Contemporary mental health

Contemporary mental health service

Task:

Contemporary mental health service delivery is informed by the underpinning values and philosophies of the culture and time.
Discuss the values and philosophies that you identify as being reflected in contemporary practice, with reference to relevant resources (such as reports, strategies, frameworks).

Please reference using APA6 style wherever possible.

please see attached this week’s module readings to gain an understanding of the task

1. Introduction
This module provides you with an overview of how contemporary values and philosophies have informed mental health service delivery. Mental health nursing practice is part of contemporary mental health service provision, which in turn is informed by the contemporary values and philosophies of mental health and mental illness.
The term ‘contemporary’ refers to belonging to, or occurring in, the present. This can be understood as being ‘of the moment’. Contemporary perspectives in mental health care build on and incorporate prior ways of thinking and doing things (McDermot& Graham 2012). Any review of contemporary mental health service delivery must therefore consider its history (McDermot& Graham 2012).
A focus on mental health history also provides a clear (and sometimes alarming) understanding that mental health treatment or ‘service delivery’ is influenced by the underpinning values and philosophies of the time. The values and philosophies of a culture regarding mental health and mental illness inform how mental health is treated. This becomes all the clearer by looking back through history.

2. Historical Perspectives
A brief look through history highlights that values and philosophies of a culture directly influence how someone is treated. It is worth noting that:
• Dominant social attitudes, values and philosophic viewpoints have influenced the understanding of, and approach to, ‘madness’ throughout recorded history, and probably before
• Ideas that may be considered contemporary at one time often have their roots in earlier centuries
• For some, the modern medical concept of ‘madness’ as an illness may be open to the same scrutiny as interpretations of the past, such as beliefs about witchcraft or mysticism (Kneisl 2013)
In ancient Greece (around 4th century BCE), mental disorder was seen as an outcome of brain disease and was therefore treated by physicians (McDermot& Graham 2012; Evans 2009). Although an understanding of health has long since moved from the ‘body humors’, Hippocrates viewed mental disorder through a medical lens (Kneisl 2013). The idea that mental disorder was related to demonology was dismissed, and instead was viewed as a medical condition caused by an imbalance of ‘body humors’: blood, black bile, yellow bile and phlegm (Kneisl 2013). This view – this underpinning philosophy – informed the way mental disorder was treated at the time. Mental disorder was treated medically – through purging, bloodletting and ritual purification (Kneisl 2013). Sharing similarities with contemporary practice, mental disorder in this time was also treated through such things as talking therapy (Kneisl 2013).
These beliefs and the related approaches to treatment did not hold through Western Europe during the Middle Ages however. During this time there was a return to the understanding that mental disorder was the bizarre thoughts and behaviors of people were the result of demonic possession, magic, witchcraft or influence from the moon – hence the term lunacy (Kneisl 2013; McDermot& Graham 2012). People were alienated from their community and in most instances had no rights and no access to humane forms of treatment. People were chained in prisons, sent to ‘madhouses’ and asylums, or in some instances burned at the stake or sent away (for example, out to sea in boatloads to ‘search for reason’) (Kneisl 2013; McDermot& Graham 2012).
Following this era of ‘alienation’ came an era of ‘confinement’ (Kneisl 2013). It was during this time that large institutions were built to remove and hold people deemed to be mentally ill. Confinement was brought about by a belief that people experiencing what we now understand as mental illness were deviant and therefore required harsh treatment (McDermot& Graham 2012). As a result, it was believed that madness could be overcome only by discipline and brutality. People were chained to walls and rather than being seen as people who had lost reason or were sick, were seen as ‘beasts seized by frenzy’ (Kneisl 2013, p. 12). People experiencing mental illness were confined with others in need of care or detention, such as people with illness such as leprosy or syphilis; criminals; the destitute; unemployed; and the otherwise chronically ill (Evans 2009). It may have been this time that facilitated the lingering stigma in society that mental illness is similar to wickedness, deviance or indigence. This persisting stigma not only negatively impacts how a person experiencing mental illness sees themselves, but influences the way mental health care is delivered (Corrigan 2004, in Evans 2009).
Across the centuries and in different cultures and societies, there were have been variations in values and therefore treatment.
Read: The founding of the first psychiatric hospital in the World in Valencia (Lopez-Ibor 2008)
Kneisl (2013) argues that the treatment of those experiencing mental illness in the 18th and 19th centuries was characterised by contradictions:
• Although ‘the insane’ were unchained, the medical treatment they received consisted of what amounted to torture with special paraphernalia.
• The nature of mental disorders could not be explained by any of the prevailing concepts – black humors could not be seen, demons or animal spirits could not be observed, and knowledge of anatomy could not be applied to the workings of the mind. Because mental disorders could not be satisfactorily explained, the deeply held fear of ‘the insane’ could not be dispelled.
• Mental disorders were believed to be incurable and ‘mad’ persons were thought to be dangerous. (Kneisl 2013, p. 12).
Explore: Bethlem: Museum of the mind
Australia
Australia’s mental health system was influenced by the Sisters of Charity and the work of Florence Nightingale (Evans 2009). Sydney Infirmary was built in 1811 and staffed by convict women. In 1839 five Sisters of Charity arrived in the colony to minister the poor and by 1857 St Vincent’s Hospital was built at staffed by the sisters (Evans 2009).
The first ‘lunatic asylum’ was opened in Castle Hill, NSW in 1811. All ‘lunatics’ in the new colony were sent there, and by 1825 this institution was overcrowded. Gladesville Hospital opened in 1837 to accommodate the growing number of people ‘requiring’ placement in an asylum – and although humane care was the aim, care was more custodial in nature.
Read: Appreciating the importance of history: a brief historical overview of mental health, mental health nursing and education in Australia (Happell 2007)

