Contemporary Issues in Mental Healthcare - Essay Example

Contemporary Issues in Mental Healthcare Introduction The care of the mental health patient has evolved throughout the years. The past centuries have seen mentally ill patients relegated to asylums largely for the protection of society and not so much for their betterment. The mental health hospitals that soon followed did not help their situation much. The rehabilitation and treatment administered to them in these hospitals was focused on scientific methods with limited basis on patient effect. The patient had a passive role in his care, and his institutionalization carried a stigma from the members of society which made a possible smooth transition to community life difficult. The District General Hospitals that soon replaced Mental Health Hospitals was an evident shift into a more community-based approach to mental health practice. It was also an attempt to incorporate mental health care into the other fields of medicine. The more recent introduction of the Community Mental Health Team (CMHT) “espouses the community care model in preference to the hospital system, and an individual approach to patients as opposed to a collective one” (Nolan, 1998, p 10). The issues that have been raised in the care of the mental health patient are rooted in the stigma placed on them by society. The shift to a more community-based practice has not diminished this stigma. The treatment of the mental health patient has also shifted to a more evidence-based practice as opposed to a more clinical and scientific based practice. This evidence-based practice has not been fully accepted by practitioners, but it has been embraced by many patients. They claim that evidence-based practice focuses more on them, not on what clinicians claim to work. It is a more personal and reliable mode of treatment that focuses more on outcome and results. Evidence-Based Practice Evidence-based practice (EBP), “are interventions for which there is consistent, scientific evidence showing that they improve consumer outcomes” (New York State Office of Mental Health, 2008). This practice gained much attention when patients and third party payers started to demand evidence of the effectiveness of various pharmacological and psychiatric interventions. This clamour for answers had various practitioners scrambling to seek and provide evidence to their clients in order to prove that their treatment methods were effective. The evidence base for evidence-based practice is found in research. This fact has prompted many researchers to make research more applicable and usable to clinicians and practitioners. And now, many practitioners are basing their practice more on evidence, on proof that preferred interventions really work for mental health patients. One particular proof used in EBP is “strong evidence from at least one systematic review of multiple well-designed randomized controlled trials” (Trinder & Reynolds, 2000, p. 78). This method enables an assessment of various studies undertaken on a particular subject and makes possible an interpolation of trends in outcomes and results. The evidence here is based, not just on one research, but on several researches studying a particular subject matter. The reliability of the evidence is enhanced and the variance is reduced through this systematic review of multiple trials. Another evidence base is “strong evidence from at least one properly designed randomized controlled trial of appropriate size” (Trinder & Reynolds, 2000, p 78). This method has yielded “persuasive evidence that the randomized controlled trial, when properly designed and implemented is superior to other study designs in measuring an intervention's true effect” (Coalition for Evidence-Based Policy, 2003, p 2). Other comparison studies, even those which are well-designed, sometimes yield erroneous and unreliable results which consequently do not make for good evidence in EBP. The third evidence that may be used in EBP is “evidence from well-designed trials without randomization single-group pre-post, cohort, time series, or matched case-control studies” (Trinder & Reynolds, 2000, p 78). This method also helps reduce variance and helps improve the reliability of results. The fourth evidence is evidence from well-designed non-experimental studies from more than one centre or research group. This evidence is mostly conducted through surveys of concerned and affected groups of individuals. It also contains more reliable evidence for EBP. Lastly EBP is also based on “opinions of respected authorities based on clinical experience, descriptive studies or reports of expert committee” (Trinder & Reynolds, 2000, p 78). Through their years of experience, these authorities have established expertise in the mental health practice which serves as reliable and repeatable methods in the care of the mentally ill patient. Their expertise is not based on conjecture; it is based on real reports from their practice and dealings with mental health patients. Collaborative Care: Primary, Secondary, and Tertiary Care Collaborative practices in mental health care involves “providers from different specialties, disciplines or sectors working together to offer complementary services and mutual support, to ensure that individuals receive the most appropriate service from the most appropriate provider in the most suitable location, as quickly as