Hope, Mental Health, Mental Health Nursing, Mental Health Treatment, Recovery

Mental health treatment perspectives. From the medical model to recovery approaches and individual empowerment.

This topic interests me greatly from all of my perspectives – as service user, carer and nurse. One of our final modules at university was around mental health recovery. I thought I’d share my submission as you may find it thought provoking and it would be interesting to hear your views?  It’s based on research I found but due to the imposed word limit and the brief I couldn’t include everything I wanted to. Some areas I would’ve liked to expand on and be more critical.

Excuse the fact some sentences are compact – I was obviously on a word count! I was 2% off a 1st for this piece – damn!!! Excuse the appendix references bits towards the end and my development stuff as you may find that boring!

Anyway here it is:

Over the last few decades mental health care has transformed. Currently the focus of policy and practice is on service user (SU) collaboration with an emphasis on a recovery approach. This is in stark contrast to the historically dominating medical model of healthcare, in which patients were passive recipients. This essay will outline the history of these developments, their differences, issues, strengths and weaknesses, particularly within an inpatient environment and the effect on the mental health nurse. The service user voice is paramount to recovery and this will be explored in an attempt to guide nurses to improve their practice. I will then focus on my own learning, development and practice throughout my journey of becoming a nurse against the four NMC domains (2010): professional values; communication and interpersonal skills; nursing practice and decision making and leadership, management and team working. Through this exploration, I will conclude with reflections and recommendations for acute inpatient services, mental health services in general and for my personal development. An action plan has been devised separately to help guide me through the beginning of my nursing career and will be part of Component B.

Views towards mental health treatment has changed dramatically from the 20th century to the present day. In the 1950’s around 150,000 people were held in asylums (JLO Productions, 2014). Some stayed for years, others for life (Royal Society of Chemistry, 2016). People were offered little but containment, often abused and received experimental ineffectual treatment. Some included lobotomies, electroconvulsive therapy and insulin induced comas (JLO Productions, 2014). During this time the first major tranquiliser chlorpromazine was introduced, appearing to resolve schizophrenia symptoms almost overnight (Royal Society of Chemistry, 2016). Recovery seemed possible, leading to beliefs that these helped treat an underlying biological cause of psychosis. The dopamine hypothesis of psychosis was born (Moncrieff, 2002).

Following a speech in 1961 by Health Minister, Enock Powell care slowly changed. 1962 saw the introduction of the Hospital Plan resulting in bed closures. Patients moved into the community or general hospitals wards, though not on a large scale until late 1980s (Kings Fund, 2014). In 1983 the Mental Health Act was updated to protect SU’s civil rights. At this time multi-disciplinary community mental health teams or GPs could take responsibility for looking after SU’s. In 1990, through the introduction of the Care Programme Approach (CPA) social services or NHS staff began individual care coordination (Turner et al, 2015). The Department of Health (1999) pledged a larger range of services aiming to prevent crisis, discrimination and improve access to services. One such service was the Improving Access to Psychological Therapies programme (IAPT) in 2006, where patients could self-refer for anxiety/depression (IAPT: Improving Access to Psychological Therapies). It is evident services have developed in the interests of patients however there is still ongoing debates surrounding the medical model that is still part of treatment today.

Traditional medical/biological views of mental illness often have detrimental disempowering effects on SU’s. With diagnosis and medication viewed largely as ‘cure’ it disregards individuality and other factors (Lehmann, 2013). These are fundamentally social problems (Lehman, 2013) and McNeil et al (2012) argue formulating diagnosis from symptom clusters disregards aetiological factors such as trauma, childhood experiences, circumstances and personality. Narrow views lead to ineffective treatment and can worsen illness. Many SU’s as a result can feel stigmatised and marginalised leading to unacceptance of being a SU with a mental health ‘diagnosis’. This sometimes results in loss of identity, independence, preventing care participation, sometimes risking disengagement (Barker and Buchanan-Barker, 2011).