3. Contemporary Perspectives.1
The power of language
The terms ‘mad’ and ‘insane’ are not commonly accepted terms for mental illness today, but these terms have in the past been used to describe a range of symptoms and behaviours (Evans 2009). Language both shapes and reflects the way people see the world, and is used to define or describe personal experiences or situations (Hungerford 2012). Language has the power to persuade, control and even manipulate the way people think, act and react (Fairclough 1989, in Hungerford 2012). For these reasons, the language used by mental health professionals must be carefully considered.
Question: How does the language you use in practice reflect your values and philosophies?
Philosophical questions in mental health
The philosophical concepts below represent a small sample of contemporary thinking that has spurred much debate. As a result of such questions being asked, various conflicting perspectives have emerged in mental health. Such philosophical questions inform contemporary research and therefore influence mental health service delivery today.
• The question of human consciousness, and particularly the relationship between mind and brain (Strickely& Wright 2014)
• The question of mental illness as a disease. How to make sense of it, its causes and effects (Strickely& Wright 2014)
• The question of understanding the subjective experience of mental distress. How is it possible to understand and empathise with a ‘mad’ experience? (Strickely& Wright 2014)
• The ethical issues of mental health, particularly the question of coercion and care (Strickely& Wright 2014)
• How to respond to mental illness? (Meadows et al. 2012)
• Who is it that should do something about, or for, or with, people with mental illness? (Meadows et al, 2012)

