomous, according to the reading of a researched article by Santora (2004). Within the framework of forensic psychology this can often times be more difficult to establish because some client's might be delusional at times but at others totally coherent and comprehensible to what is taking place around them. So, although they might appear to be autonomous it does not necessarily mean that they are wholly competent. In caring for 'Josh' it came to my attention that he was a threat to himself and so he was placed on a medical suicide watch against his own free-will. This was felt necessary because obviously he was unable to make a competent judgment to safeguard his own well-being so it was believed crucial that the medical team do that for him. This interaction goes well with what was previously explained with regard to autonomy and competence as although Josh appeared fully competent he was precariously close to taking his own life without his conscious even realizing it so he was a danger to himself and possibly anyone who attempted to intervene at the time of his initial admittance to the mental health care ward. Risk Assessment Although there was already an awareness by the staff that 'Josh' was at risk of injury to himself or possibly to others there was still a need to carry out the appropriate risk assessment on him just as would be done on any patient brought into the ward. During the assessment of 'Josh' a great deal of knowledge was acquired by me with regard to the appropriate ways in which a mental health care patient must be treated and supervised. Safety of the patient is always the most important factor and by this what I mean is that anyone working with a patient on a forensic mental health care ward should have the appropriate training in order for them to better understand the risk of both suicide and violent tendencies of the patient. Safety first is a program that has made strong recommendations that any mental health care staff dealing with patients who are suicidal or who have severe mood disorders or aggression disorders (such as Josh) should have the adequate knowledge to work effectively with the patient but follow a strong ethical and legal framework at the same time (Essock et al 2006, p. 193). The National Service Framework has been very specific in recent years of having the appropriate management skills when dealing with patients on a forensic ward, especially those who suffer from mood disorders and have attempted or are threatening to attempt suicide, which has been explicitly emphasized, according to much of the research findings by Essock et al (2006). The reasons for this, which I have discovered are due to the fact that it takes a high level of skill to efficiently work with patients like Josh. The management needs of the patient go along with the risk assessment of the patient very intricately and therefore through clinical governance the emphases should be on the correct delivery of the contemporary mental health services to the patient without question. The main reasoning in-behind this is so that medical caregivers will have a way to justify, defend, or explain certain judgments that they make about the risks and the type of care that a patient such as Josh will receive (Blum 1992, p. 246). It is definitely believed that without dedicated case managers providing sufficient and accurate care to forensic mental health patients, the system will be ultimately failing in it's duty to serve mental health care patients effectively, there is no doubt about this (Friedmann et al 2004, p. 88). Monitoring and Controlling Behaviour of the Mental Health Patient Before the right treatment regimen can be established for a mental health patient those working closely with the patient have to identify the underlying causes for any violent or disturbing behaviour that they exhibit (Palmer & Maggiore 2002, p. 1). Sometimes this can be extremely difficult and time consuming in forensic psychology because the patients behaviour has to be controlled in order for medical health specialists to determine the factors contributing to the violence or depression, or possibly both symptomatic features together (Boyle 1995, p. 7). Often chemical restraints are used rather than physical restraints because it has been found to be more potent and flexible than stressing the patient more by physically restraining them against their will. Some of the more common medicinal ways of doing this is with the utilization of the drug known as, 'diazepam' or even 'midazolam' (Palmer & Maggiore 2002, p. 1). The drug 'diazepam' is of course a controlled substance. It is very often prescribed for those who have high anxiety, mood swings, depressive disorders, and also for those who are known to have high agitation (Wineburgh 1999, p. 434). Diazepam is an extended release medication, normally given in tablet form but for some patients there is a liquid concentration that can be administered as well. For 'Josh' the medication was given four times per day but it can vary from patient to patient and the maximum dosage is up to four times a day for those patients who are highly anxious or are prone to agitated outbursts. In the concentrated liquid form which I have witnessed being administered to other patients, it is always given