Conversely, the medical model has proved helpful to other SU’s wanting an explanation for symptoms, favouring diagnosis. This helps them and carers understand the illness, without which creates further distress, impeding recovery (South London and Maudsley NHS Foundation Trust and South West London and St George’s Mental Health NHS Trust (2010). Furthermore for psychosis, medication can be efficacious achieving symptom reduction in up to 75% of patients (Mental Health Care, 2015) enabling community living rather than hospital admissions. Compared to other interventions it is cheaper and quicker to implement (Mcleod, S (2014).

The recovery approach originates from the survivor movement and is distinctly different from the medical focus of cure (Tew et al, 2012). Early definitions stemmed from Pat Deegan, herself a SU and further developed by William Anthony (Stickley and Wright, 2011). Anthony (1993) is frequently cited in recovery literature stating

recovery is described as a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by illness. Recovery involves the development of new meaning and purpose”.

Work has since continued to develop recovery concepts (Stickley and Wright, 2011). Policy and practice development are aiming to firmly embed recovery ideas (Barker and Buchanan-Barker, 2011). However its definition needs to be shared with those with lived experiences to deliver it, not solely defined by preoccupations of clinicians (Slade et al, 2012; Kidd et al, 2014). Kidd et al (2014) argues to fail to will impede changes needed, creating an element of discrimination. However SU’s have been involved in over 40 general health policies and legislation since 1990 (National Service User Network, 2015). They are viewed as ‘experts by experience’, involved in commissioning (Tew et al, 2012), education (Department of Health, 2008), peer support and recruitment of professionals.

To draw together views of recovery it is helpful to provide a definition of both clinical and personal recovery.

Personal recovery looks beyond the narrow medical model towards helping someone individually and holistically, in their social context. This is defined and led by SU’s, supported by carers, community and professionals (Whitley and Drake, 2010). It is an ongoing management process (Kidd et al, 2014) and symptoms of illness may continue rather than full clinical recovery (Mental Health Care, 2012). SU’s have control over their lives making their own decisions rather than professionals (Mental Health Care, 2012).

In contrast, clinical recovery relates to the medical model, ‘emphasising outcomes e.g. cure (Barker and Buchanan-Barker, 2011), including medication and therapy to minimalise/manage symptoms’ (Whitley and Drake, 2010). When symptoms disappear a person is considered recovered’ (Mental Health Care, 2012).

However, Whitley and Drake (2010) proposes five areas for recovery: clinical; existential; functional; physical and social. SU’s lead the order/inclusion of these with help from different sources. Slade et al (2012) refers to the recovery process as; connectedness, hope/optimism for future, identity, life meaning and empowerment. These appear an incorporation of both personal and clinical ideas, however SU’s and providers presently grapple with a precise definition (Rinaldi and Watkeys, 2014).

Optimism and encouraging relationships are key to recovery (Tew et al, 2012). This can be difficult for nurses who play two roles; one is “positive, health-focussed and collaborative” and two, closer to traditional psychiatric nurses; “paternalistic, illness focussed and frequently coercive” (Barker and Buchanan-Barker, 2011). When SU’s risk harm to themselves/others, lacking capacity to make care decisions, we have a duty to protect them (NMC, 2015). In these cases professionals may need to refer to the Mental Capacity Act (2005) and exercise powers under the Mental Health Act (1983).

Removing autonomy is an ethical issue; one can argue harm can be caused through forced authoritarian approaches by intensifying feelings of powerlessness, injustice, maltreatment or “social defeat” (Tew et al, 2012). Various ways SU’s can mitigate power includes advance statements outlining their wishes (Rethink Mental Illness) and appointing a power of attorney for making their decisions (Rethink Mental Illness). Professionals can share power, providing treatment information/choices and access to independent advocacy (Gamble and Brennan, 2006).

There are many challenges implementing the recovery approach in inpatient settings. SU’s with limited or no awareness they are unwell (Polacek et al, 2015) can dismiss help (Tait et al, 2003) arguably due to stigma or lacking acceptance (Tait et al, 2003; Polacek et al, 2015).  According to Tait et al (2003) ‘nurses must be respectful of this, helping to provide them with a validated view of their life story’. Given the importance of nurses establishing a therapeutic relationships to advance recovery, being detained, restrained, imposing restriction of movements and focussing on risk can impede positive relationships (Stickley and Wright, 2011).

