This essay will focus upon an appraisal of the "package of therapeutic care" which is experienced by a selected client. The intention is to consider the rational for and the relationship between care, treatment and other therapeutic interventions in effectively meeting the clients needs. Within this essay, the author will present a profile of a client, followed by the identification of the client's needs. The author will then identify the therapeutic interventions that the client has been prescribed by the care team. The therapeutic interventions identified will then be analysed and recommendations made following that analysis.

The client will be given the pseudonym Joan, to comply with the UKCC Code of Conduct (1992), clause 10. Joan is a seventy-nine year old lady with an extended history of depression that has been treated in the community by her allocated keyworker since Joan's initial admission to hospital. Thompson, (1989) states that it is important to remember that the word depression can describe anything from low mood to a life threatening disorder, or even fluctuations between the two. According to Wood, (1992) women are twice as likely as men to suffer from a serious depressive episode at sometime in their life. Seligman, (1992) goes on to say that women are ten times as likely to suffer from depression as their grandmothers.

Joan was originally referred to the psychiatric services by her GP after an overdose following the death of her husband. Joan's presenting symptoms were, loss of appetite, sleep, and concentration, and thoughts of suicide. She lives alone in her own house as Joan's family has immigrated to America. Joan expresses a lot of love for her estranged family, especially her numerous grandchildren who she sees maybe once or twice in a year.

McFarlane, (1992) states that a poor family situation has been proved in several studies to be the cause of disorder and also contributes to relapse, he goes on to say that the individual may be more vulnerable to other stresses that exist within everyday society. In addition Joan has only her two neighbours that she can call friends. Physically Joan has difficulties with mobility due to a previous hip operation and being overweight caused by the anti-depressant medication. Joan also has arthritis which often compounds the mobility problems, however Joan says that the pain killers and anti-inflammatory medication alleviates most of the arthritic symptoms. Joan's needs are assessed on a regular basis using a systematic approach derived from Ropers Model, (1986).

This approach has also assimilated some of Neuman's, (1989) theories of stressors in the clients environment and self. Neuman, (1989) identifies three types of stressors, these are intrapersonal that is related to the person, interpersonal which is related to others, and extrapersonal that is related to a wider context, for example the environment, or society. In relation to Joan, her intrapersonal stressors are her mobility difficulties, arthritis and compliance with medication. The interpersonal stressors present are concerning her distance from and communication with her family, as well as lack of social contact with friends. Joan's extrapersonal stressors are access to facilities in order to allow her to benefit socially. Joan's keyworker will take all of this into account when assessing Joan's needs and how they will be met by the care team.

Joan's allocated keyworker has been with Joan for two years and has been able to build a good therapeutic relationship between them. Joan is usually visited in her home due to her mobility difficulties, this helps the relationship as Joan is familiar with the surroundings and feels relaxed and at ease. The assessment meetings are conducted in the style of a friendly chat rather than like an interview. The keyworker chats with Joan but keeps control of the conversation enabling the keyworker to extract the required information at a pace and manner that is comfortable to Joan. Lyttle, (1994) states that being approachable develops an attitude of tolerance and acceptance. Rogers, (1951) suggests that the interviewer allow for questioning and offers feedback and reassurance to the client, the interviewer should speak calmly and clearly in order to build trust, as it is only through trust that the assessment can be successful.

When asked Joan identified her need as "needing friends, company, and getting out of the house to stop the isolation and loneliness that she feels." Her keyworker assessed Joan's needs and concluded that "Joan had got to the stage in life where she feels isolated and alone. Her husband has died, most of her friends have died, and her family lives away and rarely visits. She needs to be encouraged to go out, develop new friends, and meet others in similar circumstances. Joan also needs to be encouraged to comply with taking the medication to lift the depression." Joan's self-assessment supports the assessment carried out by the support worker, this indicates to the care team that the assessment tools and method of assessment were effective in this situation. In order to continue to improve on the client's package of therapeutic care it is also necessary to complete a risk assessment the outcome of which will have a bearing on what the package will contain.

Joan stated that she had lost all motivation and feels nothing is worthwhile. Her keyworker feels that if the medication does not relieve the symptoms of depression and Joan does not begin to meet new people and start to socialise, she will be in danger of neglecting herself, or attempting suicide. Joan's keyworker after consultation with the care team has derived a package of care consisting of short and long term goals. The short-term goal is to lift the symptoms of the depression with medication and to continue with regular visits from her keyworker so that the effectiveness of the medication can be assessed on a regular basis. Regular visits from the keyworker will also act as a support for Joan, having an allocated keyworker means that at any time Joan can contact her keyworker or someone from the team if she feels especially low. McKeon, (1992) states that a therapeutic relationship between carer and the depressive client is of crucial importance if the client is engulfed by low self esteem, as the client will then benefit from some affirming positive regard, a listening ear, and effective supervision to ensure safety.

