INTRODUCTION
Psychosis is a complex and severe mental disorder that affects a person’s ability to think, feel, behave, and interact with others.[1] It has been reported as one of the important public health problems in the world and leading to a disabling condition.[2] It has an influence not only on the person who is afflicted but also on the people who care for them.[3] Many times, people with severe mental illness may abscond or disorient from their homes due to cognitive dysfunctions and land in government hospitals or rehab centers as homeless patients. Although pharmacotherapy is the mainstay of treatment, psychosocial interventions, especially focusing on regular follow-up, drug adherence, family support, and vocational training, help with the earlier recovery of homeless people with psychosis.[4,5] This case study briefly demonstrates the psychosocial perspective of intervention for community reintegration of an unknown patient who has been diagnosed with severe mental illness.
CASE REPORT
Ms. F, 45-year-old, illiterate married Muslim female from low socioeconomic status with a rural family background of Andhra Pradesh was brought to a tertiary care by a local organization. The client was apparently well before hospitalization. She was self-employed and selling bananas in a nearby village. One day, she got into an express bus to reach the local market to purchase bananas. However, she had forgotten to get down at the local market and reached Hyderabad as she was tired and slept off in the bus. She did not know how to go back, but she somehow managed to reach the railway station and got into a train going to Bengaluru, thinking that the train may go through her village. As she was not familiar with the rain route, she got confused and landed in Bengaluru instead of her village. In Bengaluru, she found it more challenging because it was totally a new place for her and she was unable to seek help as she did not know the local language. She was noticed by the members of a Kannada association showing irrelevant behaviors and poor self-care. Hence, they had taken her to NIMHANS for psychiatry evaluation and treatment. The treating team assessed and noticed that she was having muttering to self, irrelevant speech, abnormal behavior, and social withdrawal. Subsequently, she was admitted in the NIMHANS close ward under reception order and she was diagnosed with psychosis NOS. As she was not able to tell her correct address, she was called “Cinnamma” (the name given by the ward staff for communication purposes).
The psychosocial analysis reveals that the patient seems to have struggled to have a satisfying job throughout her life because of poor education, poor work skills/competence, and self-doubt about her competence. She was the functional leader of the family and used to run the family with her income from banana selling. Her husband was bedridden due to a chronic medical problem and was not able to take any family responsibilities. It was noticed that the family has inadequate primary and secondary social support. However, NIMHANS hospital was the only tertiary support available for her. All these psychosocial factors such as being unable to trace the family, long stay in the close ward, difficulty in communication, poor social support, self-care, and coping skills contributed for significant psychological dysfunction in the client.
Psychosocial perspective
The interventions are based on potential psychosocial factors of an individual who is suffering from a mental illness and associated social issues.[6] An evidence-based psychosocial interventions given to the patient are discussed below.
Supportive work
Many people believe that the way to free themselves of unwanted emotions is to relieve through catharsis.[7] At the beginning of the session, rapport was established with the client where the therapist had made the client comfortable ensuring her confidentiality. After a while, the client started telling her difficulties, and she was able to open up her feelings. Support was given to her by allowing her to cry and express her negative feelings of being lonely and loss. She was allowed to ventilate her pent-up emotions about her experiences. She was helped let go of the pain by generalization and normalization of the situation, and further assistance was given to the client by substituting the negative thoughts with positive thoughts. The focus of the intervention was to provide supportive therapy to enable her to ventilate her emotions. This has let her realize the need for changes in her behavior and sense of independency.
Psychoeducation
Psychoeducation is seen to be one of the components in treating or management of psychosis disorder.[8] In the session, initially, the assessment was done on the client’s illness. The client was ignorant about the illness; she did not initially seek treatment because she did not understand why she was kept in the closed ward. After the assessment, the client was explained about the nature of her illness and symptoms. The relation between the stressor and symptoms was discussed, and the need for medications and follow-up was emphasized. Further sessions focused on clarifying the doubts she had regarding the causation, nature, course, and treatment of the illness.
