The Case of Sam: Multidisciplinary Perspectives

Sam has been involved with mental health services since his first hospitalization at age 18. Despite the abundant services provided to Sam and the relative continuity of key people in his treatment, Sam's ability to function has not significantly improved, and he is seen by some to be steadily declining.

To effectively determine what Sam needs, one might begin to look with Sam at the question, What does Sam want? How would Sam like to proceed with his life? His life was derailed shortly after he left home to begin college. What does Sam believe is possible for him to achieve? Does he feel "stuck"? Does Sam feel that he benefits from the current arrangement?

Sam's service providers clearly feel stuck about how to proceed. Do they feel this way because he has stayed beyond the expected time in a program designed for short stays? Is he actually stuck because providers cannot reach agreement on his discharge plan? If Sam and his providers see him as comfortable and doing reasonably well in his current setting, is there a way to replicate the positive elements of the program in a more permanent setting?

The case summary is replete with references to interventions that inadvertently support dependency and reinforce passivity, both reminiscent of Sam's expressed problem of "chronic fatigue." Rather than supporting the life position represented by chronic fatigue, Sam's service providers should help him overcome it. The case description suggests that his caregivers are supporting his life position. For example, the team of professionals working with Sam are "providers," people who deliver a service to a passive recipient. Sam is transported to all of his appointments. He is taken to the store for weekly grocery shopping and on outings planned by staff. He repeatedly refuses to participate in a day program. A case manager coordinates his service plan and his life. Sam consistently discontinues taking his medications after discharge from a hospital. His week may include a therapy session and a medication appointment, and when a crisis arises, access to respite or crisis services.

Is this the community Sam wants? Does he want to live in a community in which his service plan and related activities constitute the total of his life experiences and in which the management and control of his activities are given to individuals other than himself? Paid staff take him to paid staff who tell him what to do. Sam asserts what little autonomy he has by often refusing services, sometimes actively, most often passively.

Improving the quality of Sam's life experience begins with Sam. It is not necessary to challenge his definition of his problem, chronic fatigue. Sam may be able to be engaged in a plan of activity during the day—when many people Sam's age are working—that is known to increase energy. He may be motivated to engage in his own treatment if he is working to improve his nutrition and increase his daily exercise and choose some form of productive daily activity that might improve his energy level. These activities would likely create a level of structure in his daily life that is closer to cultural expectations than his current situation. Such activities would probably provide Sam with the opportunity to develop personal relationships beyond those with paid staff.

Engaging with his siblings and parents is possible for Sam if that is desirable to him. Because the case description provides no substantive information about Sam's family relationships or Sam's preferences, it is difficult to formulate a strong opinion about the involvement his family should have in his life. Generally, the decision to help an adult engage with his family should be motivated initially by the preferences of the individual. I would not see any value in contacting Sam's family if they knew he was in a respite bed and had made no effort to contact him and if Sam was unwilling to give his consent. The only circumstance in which contacting his family without his consent might be considered is in a crisis situation or when a family member is the appointed guardian.

To determine a realistic goal for family engagement, the issue of reengaging Sam with his family should be explored with Sam and, if he agrees, with his family members. Often families are hesitant about becoming involved in the lives of their relatives with mental illness, either because the relationships have previously been damaging or because they do not know how to be involved. I would be inclined to work with Sam to obtain his consent to contact family members. If a mutual interest exists, I would work to reconnect Sam and his family in a way that would respect the distance they need but would foster the connections among them. Perhaps Sam's relationship with his family could play a role in reinforcing the rehabilitation that Sam needs.

Sam's dependence on the system is a function of the system's relationship to him as an individual. It is valuable to attend to the individual and to create interventions to help an individual achieve his goals. However, it would be equally advantageous to examine a major part of Sam's community, the treatment system, and assess the need for changes in the system that might promote Sam's growth as well as the system's growth. It is crucial to identify functional changes that might help the system offer a continuity of services to help Sam accomplish his goals for rehabilitation. Too often, fragmentation of mental health services results in intermittent and episodic treatment interventions, which produce few lasting effects. In Sam's case the absence of rehabilitation goals, the lack of awareness among his service providers about specific issues of concern to him, and providers' polarization about what setting is suitable for Sam's treatment all contribute to maintaining his poor functioning.

To view Sam's situation with the aim of expanding the options available to him, it is important to momentarily ignore the framework initially presented in the case description. The options proposed—maintenance in the local community versus long-term hospitalization with a rehabilitation push—impose artificial limitations rather than expand Sam's opportunities. Treatment sometimes occurs in some hospitals and in some local community mental health systems. However, in both the hospital and the community, maintenance rather than treatment is often the rule. For a subset of individuals, maintenance is a legitimate treatment goal. This goal probably is not appropriate for Sam.

Sam can and should be expected to participate in the creation of the kind of future he wants for himself. All viable communities are sustained by the contributions of their members. Sam can be expected to be a contributing member of a community whose members are expected to develop their potential and to do much more than just sleep. The mental health system and its staff should be organized to support Sam's participation in a community in which he can experience a sense of belonging over time. If Sam is presented with this challenge and accepts it, he can learn to conduct his own life in the context of a community. Opportunities for rehabilitation should be structured so that Sam's participation is expected in all aspects of the rehabilitation process.

Currently, Sam's future is uncertain. Neither he nor his providers have an image of a future for Sam. He will need help to imagine a future and establish the goals to move forward. If the hospital is the only real community experience available to Sam, then hospitalization would be the optimal choice. However, one would hope that the sense of belonging and contributing that sustains an individual like Sam within his community would be available to him in settings where the rest of us live.

Ms. Sprung is community services manager in the Massachusetts Department of Mental Health, P.O. Box 389, Northampton, Massachusetts 01061 (e-mail, [email protected]).