i) Rehabilitation team
The rehabilitation team may be part of the management challenge.
Individual members of a rehabilitation team have their own biases about mental health
For example, some team members might see that mental health treatment is of no value or they are dismissive of it , they might be very negative about pharmacological therapy. You can have a situation where the rehabilitation team does not support or reinforce the importance of the management of mental health problems. The team's goals could be obstructed by the mental health goals in relation to response to treatment. One of the classic examples is when people develop a psychotic illness.
Conflicting goals
Psychotic illness after a brain injury is a serious situation. A situation arises in that the person's psychotic illness can be managed, control their symptoms adequately, but when they return to their rehabilitation goals the stress of the rehabilitation causes the relapse of their psychosis. You are then in a double bind where the rehabilitation team want to get the person better, back to work, back to their normal community activities but the stress of that, the person dealing with their cognitive impairments in that environment, precipitates their psychosis.
You can have two health professionals at loggerheads trying to negotiate the real goals in relation to management of the patient. That is a huge challenge and can only be overcome with team meetings, appropriate communication and the setting of goals in a group format rather than individual members forming the goals. When you have problems with the establishment of goals it is often reflected in the patient not doing well.
ii) Sometimes services exclude people when they have a mental illness
One of the challenges is that sometimes services exclude people when they have a mental illness.
Many years ago I often would receive a referral for a patient as being mentally ill, having had a brain injury. Their file would be closed in rehabilitation, particularly in the work rehabilitation environment. Sometimes it was prematurely closed. It was then very difficult to get the patient returned to a rehabilitation setting.
Of course the converse can also occur. Mental health services can be quite anxious that they are going to acquire a patient and not be able to refer the patient back or to manage the patient appropriately.
The entire rehabilitation process needs to be very carefully managed so it does not become a challenge for the patient.
In Sam's case he did not have a rehabilitation team that was actively involved, he was not working.. Therefore a lot of the issues that often arise in rehabilitation, e.g. a return to work etc, did not emerge in Sam's case. Unfortunately Sam's outcome was not very positive as in the long term ultimately no service was involved.
There was a large split or dichotomy in the family between what they thought was wrong with their father, what should happen and what should not. They dealt with this by withdrawing their father from any kind of services. They declined any kind of community involvement from rehabilitation services, they declined any kind of psychiatric involvement. Ultimately Sam has not had any kind of effective treatment and his psychosis has never really been very well managed.
He did have a settlement of his case but it was very limited and the effect of that was that they did not have an ability to buy services for him, for example, attendant care or respite facilities, because the family's resources were very, very limited.
Ultimately we had someone who is very mentally ill, who has had a significant cognitive impairment, living at home with his extended family, his wife had an incredibly high burden of care. The outcome ultimately has been extremely unsatisfactory from all parties' perspectives, but particularly from Sam and his family's perspective.