in a marked dropper to ensure the appropriate medicated dosage. This method is more complicated because it often has to be diluted with juice, water, or even with a mixture of carbonated beverages before it can be given (Grange 1997, p. 3). Even though this medication has worked well for 'Josh', myself and other forensic mental health workers have had concerns over a prolonged usage because it is known to be habit forming. Taking larger doses than required can also create a higher possibility of a patient becoming addicted to the medication. Furthermore a tolerance level can also develop and in cases such as these the medication has had to be switched so that control over more violent patients or those with episodes of schizophrenia could be maintained (Tintinalli 1993, p. 1278). When a concern does become more evident that a patient might be becoming addicted then care givers have to gradually wean the patient from the medication because suddenly taking it away can worsen their mental health and promote more violence, so management is a necessity to guarantee the well-being of the patient. Midazolam is far stronger than diazepam and it is administered differently as well. Although I have had no personal contact with this drug in any clinical experiences; I have witnessed it being given to other patients. Midazolam is given by injection and because of this the affects of the drug are normally felt by the patient almost immediately (Waraich 2004, p. 44). Since it is considered to be a somewhat hypnotic drug it directly relaxes the patient and changes their mood dramatically. Of course it also puts them to sleep and many times this is the best way to control some of the patients during very violent episodes. Furthermore, normally this narcotic is only given to those patients who show signs of severe violence such as people who are suffering from split personality disorder, obsessive & compulsive disorder, mood disorders, schizophrenia, manic depressives, bipolar disorder, and other cases that are extreme. Often it is a method that is used to sedate patients (which were briefly mentioned) that are causing harm to themselves or have threatened to cause harm to a member of staff or another patient on the ward. There are various circumstances for administering such a medication and it is not something that is given on a daily basis such as other mood altering drugs are meant for. There are many more prescribed drugs that I have knowledge of, some of these being fluoxetine (which is Prozac), alprazolam (Xanax), and haloperidol-promethazine. I have come to the understanding that many of these drugs are prescribed and administered in various ways, some intravenously, some through liquid form mixed with juice, some even placed in food without the patient's awareness, and others through a shot in the hip or arm. The point is they are all based on individual patient's assessments and how they react to the different prescribed medications. Normally after one or two trial and errors the mental health care practitioner hits on the correct narcotic to prescribe which keeps the patients behaviour and actions correctly controlled and more manageable. The various clinical situations I have found myself in, as well as my educational pursuits in the study of mental health, have led me to examine other areas of mental health disease so that I could comprehend the differences between mental health problems such as schizophrenia and a person such as 'Josh' who is a manic depressive. Mental Health Illnesses, Disorders, Possible Treatments Many records of the various types of disorders are unknown; along with many of the other records of treatments given to people inflicted with a disorder. This is mainly because in the early 1900's people thought that people with disorders were just ignorant and lazy and they did not investigate further into the matter. In today's current times mental health care has become a very important medical aspect in the medical world. It has come to be realized that those suffering with mental illnesses deserve quality care and respectfully treatment so that they might be able to have some sense of a normal life, far different from back in the 1900's. The quantity of people that have a disorder is unknown. There is an estimated guess that 15% of the U.K. population has some sort of disorder but that is not factual, Hickie et al (2005) claims these numbers are relatively higher than at one time thought or estimated to be. This is because many of the survey's that have been carried out can only estimate on those who took part in the studies and also in those who check themselves into an institution. The ones that do voluntarily check themselves into a mental health care facility make up 3% to 15% of the population. The U.K. in 1999 spent an estimated 148 billion on treating mental disorders which clearly shows that there are more people with mental health problems than any survey itself has specified (Hopkins & Glenberg 1994). Several Mental disorders are evident first in infancy, childhood, and then adolescence. Mental retardation is characterized by the inability to learn normally and to become as independent and socially responsible as others of the same age in the same culture. A retarded person can go through a