necessary, and with a minimum of obstacles” (Craven & Bland, 2006). This practice implies the blending of various disciplines into a coherent and complimentary whole. This practice fills in gaps in mental health practice. A collaborative practice in mental health care is seen in instances when mental health patients, their families and caregivers, and their health care providers align their efforts to achieve and promote health services. The primary health care giver in this instance is the general practitioner who serves as the entry point for mental health care. In fostering collaboration between primary care and the different areas of healthcare, “a clear referral and linkage system should be in place” (Gagne, 2005) This referral system serves to open the consultation channels with the district and regional levels of health care. In instances where there is no proper coordination and collaboration between the primary, secondary and tertiary levels, “care is often duplicated” (Gagne, 2005). Some examples of collaboration include data-sharing and information exchange between and among the sectors involved. It also involves coordination and planning of services as regards patients requiring coordinated care. Intense collaboration is often seen in the planning and delivery of new services. At its most intense level, collaboration is seen in specific services that require joint funding, development, and managerial planning for utmost efficiency. The collaboration between and among the primary, secondary, and tertiary levels of mental health care includes an acceptance of the need for collaboration by these different sectors. “Mental health agencies and the people involved in the planning and delivery of mental health services have to take a lead in explaining and convincing people in other sectors, especially those outside health, of this need” (Funk, et.al., 2003). Collaboration may also be achieved through policy formulation. This policy formulation should include many sectors. The government may establish its database for policy formulation by coordinating with academic and research institutions. Collaboration also involves delegation of responsibility. Government agencies may achieve this by training and supervising mental health workers in different regions of the country. Professional organizations can help the government provide adequate training by producing educational and training manuals for mental health workers. Collaboration may also be achieved through the coordination of mental health programmes. This may be ensured by keeping the lines of communication open between the various sectors involved in the mental healthcare process. “Communication can be maintained through electronic media, briefs and newsletters” (Funk, et.al., 2003). The information network can help maintain an accurate assessment of the different activities of coordinating sectors. It also helps assess the progress of the different policies being implemented in the mental health care practice. In relation to a range of specialist mental health services, collaborative practices in nursing care provision is seen in instances when various psychiatrists and clinical specialists involved in more specialized mental health care transfer their outpatients to general practitioners located in areas near the patient’s homes. “Other psychiatrists have established consultation-liaison relationships with general practitioners” (Keks, et.al, 1998). In so doing, psychiatrists offer secondary and tertiary consultation; they also see patients with GPs; discuss cases with them and clarify difficulties. This collaboration helps GPs and nurses improve their psychiatric skills. In the case of patients with chronic mental illness, GPs consult with different professionals-not just psychiatrists, but the entire multidisciplinary team. A more recent and innovative collaborative effort involved “setting up a multidisciplinary primary care psychiatry team within a general practice” (Keks, et.al., 1998). Primary Care and Mental Health Service Provision Primary care in mental health practice is seen in the “provision of basic preventive and curative mental health care at the first point of contact of entry into the health care system” (Bower & Gilbody, 2005). Primary care lays down the groundwork for other services in the care of the mentally ill patient. From primary care, higher and more specialized areas of practice branch out. In providing a more collaborative link to the various levels and areas in mental health care service, primary care functions through a multidisciplinary mental health team in the hospital and community care setting; it provides for a single point of access in referral cases; it furnishes a more coordinated and case managed package with the GP; it provides a coordinated weekly liaison with the mental health care team and various specialists involved in the care of the patient; it provides for specialized training packages for the mental health care team; and it offers an improved range of psychological therapies. Primary care borders the different areas and levels of mental health care and practice through properly trained primary care staff, consultation/liaison, collaborative care, and referral. Traditional and Contemporary Issues in Service User Movement The traditional issues raised by the service user movement were seen as early as the 1600s when mental health patients