Furthermore, SU’s are often administered medication by nurses without consent (Care Quality Commission, 2010) with continual observation and management of activities (Gunasekara et al, 2014).
With power imbalances and rules restricting autonomy, violence/aggression risk increases which is detrimental to all.

Nurses can be invaluable in recognising environmental and individual factors impacting on SU’s wellbeing, developing shared care plans with as much flexibility as is feasible (Hamrin et al, 2009).

Increasing autonomy is important (Gunasekara, 2014). However nurse’s struggle working in recovery focussed ways due to lack of direction when factoring ‘risk, administration, other responsibilities and lacking confidence in ‘psychiatrically dominated’ environments, compromising time spent with SU’s’ (Gunasekara, 2014).

Shortages of beds puts pressure on abilities to work in a therapeutic recovery focussed way, due to the revolving door phenomena, with SU’s becoming poorly again quickly (Botha et al in my folder). Readmission with 30 days is common due to various factors; poor discharge planning, exclusion from care planning creating feelings of stigmatisation/discrimination and hopelessness (Rayner, 2015). Hope is essential for recovery; without it we cannot help SU’s towards recovery (Shepherd et al, 2008).

Many good things are in place to support recovery on the ward. Initiatives such as ‘Starwards’ suggests good practice to improve SU experience such as environmental improvements, activities, ways to work and ‘Safewards’ provides a framework of ‘staff modifiers’ to reduce conflict, keeping the ward as safe as possible (Starwards; Safewards, 2016).

SU’s have indicated how nurses can facilitate recovery, which I find common courtesy and, in the main, have witnessed on wards; taking time to know them as a person establishing the fundamentals of a therapeutic relationship; paying interest through listening/curiosity; team work; updating them and retaining ‘passion for nursing’. Importantly, learning about ‘goals, strengths, aspirations and how they can help toward recovery (Gunasekara, 2014).

Reflective practice is essential, enabling nurses to critically learn from practice, developing as an effective practitioner (Bulman and Shutz, 2013). Crucially it helps develop self-awareness, identifying required improvements, discovering strengths, benefiting SU’s (Burnard, 1992). Furthermore, clinical/managerial supervision from experienced practitioners helps support and examine practice (Gamble and Brennan, 2006). I have found utilizing these invaluable for my development.

My professional values are firmly embedded into my everyday practice as evidenced within SU and organisational feedback (Appendix 12; 13). I have challenged care demonstrating professionalism and trust (Appendix 10), preserving safety, practising effectively and prioritising people as per the NMC code (2015). The code has guided me throughout training and I strictly adhere to the standards, working within ethical and legal frameworks. The Interprofessional module in year 2 highlighted the importance of learning about and working with other professionals to achieve best outcomes, as full information is needed to avoid wrong decisions (Atwar and Caldwell, 2005) disadvantaging SU’s (Martin, 2011). I have always sought time with individual staff for this purpose.

Through undertaking and reflecting on the tribunal report, risk assessment and care plan (appendix 1; 2; 3) I realised difficulties in using recovery language, the tensions faced in inpatient environments and how these are more likely to affect nurses than other roles when providing person-centred care, balanced with risk (Gunasekara, 2014). I am more mindful of using recovery language to convey hope and goals as outlined by the Mental Health Coordinating Council (Ref Z leaflet). It states personal outcomes may be negatively influenced by words and ‘stories we tell’. I have used words such as ‘delusional’ within documentation because that appeared the medical norm but now feel better equipped to change my practice.

My nursing practice and decision making has progressed. I have established therapeutic relationships according to Rogerian principles (Rogers, 1961), Peplau (Peplau, 1952 cited in O’Carroll and Park, 2007, p41) and used various assessment tools, undertaken CPA’s, keeping good standards of record keeping (Appendix 12).