lot of emotional problems because of society making fun of these people. A retarded person has an IQ of less than 70 (Hopkins & Glenberg 1994). Attention-deficit hyperactivity disorder includes conditions marked by inappropriate lack of attention, by impulsiveness, and by hyperactivity, in which the child has difficulty organizing and completing work, is unable to stick to activities or follow directions, and is excessively restless. Anxiety disorder includes emotions of fear for having to leave home and move away from parents and also emphasizes excessive shrinking from contact with strangers, and excessive, unfocused worrying and fearful behaviour (Barlow & Campbell 2000, p. 57). Persuasive development disorders are characterized by distortions in several psychological functions, such as attention, perception, reality testing, and motor movement. An example is infantile autism, a condition marked by unresponsiveness to other people, bizarre responses, and gross inability to communicate to the others in the world (Barlow & Campbell 2000, p. 57). Schizophrenia is one of the more serious forms of mental illness and I personally have witnessed more than one case of severe schizophrenia in my clinical experiences. This mental illness is a predominant disorder of patients on a forensics mental health ward also as many individuals end up in an institution due to a deviant societal act that they have been involved in. This mental disorder normally starts manifesting symptoms in young adulthood (Wineburgh 1999). Also, there are a myriad of different symptoms but the main ones are disturbances in thought, perception, emotion, and interpersonal relations. What this disorder basically means is that the person is split minded but by no means do they have a split personality (Simon 1994, p. 43). Split personality means that the one person acts like two people or several people. This disorder also always occurs before a person hits middle age. All scientists agree that there is no single cause for schizophrenia. What is known is that LSD is one of the major causes (Wineburgh 1999). There also exists a better chance for an offspring from a parent who has been diagnosed with the disease to be diagnosed with it with far more probability than a normal individual who does not have any direct relatives that have been defined to have the disorder. Another common mental health disorder that I have encountered in my clinical experience is bipolar disorder. The phenomenon of bipolar affective disorder has been a mystery since the 16th century. Bipolar disorder or as the alternate names, manic depressive illness or affective bipolar disorder can be classified as a mood disorder characterized by mood swings from manis (exaggerated feeing of well-being) to depression. History has shown that this affliction can appear in almost anyone. Even the great painter Vincent Van Gogh is believed to have had bipolar disorder (Wineburgh 1999). It is clear that in our society many people live with bipolar disorder; however, despite the abundance of people suffering from the illness, we are still waiting for definite explanations for the causes and cure. The one fact of which we are painfully aware is that bipolar disorder severely undermines its' victims ability to obtain and maintain social and occupational success. I have personally witnessed this with my clinical work with the patient, 'Josh'. Many mental health practitioners believe that the lithium level is what causes these mood swings. Because bipolar disorder has such debilitating symptoms, it is imperative that we remain vigilant in the quest for explanations of its causes and treatment. There are smorgasbords of symptoms that can be broken into manic and depressive episodes characterized by affective disorders. The depressive episodes are characterized by intense feelings of sadness and despair that can become feelings of hopelessness and helplessness. Either the manic or the depressive episodes can predominate and produce few mood swings or the patterns of mood swings my be cyclic. Some of the symptoms of a depressive episode include anhedonia, disturbances in sleep and appetite, psycomoter retardation, loss of energy, feelings of worthlessness, guilt, difficulty thinking, indecision, and recurrent thoughts of death and suicide (Hollandsworth, Jr. 1990 ). Some of the other symptoms that may occur in the depressive stage can be also fatigue that can last anywhere from weeks to months and a person may not be aware of why this is actually happening. Daytime sleepiness can also occur making it hard for a person with this illness to hold down any sort of a job for a length of time. Unintentional weight loss can make the doctor go in a different direction in this making it difficult for them in diagnosis because of all the possible symptoms that a person may exhibit. A person may also have some memory loss episodes or episodes of amnesia, going blank for certain periods of time. They may not even be aware that they have a family to take care of their jobs. The manic episodes are characterized by elevated or irritable mood, increased energy, decreased need for sleep, poor judgment and insight, and often reckless or irresponsible behaviour (Hollandsworth, Jr. 1990 ). When a person is in the manic stage