restricted to asylums and bedlams voiced out their opinions about their ‘incarceration’. They rightfully argued that they were not sent to asylums to be treated, but they were sent there to be kept away from the rest of society. The user movement started to gain notice and ground in the 1960s, but it was in the 1980s when the move to close down asylums and mental health institutions really gained wider notice. The issue that was raised by users was in the power that the healthcare givers had over the service users. The power to be defined as mentally ill and to be committed to mental institutions, the power to subject the service users to treatments and interventions even without their consent, the power to be stripped of civil liberties lay in the hands of practitioners and clinicians. The hierarchy was seen with the service user at the bottom of the pyramid, and the health care practitioners, at the peak of the hierarchy. Now that service user involvement is the current trend in mental health practice, the contemporary issues in service user movement largely revolves around the argument that there is too much power given to the service user. According to various practitioners, the pyramid is now reversed. The power is now with the patient or the user, not with the practitioner. This fact has been criticized by various practitioners because “service users now possess power, especially in terms of being able to provide services that statutory services providers now require” (Stickley, 2006). Some practitioners have also taken issue with the fact that many service users see themselves as activists and not as citizens. As a result, “the position of people diagnosed has improved within services but not their position in society as potential citizens” (Bertram, 2002). The traditional issues in service user movement opened doors that can not be closed again. The experiences of service users in the traditional mental health practice has had too much impact on mental health care that service user focus is now the current practice that has to be adopted and embraced in mental health care. The contemporary issues raised in service user movement are now the issues that will impact on the future of mental health practice. The level of participation in service user involvement is very much dependent on political and professional regulations. At present, there are “no specific mandates on how the processes or procedures should be facilitated. This leaves a wide gap for local interpretation and any impact” (Bertram, 2002). The potential developments to enhance or dispel service user involvement now lie with the government. This movement and trend has yet to meet full support from the government, from practitioners, and from the general public. Many of them still believe that “genuine service user involvement leads to fundamental change that is revolutionary, requiring staff to give up some of their power and if clients do gain genuine official power, they are no longer solely clients or service users” (Bertram, 2002). Psychosocial, Economic, and Political Influences on Mental Health Practice Psychosocial influences on mental health practice focus on the effect of the environment and the society in caring for the mental health patient. The environment has been widely acknowledged to affect mental health. Various theorists have discussed about the effect of broken homes and families on children and parents. Studies have revealed that some patients’ conditions can be rooted to a disturbed and traumatized home life. Environmental risks also include various areas of interaction like the peer group, the school and the community. Instances of trauma from experiences within these environments have yielded varying effects, either in developing a stronger and better adjusted individual, or in turning out a mentally ill patient. These psychosocial effects have prompted many practitioners to focus more on a “better understanding of the kinds of environmental influences that have major risk effects…, to identify origins of environmental risk factors…and to determine the changes in the organism that provide the basis for the persistence of environmental effects on psychosocial functioning or psychopathology” (Rutter, 2005). The economic influences of mental health practice have been determined by various economic barriers like limited evidence base, insufficient resources, concentration in urban areas, highly institutionalized services, neglect of particular disorders, services not matching needs, resource inflexibility, and training delays. These barriers “exacerbate problems of inequity, worsen allocative and productive inefficiencies and make it harder for services to respond to the preferences of service users” (Knapp, et.al., 2006). As a result, the current and future mental health practice in Britain and Europe call for a less bureaucratized system in order to improve the allocation of funds and resources for mental health services. There is also a need to improve equity in the allocation of services to help focus attention more on preventive measures. “Efforts need to be made – and quite urgently – to address the related problems of resources being inappropriately distributed and inflexibly deployed” (Knapp, et.al., 2006). The political influences on current and future mental health practice are seen in the policy responses in favour of mental health services. The