4. Contemporary Perspectives.2
Understanding of Mental Health and Mental Illness
The underpinning values and philosophies that inform mental health service delivery relate to how we make sense of individuals’ lived experience of mental health and mental illness; specifically, how we make sense of mental illness and mental health in our society.
The World Health Organisationrecognises that the interventions required to assist people to move from mental illness to mental health have not always been present in mental health treatment systems (Friedli 2009).
Mental health and mental illness are distinct experiences. Mental health is a subjective state of wellbeing, characterised by feelings of happiness, derived through living a life that is autonomous and satisfying and includes personal growth. Mental illness is understood as a pattern of symptoms affecting mood, thought and behaviour which cause distress and interfere with a person’s ability to achieve their personal aspirations (Stein et al. 2010). People with lived experience of mental illness can have high levels of mental health, and people who are perceived as mentally healthy may also exhibit symptoms of mental illness (Westerhof& Keyes 2010).
Mental illness
Current definitions of mental illness lack precise boundaries with regard to what clearly is or what is not a mental illness (Stein et al. 2010). This is demonstrated by differences in definitions related to mental illness in each Australian state and territory Mental Health Act (Moxham, Robson &Pegg 2012). The definition of mental illness, within a medical context, is a pattern of symptoms that manifest in an individual’s moods, thoughts or cognitions and which are recognisedbehaviourally or psychologically (American Psychiatric Association 2012; Stein et al. 2010). The symptoms cause significant distress and disability or impairment in an important area of functioning for the individual (Stein et al. 2010). A mental illness is considered to have an underlying psychobiological or neurological dysfunction and is not an expected response to common stressors or losses (Stein et al. 2010).
Mental illness is not the absence of mental health, any more than mental health is the absence of mental illness (World Health Organisation 2004). In a research project to diagnose and measure mental health, Keyes (2005) defined a state of mental health as above average functioning in the dimensions of emotional well-being, psychological well-being and social well-being. Furthermore, three levels of mental health were defined; languishing, moderate and flourishing. Languishing is considered to be below average functioning in the dimensions of mental health (emotional well-being, psychological well-being and social well-being), moderate mental health is considered as average functioning within those same dimensions, and flourishing individuals are said to exhibit high levels of functioning. Two scales of subjective well-being and eleven scales of positive functioning were used to diagnose and measure these three levels of mental health (Keyes 2005).
People with lived experience of mental illness can exhibit languishing, moderate or flourishing levels of mental health (Keyes and Haidt, 2002). Therefore, despite assumptions that a state of mental health assumes no mental illness, mental health and mental illness are considered to be two continua, not a single continuum (Manderscheid et al. 2010; Westerhof& Keyes 2010).
Mental health
Mental health and mental illness are not two ends of the same continuum, but rather, are considered to be two distinct trajectories (Keyes 2005; Manderscheid et al. 2010; Westerhof& Keyes 2010; World Health Organisation 2004). A state of mental health has been defined by the World Health Organisation (2004, p. XVIII) as:
A state of wellbeing in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.
The key components of the WHO definition, as viewed by Westerhof and Keyes (2009) are emotional well-being, psychological well-being and social well-being. A state of emotional well-being is a subjectively described feeling of happiness and satisfaction with life. Psychological well-being, as defined by Ryff and Keyes (1995) has six elements; self-acceptance, purpose in life, autonomy, positive relations with others, environmental mastery and personal growth. Social well-being as defined by Westerhof and Keyes (2010) has five dimensions that when met, indicate that an individual is functioning optimally in society (Westerhof& Keyes 2010). They are social coherence, social acceptance, social actualisation, social contribution and social integration.
A state of mental health is not the natural outcome of treatment to remove symptoms of mental illness (Manderscheid et al. 2010). Treatment aimed at lessening the behavioral or psychological symptoms of mental illness does not provide the person with a sense of self-acceptance, autonomy or purpose in life necessary to meet the definition of mental health (Keyes 2005; Manderscheid et al. 2010; Westerhof& Keyes 2010). Manderscheid et al (2010) propose that while mental health and mental illness are distinctly different, there are connections between mental illness and mental health. Programs using models concordant with principles of person centeredness (Barker 2001), a strengths-based focus (Graybeal 2001; McCormack 2007; Peterson & Seligman 2004; Rapp &Goscha 2006; Shanley &Jubb-Shanley 2007) or the recovery movement (Buchanan-Barker & Barker 2006; Repper 2000; Shepherd, Boardman & Slade 2008) can create a bridge between illness and health because their methods address the correlates of mental health and not just the symptoms of mental illness (Manderscheid et al. 2010).