This will also allow the keyworker to assess the effectiveness of the medication and any side effects that may occur. The long term goal is to encourage and facilitate Joan's attendance of the Therapeutic Day Services (TDS) run by the Community Mental Health Team (C MHT) on a regular basis. These services consist of various groups such as art therapy groups, music therapy groups, anxiety management, and depression groups. This service also has a canteen and recreational meeting area, which is run and staffed by some of the long term clients as well as clients that no longer use the service but wish to continue to offer support to others. This will allow Joan to meet other people of a similar age group and circumstance to herself as well as benefiting from some of the therapeutic groups that are available. To help relieve the symptoms of Joan's depression she is prescribed two Lofepramine 70 mg at night.

Breggin, (1993) states that the aim and justification for psychiatric drug treatment is to relieve a person who is tormented and preoccupied with their mental experiences whilst neglecting most other parts of their life. Ironbar, (1989) however, points out that chemotherapy can have unpleasant and potentially harmful side effects if not administered and monitored carefully. Lofepramine is a member of the tricyclic antidepressant group. The most important point to remember about tricyclic drugs is that they take a number of weeks to exert their antidepressant effects. As the effect is delayed and as depressed clients may not comply with medication if it appears ineffective, it is important that Joan's keyworker informs Joan about the dynamics of the medication and continues to encourage and monitor Joan's compliance with the medication. Lofepramine also has a wide range of physical side effects that Joan's keyworker should monitor for, from dry mouth to gastrointestinal upset.

Joan's keyworker also arranges a regular weekly visit to Joan's home, this is not only to monitor medication, but also to allow Joan's keyworker to assess her mental well being and presentation of self. This will allow the keyworker to monitor for any signs of the depression worsening, and to ensure that Joan does not neglect herself. To meet Joan's long term goals the care team arrange for Joan to attend the Therapeutic Day Services initially for one day per week during the first month, and then to increase this, after an assessment at the end of the first month, to two or three days per week. The assessment after the first month will focus upon the effectiveness of the medication, and how Joan has managed within the day services. Joan will also be present at this assessment so as to feed back to the carte team her own thought and feeling on the package of care she is receiving. If Joan and the care team then decide that Joan will benefit from continuing with the services currently provided, there will be a monthly assessment focusing upon Joan's progress.

In addition to this there will be continuous monitoring from the keyworker so that the team can take any action necessary if Joan relapses into crisis. Taking into account the variables surrounding Joan's situation and the fact that the care package has only recently been implemented it is difficult to analyse how effective the package of care will be. However, Joan is a very sensible lady who has no problems with contacting someone for help, as long as that help is made readily accessible. Joan's depression stems from poor contact with her family and gradually increasing isolation from society. Most of Joan's social circle has died around her leaving a social void in her life, attending the Therapeutic Day Services is meant primarily to allow Joan to leave her house and meet with new people on a regular basis.

The care team decided Joan's visits to the day centre should start with one day a week and increase after a month, this is to give the medication time to become effective, and to allow Joan time to get to know the layout of the day centre and get to know some of the staff and clients that are there. Social interaction is a vital part of our mental well being. Smith, (1990) states that people who experience poor family relations often need a great deal of social support, social and emotion stress plays a significant role in the symptoms of serious mental disorders. In addition to the social benefits of Joan's attendance of the day hospital, it will also give the care team a chance to meet Joan and to encourage her involvement in some of the therapeutic groups available. Joan's medication if effective will lift the main symptoms of her depression which will allow Joan to feel better within herself and so more able to interact with others. Regular visits from the keyworker will allow Joan to be monitored for any side effects of the medication, and allow the keyworker to chat to Joan and listen to her thoughts and feelings.

In conclusion the author feels that the care package that has been put in place by the care team is the most appropriate for Joan's current circumstances, the regular assessments will allow for changes in Joan to reflect in the care package. The medication prescribed to Joan will help relieve the main symptoms of depression chemically, so that Joan may feel able to work on her depression cognitively through therapy groups and one to one sessions. This may lead to a lesser reliance on medication, and leave Joan at less risk from the many side effects that may occur... BREGGIN.

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