they may become agitated which makes them more talkative than usual or they feel pressured to keep talking, they also may wring their hands or fidget because they feel unsure of the situation that they are in and seem to have just extreme restlessness to them. They might appear to have put on quite a bit of weight and anger extremely easy. Their erratic behaviour can make it hard for their families to be around them. Eventually pushing their families aside, and gaining the diagnosis is harder to get because of the lack of support from others and their behaviour is often so off (Lish 1994). In this stage the sexual activity can be increased dramatically, making the patient seek other people to be with if they are not fulfilled in their relationship at home. This can lead to the disruption of the family unit. This disease is very serious and can affect anyone, very much like schizophrenia can but in a very different manner. Bipolar disorder affects approximately one percent of the population (approximately three million people) in the United Kingdom. Bipolar Disorder can affect both males and females and involves episodes of mania and depression, as has been expressed. Bipolar disorder is diagnosed if an episode of mania occurs whether depression has been diagnosed or not (Goodwin et al 1989, p. 11). Individuals with manic episodes most commonly experience a period of depression. The rarest symptoms were periods of loss of all interest and retardation or agitation (Weisman, 1991). As the National Depressive and Manic Depressive Association (MDMDA) has demonstrated, bipolar disorder can create substantial developmental delays, marital and family disruptions, occupational setbacks, and financial disasters, loss of jobs and millions of dollars in cost to society. As the patient ages or gets older they report that the depressions are longer and increase in frequency. Recent evidence has been able to conclude that there are often times bipolar states and psychotic states are misdiagnosed as schizophrenia. This is specifically the case if the family history exhibits schizophrenia or some other illness. Bipolar is most distinguished with families that have mental illness in their background and can occur most often in those settings than in any other, although it can affect anyone, which again has been clearly stated (Lish 1994). What helps distinguish between these two mental health disorders are the speech patterns of the patients. Studying the speech immediately helps mental health care givers in establishing the correct diagnosis (Lish 1994). When both manic and depressive symptoms occur at the same time it is called a mixed episode. Those afflicted are a special risk because there is a combination of hopelessness, agitation, and anxiety that makes them feel like they "could jump out of their skin"(Hirschfeld 1995). Up to 50% of all patients with mania have a mixture of depressed moods. Patients report feeling dysphoric, depressed, and unhappy; yet, they exhibit the energy associated with mania. Rapid cycling mania is another presentation of bipolar disorder. Mania may be present with four or more distinct episodes within a 12 month period (Hirschfeld 1995). There is now evidence to suggest that sometimes rapid cycling may be a transient manifestation of the bipolar disorder. This form of the disease exhibits more episodes of mania and depression than bipolar I alone. Though this mental illness can be dehabilitating, there are treatment programs that have made great differences in some patients' lives. Cognitive Behaviour treatment therapies have begun developing new ways to try and control certain behaviours and teach individuals how to focus their actions in a more positive manner as well (Barlow et al 2000, p. 2530). Of course there are more old-fashioned drugs that are sometimes still used along with the more advanced forms of mental health technology now. Lithium has been the primary treatment of bipolar disorder since Bipolar Disorder 4's initial introduction in the 1960's. Its main function is to stabilize the cycling characteristic of bipolar disorder. In four controlled studies by F. K. Goodwin and K. R. Jamison, the overall response rate for bipolar subjects treated with Lithium was 78% (1990). Lithium is also the primary drug used for long- term maintenance of bipolar disorder. In a majority of bipolar patients, it lessens the duration, frequency, and severity of the episodes of both mania and depression. Unfortunately, as many as 40% of bipolar patients are either unresponsive to lithium or can not tolerate the side effects (Jacobson et al, 1992). Some of the side effects include thirst, weight gain, nausea, diarrhea, and edema it may also heighten the suicide potential that is present with sustained depression. Patients who are unresponsive to lithium treatment are often those who experience dysphoric mania, mixed states, or rapid cycling bipolar disorder. Another problem associated with lithium is the fact the long-term lithium treatment has been associated with decreased thyroid functioning in patients. Preliminary evidence also suggests that hypothyroidism may actually lead to rapid-cycling (Bauer et al., 1990). Pregnant women experience another problem associated with the use of lithium. Its use during