Tuesday, January 5, 2016

Problem Solving: "Doris" and the Intractable Goals

"Doris" had been in mental health residential rehabilitation programs for over ten years, and had still made no progress toward her goals of taking her morning medication independently and attending all of her appointments. As I reviewed her files, I noticed that the same methods had been tried, year after year.

I thought about what kind of person Doris was and developed methods based on her specific strengths. Doris had mild developmental disabilities and had resided in a program for that disability prior to being transferred to a mental health program. She was highly motivated by point systems and enjoyed getting marks showing success in small tasks. She also followed routines regularly and once she had established a habit, she stuck with it.

Morning Medications

To help her to develop the habit of taking her medication independently in the morning, I decided to take Doris through manageable steps.

For the first month, whenever Doris took her evening medications she would put the following day's date on an empty medication envelope. At morning medication time, she would show the empty envelope to staff and get a star on her chart. Doris never missed a day.

For the second month, when Doris took her evening medication she put her morning medication in an envelope and marked it with the following day's date. Every morning she produced the correct envelope and took her medication while staff watched, then got a star on her chart.

For the third and final month, Doris would take the medication before medication time and show staff the empty envelope, for which, again, she would get a star.

After those three months, Doris would take her morning medication independently.

Attending Appointments

Attending appointments was quite a challenge for Doris because of the number of professionals that she saw. She had to keep both regular and special appointments with a psychiatrist, psychiatric nurse, cardiologist, gynecologist, ophthalmologist, and podiatrist.

Doris enjoyed the attention she got when attending appointments and was highly motivated to attend. I asked her a simple question: "Do they give you appointment cards when they make appointments for you?"

Doris answered, "Sure do!" She opened the top drawer of her dresser. It was full of old appointment cards.

I asked her if she wrote her appointments down on her calendar. She said, "Sure do!" and showed me her calendar. Therein I found the problem: If Doris had an appointment on a particular date, she would simply write the date in the square. Thus, if Doris had an appointment on June 6, she would wake up in the morning and see "June 6" written in the June 6 square. She would know that she had an appointment and make an educated guess about the time and place.

I gave Doris a simple instruction. Whenever she made an appointment she was to copy the entire appointment card onto her calendar. She dutifully followed through. Okay, instead of "Podiatrist -- 3:15 p.m." she would write "Anyplace Podiatric Services, 123 Any Street, Anytown, USA 12345, (123) 456-7890, Doris Smith has an appointment to see Dr. Smith at 3:15 p.m. on Wednesday, June 6, 1996." It didn't matter. Doris never missed another appointment. Her problem was solved in less than ten minutes.

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