1 Mental health services and nursing
development and practice
• To gain an insight into the historical development of mental health services
• To develop an understanding of the role of the mental health nurse in relation to its origins
• To identify activities that a mental health nurse may be involved in and some of the skills used in these activities
• To gain an understanding of the structure of the multidisciplinary team
History of mental health services
Institutionalisation
Following the industrial revolution and the relocation of the population in towns and cities, there was a growth in poverty and ill health (Nolan 1993). This represented an increasing problem for those experiencing mental health problems who were unable to afford the private asylums in operation at the time. Within England, concern over the conditions and treatment within private asylums facilitated a drive for lunacy reform (Porter 2002). Subsequent legislation between 1809 and 1845 allowed for the allocation of funds to build public asylums. This reflects a period of the growth of institutions across Europe and Western societies (Wright 1997). It represented a marked optimism for the benefits of the asylum, underpinned by the growing psychiatric profession and the commitment to institutional care as the vehicle to provide a cure for insanity (Rogers & Pilgrim 2001).
Throughout the history of mental health care, the beliefs and understanding of professionals and the public on the causation of mental health problems have influenced the manner in which people have been treated and the drive for “cures”. In the early days of asylums, treatments were defined by a need for physical restraint on patients. During this period, in the eighteenth and early nineteenth centuries, individuals caring for the inmates of the asylum were termed ‘keepers’. The implications of such a title suggest that those individuals had a role in restricting and controlling the movements of those admitted to the asylum (Nolan 1993).
The optimism for the benefits of a new public asylum system during the mid nineteenth century supported opportunity for the development of pioneering approaches to the management of mental illness developed within the UK and across Europe (Digby 1985, Porter 2002). This included attempts to abandon and reduce the use of physical restraint, examples of which can be seen in the work of Pinel in France, Chiaguri in Italy and Hill and Connelly in England (Porter 2002). 1796 also witnessed the establishment of the York retreat, a Quaker institution founded on the principles of Christian humanism which recognised the humanity of those experiencing mental health problems and promoted moral therapy which attempted to enable individuals to remain included within society (Digby 1985, Nolan 1993).
Within the new public system, after the 1845 Lunacy Act, the role of keeper emerged into one of attendant. The attendant’s role was one that involved the most daily contact with people admitted to asylums and they were responsible for their day-to-day care and engagement in work within the asylum. Attendants worked under the direction of the medical superintendent (Nolan 1993). Nolan (1993) notes some early examples of individual superintendents and institutions providing training for attendants but it was not until the very end of the nineteenth century that formalised training was introduced. During this time problems were experienced with the recruitment and conduct of attendants, though pay and conditions were very poor. Pessimism in the asylum system began to spread in the late nineteenth century as asylums became overcrowded and did not deliver the cure for insanity initially hoped for (Porter 2002).
Websites
http://www.highroydshospital.co.uk
State of Mind – series of programmes on BBC Radio 4 examining past and contemporary mental health services:
http://www.bbc.co.uk/radio4/science/stateofmind_20090107.shtml (accessed June 2011)
Podcasts of the Institute of Psychiatry debates on a wide range of topics:
http://www.iop.kcl.ac.uk/podcast/?id=66&type=album
Once you have accessed one of these resources:
1. Consider one piece of information that has surprised you.
2. What is it about this that was surprising?
3. Identify one issue that you have learnt.
You might want to make a note of some of these issues, in particular the implications for your practice. This can be linked with the activity box on page 21 and included in your portfolio as a record of some of your initial thoughts and reactions at the start of your practice learning journey.
At the turn of the twentieth century, attendants had become known as nurses and the term “mental nurse” was officially instigated on the nursing register in 1923. This reflected the increasing role of psychiatry and the medical approach to understanding mental health problems and therefore nursing was the most appropriate way to care for and treat the mentally ill. During the early part of the century, asylums became known as hospitals. The introduction of the Mental Treatment Act in 1930 represented some attempt to challenge the stigma associated with mental illness that was perpetuated by compulsory treatment through the introduction of voluntary admission. This was underpinned by a desire to treat mental illness within a public health framework (Freeman 1998).
During the twentieth century, further developments in the treatment of mental illness occurred. This included the evolution of a psychodynamic theory pioneered by Freud. However, alongside such developments, treatments were advocated such as psychosurgery which involved removal of parts of the brain thought to be implicated in the symptoms of mental illness. Insulin therapy was also used which involved administering large doses of insulin to cause a coma. These types of treatment, among others, have been heavily criticised as highly dangerous and abusing a population perceived as vulnerable within society. Ion and Beer (2003) warn of the need for us to avoid naively criticising the past without questioning how our own practices may be perceived through the lens of history.