Resource mobilization
The treating team has mobilized resources such as free medication and 2100 rupees for the client to travel back home (then Andhra Pradesh) from the NIMHANS poor fund and arranged a person to escort till her house.
Community rehabilitation
Skill training, drug therapy, and community support strategies are the three primary intervention techniques used by practitioners attempting to rehabilitate severely psychiatrically disabled clients.[9] For better functioning of the client, rehabilitation was incorporated in the intervention to enhance the sociooccupational functioning of the client. To rejoin the patient in the family, the psychiatric social worker wrote a letter to the police authority in Hyderabad and, through the phone, contacted NGOs for confirmation of the exact address. On clarifying the address of the patient, the social worker mobilized the recourses to send her along with an escort to her house. In NIMHANS hospital, another patient’s family member was willing to drop the patient at her residence, who knew her address and language. The escort was educated about the patient’s illness and symptoms. The train tickets to Rangareddy district through Hyderabad for both patient and escort were arranged by the team. Then after 1 day, the patient’s husband and escort called through the phone and informed them that they had reached safely. Her husband was psycho-educated about illness, treatment, and regular follow-up in a nearby mental health hospital (Institute of Mental Health, Erragadda, Hyderabad, Telangana).
Family psychoeducation
Family psychoeducation is a well-proven intervention for families of persons with psychological distress.[10] The importance of psychoeducation with families about mental illness cannot be underestimated. Assessment of level of knowledge revealed that the family had no knowledge about psychosis. The family members were called by the therapist and were given telephonic counseling. The therapist explained the various aspects of psychosis and treatment to the family members in a simple language to make them understand based on their level of literacy. The psychological status of the client was explained, and the importance of treatment and emotional support were explained to them. Their doubts and misconceptions were clarified.
Psychosocial therapy, engaging the client, helped her understand the link between stressors and illness, and she began to express herself more freely. The client was able to share her feelings and thoughts with her close ones. The client was able to reclaim her actual self and reconnect with family members, and the family was finally able to comprehend the condition, accept it, and continue to assist the client in the community.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Sadock B. Psychiatric report, medical record and medical error Sadock BJ, Sadock VA Kaplan and Sadock's Comprehensive Textbook of Psychiatry 8th ed. Philadelphia: Lippincott Williams & Wilkins 2005 834–47.
2. WHO. World Health Report, Mentalhealth: New Understanding, New Hope. Geneva: WHO 2001.
3. Vidal ML, Cortés MJ, Valero J, Gutiérrez-Zotes A, Labad A. Family environment and expressed emotion in patients with schizophrenia or other psychoses and in their first-degree relatives. Actas Esp Psiquiatr 2008;36:271–6.
4. Smartt C, Prince M, Frissa S, Eaton J, Fekadu A, Hanlon C. Homelessness and severe mental illness in low- and middle-income countries: Scoping review. BJPsych Open 2019;5:e57.
5. Moorkath F, Vranda MN, Naveenkumar C. Lives without roots: Institutionalized homeless women with chronic mental illness. Indian J Psychol Med 2018;40:476–81.
6. Suissa AJ. Cyberaddictions: Toward a psychosocial perspective. Addict Behav 2014;39:1914–8.
7. Scheff TJ. Catharsis in Healing, Ritual, and Drama. California, US: University of California Press 1979.
8. Xia J, Merinder LB, Belgamwar MR. Psychoeducation for schizophrenia. Cochrane Database Syst Rev 2011 2011 CD002831.
9. Kuno E, Rothbard AB, Averyt J, Culhane D. Homelessness among persons with serious mental illness in an enhanced community-based mental health system. Psychiatr Serv 2000;51:1012–6.
10. Kulhara P, Chakrabarti S, Avasthi A, Sharma A, Sharma S. Psychoeducational intervention for caregivers of Indian patients with schizophrenia: A randomised-controlled trial. Acta Psychiatr Scand 2009;119:472–83.
