Phoebe was a 47-year old woman who was admitted to John Munroe Hospital on 28.01.16 under Section 3 of the Mental Health Act from an NHS rehabilitation unit. At the time of her admission, she had diagnoses of Paranoid Schizophrenia, possible Schizoaffective Disorder and possible Learning Disability. She had a history of contact with mental health services from the age of 16, since which time she had had numerous hospital admissions and frequent relapses. Her presentation had comprised numerous examples of challenging behaviour, including aggression towards others, self-neglect and the expression of delusional beliefs. Her diagnosis of Paranoid Schizophrenia was described as being characterised by “deep rooted and fixated delusional beliefs, hallucinations involving responding to unseen stimuli, thought disorder, hostility, verbal and physical aggression, anxiety, self-neglect and chaotic lifestyle”. Various attempts had been made to place her in supported accommodation and care home settings, however these placements had all broken down due to her behaviour.
With regard to her history, clinical records suggested that she had experienced a chaotic and disorganised childhood, which involved a range of insecure attachments and adverse childhood experiences. In addition, it had been identified that she had experienced an abusive marriage and had three sons, one of whom had been adopted and the others placed in foster care. Although Phoebe had a brother, his contact with her was extremely limited and during her admission at John Munroe Hospital, he did not respond to telephone calls or letters from Phoebe.
Upon admission to John Munroe Hospital, Phoebe initially presented in a chaotic manner, expressing delusional ideas, refusing her medication and making verbal threats to staff. In addition, she did not engage in any activities and was preoccupied with being discharged. However, over the course of her admission, she began to participate more in activities, including Section 17 leave.
Neuropsychological assessment was completed, which provided a confirmation of her Learning Disability and highlighted specific areas of concern, particularly pertaining to her communication ability, capacity to retain and process information and impairments affecting her executive functioning. A Functional Analysis elucidated specific aspects of Phoebe’s behaviour (including antecedents and consequences) and facilitated the process of determining a repertoire of environmental and reactive guidelines to support the modification of this. As a result of these structured assessments, areas of intervention were identified and implemented by the MDT. These included communication aids developed by OT, a pictorial timetable, differential reinforcement of other behaviours, skills training and a Positive Behaviour Support Plan developed by Clinical Psychology.
Whilst a structured, behavioural approach was an integral component of the work undertaken with Phoebe, consideration of her Psychological formulation was also an essential feature of her care and treatment. Through comprehensive assessment, challenging behaviours, particularly those involving verbal or physical aggression, were understood as primarily attachment strategies, arising from feelings of fear, loss and separation anxiety, which were all compounded by Phoebe’s cognitive impairments and limited skills in self-soothing, emotional regulation and self-monitoring. Therefore, providing reassurance, safety, consistency and a non-punitive, non-judgmental approach was essential.
A guiding principle within Phoebe’s care was that of a trauma-informed approach, encompassing a person-centred stance that was validating, meaningful, emphasised relational security and incorporated a reparenting approach. As a result of this MDT approach, Phoebe was able to develop some positive and meaningful therapeutic attachments which, along with the provision of a structured and consistent routine, enabled her to participate more in rehabilitative activities, thus enhancing her functional skills as well as strengthening her own self-esteem and capacity for emotional regulation and self-direction.
Phoebe’s progress within John Munroe Hospital meant that she was able to move into supported accommodation after discharge. The acquisition and development of Activities of Daily Living skills provided her with some degree of autonomy, whilst her repertoire of stabilisation and coping resources provided greater opportunities for both meaningful occupation, positive interpersonal experiences and reduced anxiety and distress.