Antipsychotic medication was introduced in the 1950s at a time when the physical state of Victorian asylums was deteriorating and changes in mental health legislation allowed for a more open-door policy within psychiatric hospitals. Public faith in the psychiatric hospital system was diminished through a series of public inquiries and published stories concerning ill treatment, abuse and neglect in hospitals (e.g. Robb 1967). This also occurred within the context of the development of the “antipsychiatry” movement. Key thinkers, such as RD Laing and T Szasz, some of whom were trained psychiatrists, challenged some of the assumptions that mental health problems were a distinct mental illness. A number of antipsychiatrists proposed that mental illness does not exist at all and that people’s experiences were the product of an “insane” society. These, combined with other factors, culminated in an announcement by Enoch Powell, in the famous water tower speech, that psychiatric hospitals were consigned to the past and the future of mental healthcare delivery lay in the community. It was also during this time that a humanistic understanding of mental health problems was advocated by Carl Rogers (1967) and the interpersonal nature of nursing was emphasised by the work of Hildegard Peplau (1952).
Over the next 30 years, psychiatric hospitals gradually closed. Historians suggest that care in the community for people with mental health problems has existed for many years including during the asylum era (Wright 1997). However, it is the closure of mental hospitals which contributed to the growth of community nursing and the significant expansion in community services that reflects the model of care delivery we see today. In-patient beds were concentrated in smaller units and district general hospitals rather than distinct large psychiatric hospitals. Many of the service users today who have had long-term needs may have experience of being admitted to an asylum, and this is an area that you might want to explore with them once you have established the therapeutic relationship; particularly considering narratives from people with experience of using services are fairly invisible within the history of mental health care.
The majority of mental health services are delivered in the community setting and as a student mental health nurse you will have the opportunity to work in these areas. The evolution of the community teams as the main structures of support for service users provided an important opportunity to challenge the segregation of people with mental health problems and enable people to continue relationships and roles in wider society. This continues to be one of the main areas in which mental health nurses provide support for service users. However, community care has not been without its critics. The closure of psychiatric hospitals and the establishment of community services were chronically underfunded. There was concern that people discharged from psychiatric hospitals were vulnerable to homelessness or ending up as part of the prison population due to a lack of adequate support available in the community setting. During the mid 1990s there were a small number of high-profile incidents of violence related to service users. This led to severe criticism from the press and some charities concerning the appropriateness of supporting people with experience of mental health problems in the community. These incidents and the media and public response to them have been suggested to have had a significant influence on governmental mental health policy at the time, in particular the development of the Care Programme Approach (Hannigan & Cutcliffe 2002). This is explored in more detail in Chapter 8.
The introduction of Modernising Mental Health Services (Department of Health (DH) 1998) and the National Service Framework for Mental Health (DH 1999) outlined the hopes of a new government in tackling these concerns regarding the provision of mental health services and for ensuring the care provided to service users was effective and of good quality. These documents had a significant impact on the structure and development of services and were designed to be underpinned by significant financial investment, though there remains concern that the funding imbalances have not been redressed and mental health care remains a “Cinderella service”.
Over the past 200 years the role of supporting people with mental health problems has evolved from one of keeper of the insane to one of a mental health nurse working alongside people experiencing mental distress. This overview has provided a very brief insight into some of the factors that have informed and shaped this development. An appreciation of the historical roots of the profession is important in order to understand the issues of power and control experienced within mental health services today. In particular, this concerns the contested nature of treatments in mental health alongside the stigma associated with being “consigned to an institution”. Many of these issues bear relevance to today and are picked up in different ways throughout the book. Chapter 3 deals with the philosophies and theories governing contemporary mental health care, some of which you will see have their origins in theories of Rogers and Peplau highlighted here. As you work through this chapter it would be beneficial to think about the similarities and differences between these and what you have read here. Chapter 9 also considers psychiatric medication and enabling people to make choices about their treatment, while Chapter 7 explores the therapeutic relationship and some of the barriers to this. Perhaps more importantly, it is through the professionals and service users that you work with in practice where the relevance of this history may become most apparent, particularly for those who have witnessed and been part of the changes discussed here.