increase in allocation that economic limitations need in order to be eased was disappointingly not addressed by the government. The different socio-economic barriers need support from the government in order to be relieved and to be minimized; however there have been limited policy responses from the government in this regard. “There is a continuing need to take action to address human rights violations, stigma, discrimination, and social exclusion more broadly” (Knapp, 2007, p 4). The challenge for policy makers is now on fighting discrimination, closing down institutions, developing care committees, promoting broad quality of life, and developing an evidence-based decision-making approach. Role of the Nurse The mental health nurse has an educator role in the care of the mentally ill patient. It includes enlightening the patient on the disease process and on the different interventions that would be undertaken for his care. It entails having to make sure that the patient has understood his illness, the implications of his disease, and the changes that the disease would bring to his life. The nurse as an educator also imparts knowledge and skills to those who are less experienced. As a health promoter, she functions as a role model in the “promotion of mental health and the prevention of mental illness” (Forster & Barrett, 2001, p 37). More than any other role in the mental health care of the mentally ill patient is the nurse’s role as supporter. This role will make the most impact into the patient’s recovery. It will also help decide the responsiveness of the patient to various interventions. This role is most crucial in times of patient crisis where it is the nurse’s input which will be most valued by other practitioners. The nurse’s emotional support is crucial in these instances because the patient’s emotional and physical state cannot be accurately assessed when the patient is uncooperative. With the nurse’s support, the patient’s cooperation may be easily gained. The role of the nurse in empowerment revolves around the “empowerment of people (and their families) who have been disempowered by the experience of illness or the experience of inadequate care, or both” (Rolfe & Fulbrook, 1998, p 61). This calls for the nurse to help advocate for the rights of the helpless patient; to ensure that these rights are being recognized and being given adequate attention by the government and other practitioners. The role of nurse in empowerment is focused on advancing the opportunities for better and more focused mental health care. The nurse should also make sure that she has adequate training to care for the mentally ill patient. Specialized training is needed in mental health care. The nurse would be doing more harm than good if she is ill-equipped to deal with the needs of the mentally ill patient. The clinical nurse specialist requires post-graduate studies in mental health nursing. She should also have adequate clinical experience in “planning, administering, and evaluating patient care in inpatient and outpatient mental health settings, including home care” (Barry, 2002, p 18). She should also have training in psychotherapy. The nurse also has a role to play in patient well-being centres. Nursing led well-being centres have been proven to be more effective in the care of the mentally ill patient. “The Nursing led inpatient Unit (NLU) is one of a range of services that have been considered in order to manage more successfully the transition between hospital and home for patients with extended recovery times” (Griffiths, et.al, 2007). Conclusion The care of the mentally ill patient has transcended the usual traditional forms of treatment. Their care is no longer left to the whims of asylums, bedlams, and mental health institutions. There is a more active interest taken by society and by the government about their plight and condition. Medical interventions are no longer focused on pharmacological treatment, but include a wide array of community-based and support-group based therapies that gives patients a chance to take control of their lives. The present trend of evidence-based practice focuses the care of the mentally ill patient on what actually works, not on what clinicians claim to work. Through evidence-based treatment, the best possible intervention for the patient is sought and is chosen. This means a better quality of care, and consequently, a better quality of life for the mentally ill patient. The condition of the patient demands the collaboration of various practitioners. The fate of the mental health patient is no longer dependent on the will of the GP, the psychiatrist, or even the mental health specialist; instead, it is dependent on the cooperation and coordination of a multidisciplinary team. This bodes well for the mentally ill patient because gaps in his care are filled in. The nurse is a crucial cog in the wheels of mental health care. Her interaction with the patient is often vital in determining the patient’s progress. Her support or lack of it can determine the mood of the patient. Her educative and empowering role in the life of the patient helps shift the balance of power in favour of a more involved, more informed, and a more cooperative patient. And in the end, a collaborative patient will go a long way in determining the success or failure of mental health care. 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