The Case of Sam: Multidisciplinary Perspectives: The Individual and the Community: Engagement

The mission of psychiatric rehabilitation is to help individuals with severe and persistent mental illness improve their functioning so that they can be successful and satisfied in the environments of their choice with the least amount of support from helping professionals (1). The integrative model described by Corrigan and colleagues (2) identifies three broad dimensions of psychiatric rehabilitation: goals, settings, and services.

Some of the primary goals of psychiatric rehabilitation are recovery, empowerment, independence, and improved quality of life. These goals can be achieved through the delivery of a variety of services in several settings. However, psychiatric rehabilitation services, such as supported employment, skills training, and peer support, do not constitute rehabilitation; services exist to help make the process of recovery "available, attractive, and possible for the individual … who must do the very real work of self-change" (3). A core value of psychiatric rehabilitation is that all people have the right of self-determination, including the right to participate in all decisions that affect their lives. Sam's definition of the problem, his interest (or lack of interest) in treatment, and his setting of goals for his life are the starting point and the framework within which our intervention must operate.

For Sam to benefit from any of the services he is offered, he must first be engaged in the psychiatric rehabilitation process, and he clearly is not. Thus our approach focuses on the process of engaging him; the techniques used are an extension of motivational interviewing (4) and contextual behavioral approaches (5). We believe the approach should be implemented either by Sam's psychologist or by his case manager.

Our approach uses "workability" as the ultimate outcome criterion (6). In Sam's case, emphasis should be placed on assessing how well his approach to fulfilling and pursuing his particular values, goals, and wishes is working, given that he lives in communities—both the mental health community and larger communities—that have specific expectations, demands, and tolerance limitations. This approach would also be applied to the mental health community's attempts to help Sam, because it appears that direct attempts to change him have met with limited success. Three questions should be asked: What are you trying to accomplish? What methods have you used to try to accomplish your goals? How well have these methods worked for you?

Our approach begins by establishing a collaborative relationship with Sam to create a context that increases the probability that he will feel validated for his perspective. As with many other treatment modalities, the relationship established by the mental health worker serves as a powerful influence (7,8). Therefore, the initial goal of interaction is for Sam to experience the relationship as positive and rewarding.

When the case manager and other professionals acknowledge Sam's wants, needs, and desires and help him examine the costs and benefits of his approach to meeting them, Sam will learn to articulate his values rather than telling his treatment providers what he thinks they want to hear. Interacting in this way changes the control of Sam's verbal behavior from contingencies in the moment—for example, in the therapist's office—to relevant contingencies associated with past attempts to meet his goals (Holmes EP, Dykstra T, River LP, et al, unpublished manuscript, 2001). Rather than prescribing particular solutions or approaches, we evaluate with Sam whether his actions and behaviors are helping him to achieve his goals or hindering him.

Specifically, we would begin by talking with Sam about his lifestyle and asking him if he would like things to be different. We would ask him about how he uses his time, how well he likes his living accommodations, and whether he likes his social life. Should he identify specific problems or areas for improvement, we would review with him his past attempts to make these changes. Each attempted solution would be assessed in terms of the degree to which it helped him reach desired outcomes. Emphasis is placed on listening to and understanding Sam's attempts to create what is a meaningful lifestyle from the perspective of his values rather than from the perspective of the mental health professional.

As an accepting atmosphere is created in which Sam's values are affirmed, he may begin to consider the values that his caseworker represents. Thus the experience of acceptance may lead Sam to consider collaboration and compromise and to suggest workable solutions that meet both his own needs and the needs of the communities in which he participates. If Sam is unwilling to compromise, the caseworker maintains a neutral role and assists him by asking him to talk about some of the possible consequences of not compromising, such as involvement in the court system and problems with his landlord. The caseworker also asks Sam about the consequences of his refusing to take his medication, maintain his living space, or attend to basic self-care responsibilities.

The caseworker acts as Sam's coach. He or she assists him in identifying the predictable responses the other service providers might have to Sam's choices. For example, one predictable consequence of Sam's choosing not to take his medication is that he might engage in behaviors that would cause him harm, such as wandering naked in the snow. If his psychiatrist thinks that Sam might harm himself, hospitalization is a likely consequence. If Sam is hospitalized, the discussion will continue in the hospital, preferably with his caseworker, who will ask about the solution that Sam tried and how well it worked. It is important that the caseworker maintain neutrality; the caseworker does not try to coerce Sam into adhering to his medication regimen or self-care. Within the limits of professional ethics, the caseworker does not attempt to protect Sam from the consequences of failing to adhere to his treatment plan.

The intervention described is not contingent on Sam's accepting the fact that he has a mental illness. Regardless of whether there is a problem or what the problem is—mental illness or chronic fatigue—certain behaviors are required, such as keeping his apartment clean and free of pests, and other behaviors are not allowed, such as engaging in activities that might lead to his death. The issue of taking medication can be approached similarly. Regardless of the medication and its effects, can Sam refrain from engaging in behaviors that lead to hospitalization or other losses of freedom if he does not take his medication? Even if Sam experiences psychotic symptoms, such as delusions, it is not his beliefs that result in hospitalization but what he does as a consequence of the beliefs. The issue addressed by the caseworker, at least initially, is not the nature of Sam's illness. Rather, the caseworker talks with Sam about what he wants and whether his behavior helps him achieve his goals.

One might expect a discussion of the psychiatric rehabilitation approach to focus on implementing services for Sam, such as skills training, supported employment, enrollment in a clubhouse, and peer support. Until Sam sees that engaging in these services is relevant to achieving his goals, he is unlikely to participate or derive full benefit from them. Even though engagement is specifically targeted in our approach, it will take time for this process to occur. A primary benefit of supported housing and case management in this situation is to enable Sam to stay in the community long enough to provide an opportunity for engagement and to monitor his status so that appropriate decisions can be made to ensure his safety.

We would recommend following the advice of Mark Twain, "Put all your eggs in one basket, and watch that basket." We would put all our efforts in engagement and motivational enhancement strategies with the hope that in the future Sam might consider other psychiatric rehabilitation services.