My confidence sometimes undermines my sense of competence despite feedback suggesting otherwise, so I have needed reassurance. Students look to supervisors for safety due to inexperience and good clinical judgement develops from novice through to expert, taking number of years. As a new graduate (Advanced beginner), I will have full professional and legal responsibility, helping my growth (Benner, 2004). I look forward to furthering skills through experience and continuing professional development.

My leadership, management and team working skills are improving however through completion of the workbook, reflection (Appendix 8) and Microteach (Appendix 5) the resounding theme is the need to work on self-confidence particularly when speaking within groups, along with managing anxiety, time and stress. Organisation helps counteract stress and this is where my Microteach lesson plan (Appendix 4) served me well. As evidenced in OAR feedback (Appendices 12) and Appendix 5 I do not display my feelings and have increasingly led effective care. In NP6, I was able to practice these by having a small caseload with more autonomy. Close team working and supervision with my mentor ensured I was practicing safely (NMC, 2015) and supported decision making in partnership with SU’s, various internal and external teams. I will continue to use regular reflection and supervision addressing issues identified here in my action plan (Component B) to support practice.

Completion of my WRAP helpfully identified ways I can manage stress (Appendix 9).

Through practice, undertaking the placement profile and analysis of a complex drug regime (Appendix 6) I realised the many roles the whole team play in medication management. In Year 1, I advocated for a SU regarding medication (Appendix 11) realising though a person takes their medication it does not necessarily imply consent and use of advance directives/collaborative medication care plans help overcome the power imbalance (Harris et al, 2009, p162). This along with knowledge from drug data sheets (Appendix 7) and medication exam has helped prepare me for the medicines management role required by the NMC (2007) who state it is not ‘merely a mechanistic task determined by the prescriber’.

Communication skills have been my strength with SU’s/teams. I have learnt to adapt my approach, but not without challenges. Both SU reflections show my vulnerabilities but also how compassion, empathy and listening skills have developed. Appendix 10 triggered personal emotions, teaching me issues of transference, countertransference, boundaries and my ability to remain objective. Appendix 11 also challenged emotions, however I learnt this was not personal but instead an expression of unmet need. Gamble and Brennan (2006) discuss the importance of exploring reasons for anger. In doing so I deescalated the situation. After both encounters, trust and strengthened relationships occurred.

In conclusion, SU’s have increasingly powerful influences over services and many professionals, including psychiatrists, aspire to achieve these through the recovery approach (South London and Maudsley NHS Foundation Trust and South West London and St George’s Mental Health NHS Trust, 2010), however there is a need to share the same vision collectively. Parts of the medical model still remains and has its place. With the use of the Mental Health Act (1983), there will always be tension that is impossible to counteract completely. Evidently there are steps nurses can take, as outlined within this assignment; a human approach, listening, respecting and advocating for our SU’s as well as carer inclusion. The use of person-centred shared care plans using recovery language, identifying strengths, aspirations, goals and not just risk, illness and problems will help achieve this (Gunasekara, 2014; Rinaldi and Watkeys, 2014).

Change will take time and professionals will need to be committed and united to embed a recovery culture. SU and carer feedback can benchmark this.

I will take forward my learning, evaluating how much the recovery approach has been adopted in my inpatient environment, sharing ideas and learning from my colleagues as well as undertaking regular reflection and supervision to enhance my self-awareness, skills and recovery orientated practice. I know I need not know all answers but where to find them and evidence based practice will be referred to in everyday practice, ultimately benefitting SU’s and reducing risk of harm; an essential element of practice that can be overlooked (Atwar and Caldwell, 2005) but to which we have a duty (NMC, 2015; NMC 2014).

I will work hard to improve my confidence through stretching myself, reminding myself of my achievements and the incongruent view between my feedback and feelings. Reviewing the Dreyfus Model of Skill Acquisition (Benner, 2004) will be helpful in this respect. I remain passionate about mental health and helping SU’s along their journey to achieve a life they are happy with. To do this I need to manage my own mental health (Cleary et al, 2012) to prevent burn out. This will be addressed in my action plan (Component B).

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