3 Principles of contemporary mental health practice
• To demonstrate an understanding of how the principles of recovery apply to a mental health context
• To analyse the role of values in influencing the decisions made in mental health practice
• To critically reflect upon your own values base in relation to the attitudes and beliefs which underpin your understanding of the role of a mental health nurse
• To critically discuss how a range of understandings of mental health problems can inform creative approaches to mental health practice
• To describe the relevance of health policy for nursing practice
• To identify key policy drivers for the delivery of mental health care
• To explain the role of the NICE guidelines
• To introduce the relevant mental health law and how this impacts on the role and responsibilities of the nurse
Recovery-orientated mental health care
Underpinning principles of recovery
• Recovery is possible for everyone and will mean something different to every individual.
• The continuation or recurrence of symptoms of a mental health problem does not preclude the person from recovering a meaningful and valued life. Therefore, support should focus on the person’s whole life and working towards wider goals.
• Recovery is something a person achieves for him or her self and, while it can be supported by professionals, it should not be dependent on professional intervention and can occur without it.
• It is often the effects of prejudice and discrimination that restrict people’s opportunities and not the people themselves. This can stem from the consequence of receiving a psychiatric diagnosis which usually has negative associations.
• The starting point of recovery is the individual’s experience and facilitating an understanding of what they have been through.
• Recovery does not have an end point but is a continuous journey of growth and adaptation. This may not be a linear journey and it may well involve setbacks.
• Carers, relatives, friends and colleagues are often a part of a person’s recovery and they may face the challenges of recovery themselves.
Barriers to recovery
• Prejudice and discrimination, which prevent people who have experienced mental health problems from participating in everyday life. This obstructs people from engaging in roles, activities and relationships which give life its meaning and is often referred to as social exclusion.
• The lack of belief or reluctance that people may have in their own ability to take control and responsibility.
• The attitudes of people who deliver mental health services who may portray a hopeless picture of the person’s future. This is often based on a belief that mental health problems will disable the person for the rest of their life and that they will be incapable of achieving their goals.
• The attitude within organisations that maintenance of mental health is good enough and therefore service users should be discouraged from taking risks which may not have a predictable outcome. This is sometimes called defensive practice and can be as a result of professionals’ fear of litigation.
• The nature of the mental health problem itself which has a negative influence on people’s mood, motivation to change or perception of themselves.
1. Make a list of the 10 things that you most value in your life.
2. Do they fit into categories or themes?
3. Would this be different from or similar to people who experience mental health problems? If so, how? Evidence suggests that when service users are asked this question, the following are commonly prioritised:
4. How does your list relate to this list?
5. What have been the barriers for you in achieving these things?
6. What do you think might be the barriers for people who experience mental health problems in achieving these things?
Recovery models
Despite the supposition that recovery from mental health problems does not always necessarily require professional intervention, it has been identified that some elements of professional practice can obstruct the person’s attempts to move forward in their journey. Therefore a number of models, frameworks and approaches have been developed in order to encourage recovery-orientated practice in mental health care. The principles stated above consistently underpin these models, however the language used and ways in which they are applied are slightly different. You may or may not see one of these models being implemented in your placement area or hear your mentor talk about the approaches supported by the authors cited here. The evidence to support the impact of implementing some of the models on changing ways of working has emerged (e.g. Stevenson et al 2002, Cook et al 2005, Gordon et al 2005, Berger 2006, Lafferty & Davidson 2006). However, it has been recognised that due to the uniqueness of the recovery experience, traditional outcome measures, such as readmission rates and levels of medication use, are too narrow to appreciate the complexity of the process of recovery.
Social inclusion and recovery: components of a model for mental health practice – Julie Repper and Rachel Perkins
This model emphasises the potential impact mental health services can have on a person’s opportunities for recovery. It draws upon personal accounts of people’s experiences of using mental health services and identifies that the stigma that results from contact with mental health services, the side effects of some psychotropic medication and disempowering practices which are present within organisational culture can act as barriers to recovery. Repper and Perkins (2003) maintain that significant change is required in the attitudes of professionals and the ways they perceive their role if recovery-orientated mental health services are to become sustainable. This model identifies three interrelated components which are proposed to promote the principles of recovery among mental health professionals. These include: developing hope-inspiring relationships; facilitating adaptation which enables personal understanding and opportunities to take back control; and promoting inclusion by helping people to access the roles, relationships and activities that are important to them.
Tidal Model – Phillip Barker and Poppy Buchanan-Barker
The Tidal Model has been developed by mental health nurses in collaboration with service users. It is a philosophical approach to the discovery of mental health. This means it is a way of thinking about how people might reclaim their personal story, as a first step towards recovering their lives. It is maintained that the Tidal Model is an approach to recovery as opposed to a rigid system or a set of prescribed procedures. You can learn more about the Tidal Model at http://www.tidal-model.com.
Values-based mental health nursing practice – K Woodbridge and B Fulford
The influence of personal values on the way we practise as nurses has recently gained recognition in mental health care (see Department of Health (DH) 2004, Woodbridge & Fulford 2005, Cooper 2009). This school of thought identifies that the decisions we make and the way we work are not only influenced by research evidence but also by our values. This recognition prompts us to be aware of what influences our response to a particular person, their behaviour and how this might impact the direction of their care.
Definition
Values-based practice (VBP) is the theory and skills base for effective healthcare decision making where different (and hence potentially conflicting) values are in play (Fulford 2004).