pregnancy has been associated with birth defects, particularly Ebstein's anomaly. Based on current data, the risk of a child with Ebstein's anomaly being born to a mother who took lithium during her first trimester of pregnancy is approximately 1 in 8,000, or 2.5 times that of the general population (Jacobson et al., 1992). There are other effective treatments for bipolar disorder that are used in cases where the patients cannot tolerate lithium or have been unresponsive to it in the past. The main point is that now that the illness is fully recognized then the treatments that are given are working for many of the patients. I have clearly seen some very agitated and aggressive patient's personalities change dramatically after being on a regularly managed routine treatment of care that has included lithium or a substitute drug to control their behaviour. The sad fact does remain however that there is no cure for any of these mental health disorders. There only exists therapy, treatment, and efficient management of the patients care to try and bring back some quality of life for them despite the societal adversities that they might have been involved with. Conclusion Although our current mental health system is not perfect it has been able to bring us where we are today. The current methods have benefited many individuals when going through crisis then stabilizing individuals to the point that they can function in society. So what happens when the benefits are not reaped These individuals could go through psychotic change. Thomas Hudson stated (1978), "the mind has a dual character, which he described as the subjective mind and the objective mind. The objective mind takes cognizance of the objective world. Its media of observation are the five senses. It is the out growth of man's physical necessities. It is his guide in his struggles with his material environment. Its highest function is that of reasoning. The subjective mind takes cognizance of its environment by means independent of the physical senses. It perceives by intuition. It is the seat of the emotion and the storehouse of memory. It performs its highest function when the objective senses are in abeyance. (Hudson 1978). It's when the subjective mind assumes complete control, that the individual goes psychotic." (Michael 1997). When these individuals enter the psychotic state, studies have shown there can be some risk factor for criminal behaviour, but none with solid evidence. Most individuals with depression and other mood disorders are said to have violent behaviour and violent hostilities, but none proven to show any criminal tendencies. This is the case with my clinical experience with 'Josh'. Although he did show violent tendencies both in the ward and in public his actions were not wholly criminal but there is the possibility that they could turn that way without treatment and the right form of medication on a continuous basis. According to K. Taridiff, (1984), "people with severe depression are often dependent on family for care. Within the family, the person most involved in the depressed person's care, usually the mother is most at risk, with the violent person usually being a son or spouse. One study of patients admitted to psychiatric hospitals found that, among those who had attacked people during the time close to their admission, 65 percent of the sample had attacked a family member." (Taridiff 1984, p.164). Still, there has not been any solid data linking depression to criminal behaviour, only very violent behaviour. But, does violent behaviour lead to criminal behaviour That is the main question that I ask myself and that I review in a comparative way with the knowledge that I have acquired. Research has shown no clear cut relationship between violent behaviour from depression and normal criminal behaviour. We do know that depression sufferers suffered in childhood, in the forms of sexual or physical abuse or neglect has long term consequences, leading to depressive related problems in later life. Also, cycles of familial violence is passed on from generation to generation. These people will continue to go through this cycle if not treated and in most cases, dangerous or violent acts committed by persons with depression disorders are mainly the result of neglect or inappropriate or inadequate treatment. We must understand most depression can and is most commonly treated by counselling and that depression is not a mental illness, but an affective disorder that may lead to criminal behaviour. Yes, depression is serious problem in and of itself, is a risk factor for aggression and possibly even for criminal behaviour. Mental Illness and Violent conditions for depression and mental illness are the same, whether a person has a mental illness or not. Studies of violence and mental illness have shown that people with a mental illness who came from violent backgrounds are often violent themselves. So, in finality the main point is that these patients need to be treated following an ethically sound structure. According to Peplau's model of nursing care the treatment should be therapeutic for the patient and more than anything it should be sincere and not just a seemingly mundane act of treatment. 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