The term ‘values’ is difficult to define. To help you start to understand this concept, use the thought bubble in Figure 3.1 to identify any words, phrases or terms you link with the term ‘values’. We have started you off with some suggestions.Now try and put this into a definition.
Values are ……………………………………………………………………………………………………………… …………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………. …………………………………………………………………Cooper (2009, p. 22) offers a definition of values: The worth, desirability, importance, or emotional investment (either for or against) we attach to something.
Complexity of values
You may have found that your definition of values is different to Cooper’s. This does not mean that it is wrong but it does tell us that values are complex. Woodbridge and Fulford (2003) suggest this is for the following reasons:
Values applied to mental health practice
It is important to explore the values that you bring to your work as a student nurse in order to recognise how they are influencing your practice and identify why you may feel in conflict at times with people you are working with. This can include service users, their carers and also your mentor or other professionals. A good way to start this process is by completing the activity in the reflection point box below. This activity will aim to help you clearly define the values you bring to your work. It can become part of your portfolio and you may wish to reflect on it throughout your programme to identify when your values are challenged or reinforced in your practice and how you respond to this.
The values which have been advocated in relation to mental health care were formally brought together in a document called The Ten Essential Shared Capabilities (DH 2004). This document was developed in collaboration with service users, carers and mental health practitioners in both the voluntary and statutory sector. It represents a set of overarching principles for the whole of mental health care which aim to promote a recovery-orientated service. These principles were further reinforced in the Chief Nursing Officer’s review of mental health nursing which was named From Values to Action (DH 2006). This policy sets the direction for the future of mental health nursing practice and emphasises the importance of adopting person-centred values in order to facilitate and promote recovery. A description of these documents and their application is given on Chapter 4.
Principles of values-based practice
Woodbridge and Fulford (2003) have developed the framework of VBP which is defined as:
• Raise awareness of values. Often, we are not aware of our values until they come into conflict or we feel our values are being ignored. As a professional, our values are usually advocated as a result of the power that is given to us in our role. However, service users often feel their values are dismissed or viewed as less valid as a consequence of their mental health problem. Therefore, it is important to consciously explore values in order to consider how they influence practice. This involves exploring personal values and creating forums for the discussion of values within teams.
• Adopt strategies for reasoning about values which enable the exploration of values which are influencing a situation and justify the outcome of a decision.
• Gain knowledge about the values which are likely to be influencing a situation. For example, gathering the past experiences of people involved, considering how the media may have portrayed a similar situation or exploring research which has been published on the issues arising.
• Adopt communication skills which enable people to give their views and feel listened to. This may involve some negotiation skills or resolution skills where there is conflicting values. This is important in order to ensure that each person’s values are given equal attention.
• Start the decision-making process from the perspective of the service user to ensure that practice and policy are applied to the individual.
• Attend to the values of all others involved including the service user’s family, friends, informal carers, support workers and all mental health practitioners. This is known as multidisciplinary practice. This will enable potential sources of misunderstanding or conflict to be converted into opportunities for discussion and creative working.
• Consider the influence of both the values and the facts when making decisions. This challenges the assumption that decisions made based on science, such as diagnosis, are not influenced by values of the person conducting the assessment. Values are, in fact, relevant to these decisions and can account for some of the inconsistencies in how different diagnoses are applied to the same symptoms or behaviours.
Barriers to implementing VBP and helpful strategies to facilitate VBP are listed in Table 3.1.
Table 3.1 Barriers and strategies for facilitating VBP
| Barriers to implementing VBP | Helpful strategies to facilitate VBP |
|---|---|
| Forums for the discussion of values are not routinely in place in practice | Clinical supervision, care reviews or multidisciplinary team meetings can be reformatted to enable this discussion |
| Decisions are sometimes made in an emergency situation which limits the time given to collaboration or effort to involve all parties. Also, when the service user is in crisis, they may be seen as unable to contribute to decisions made about their care | Crisis planning can allow for people to express their values in anticipation of an emergency situation. Therefore, you can be assured that action taken is in line with a pre-agreed plan. This is where a wellness recovery action plan (WRAP) or alternative relapse prevention plan can become very useful! |
| Some people you are working with may not see the value of considering other people’s views or be unwilling to listen to alternatives which limits opportunities for negotiation | This will require you to step into their shoes and question why they may find this way of working challenging. The individual may have personal support or professional development needs |
| The wider organisation of mental health services places the responsibility and accountability of a decision with the professional. This may mean that some professionals are reluctant to consider others’ views due to their accountability | A multidisciplinary approach to the decision-making process helps to share this responsibility as it enables concerns to be discussed, explored and strategies to be put in place which the whole team agrees upon. It also allows for the service user to take some responsibility for their actions and feel an increased sense of control |
Models of mental health
Biological
Biological explanations of mental health problems have consistently dominated approaches adopted within mental health services in the UK since psychiatry was first established. This school of thought is sometimes known as the medical model or disease model and views mental health problems as a disease of the brain. It assumes that mental health problems can be assessed and treated in the same way as physical health problems. This involves the identification of a set of symptoms which are grouped together to inform a diagnosis and a plan of treatment. This process is led by a psychiatrist and can require admission to hospital. It often incorporates the use of medication which affects the central nervous system and the ways in which specific neurotransmitters work within the brain. This area of mental health nursing practice will be explored in more detail in Chapter 9.
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