5. Contemporary Perspectives.3
Mental Health service delivery
An understanding of how contemporary values and philosophies have informed mental health service delivery in Australia can be garnered from a review of key documents and the work of particular groups and organisations.
Each of these documents reflects the time, the movement, the values and philosophies, of the moment. They are built on particular values and philosophies and seek to support , guide and/or change mental health service.
UN Principles for the Protection of Persons with Mental Illness 1991
The 1991 United Nations Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care (United Nations 1991) established the ‘minimum human rights standards of practice in the mental health field’ (World Health Organisation [WHO] 2005, p. 13). According to the World Health Organisation’s (2005, p. 1) Resource Book on Mental Health, Human Rights and Legislation, “the fundamental aim of mental health legislation is to protect, promote and improve the lives and mental well-being of citizens”
Worldwide, mental health legislation governing the treatment and care of people deemed to be mentally ill reflects the United Nations principles (United Nations 1991). Legislation from Australia (see Mental Health Act 2007 [NSW] and Mental Health Act 2014 [Victoria]) and other nations, such as the United Kingdom (see Mental Health Act 2007) and Canada (see Mental Health Act 1990 [Ontario] and Mental Health Act 2000 [Alberta]), each reflect these principles.
See: http://www.un.org/documents/ga/res/46/a46r119.htm
See: http://www.who.int/mental_health/policy/en/
National Standards for Mental Health Services
The Australian Commonwealth’s National Standards for Mental Health Services (2010) were first introduced in Australia in 1996 and outline the minimum standards of service delivery expected in all mental health services, including government, non-government and the private sector.
The ten Standards are used both to guide and assess the development and implementation of mental health services across Australia and are underpinned by eight key principles. These principles are:
• Mental health services should promote an optimal quality of life for people with mental health problems and/ or mental illness.
• Services are delivered with the aim of facilitating sustained recovery.
• Consumers should be involved in all decisions regarding their treatment and care, and as far as possible, the opportunity to choose their treatment and setting.
• Consumers have the right to have their nominated carer(s) involved in all aspects of their care.
• The role played by carers, as well as their capacity, needs and requirements as separate from those of consumers is recognised.
• Participation by consumers and carers is integral to the development, planning, delivery and evaluation of mental health services.
• Mental health treatment, care and support should be tailored to meet the specific needs of the individual consumer.
• Mental health treatment and support should impose the least personal restriction on the rights and choices of consumers taking account of their living situation, level of support within the community and the needs of their carer(s).
See: http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-pubs-n-servst10
A National Framework for Recovery-Orientated Mental Health Services
A focus on this framework serves to highlight, as just one example, how contemporary practice is informed by contemporary understandings, values and philosophies related to mental health recovery.
The national framework for recovery-oriented mental health services was developed under the guidance of the Mental Health, Drug and Alcohol Principal Committee and provides new policy direction to enhance and improve mental health service delivery in Australia (Commonwealth of Australia 2013). The framework is presented in two documents:
• A national framework for recovery-oriented mental health services: Guide for practitioners and providers
• A national framework for recovery-oriented mental health services: Policy and theory
The framework seeks to guide and inform contemporary practice and outlines seventeen practice capabilities in five practice domains. These capabilities and domains are underpinned by the concepts of recovery.

6. Recovery
Breaking away from policy, strategy and frameworks, we will now turn our attention elsewhere.
A review of developments in the provision of mental health care needs to address the development of recovery-orientated practice.
Recovery
‘Recovery’ is a term adopted by the consumer movement to describe a more hopeful outcome of serious mental illness. Although there is no single definition of the term, Fitzpatrick (2002) described a continuum in the interpretation of its meaning. Four points along this continuum can be described:
– First, recovery as used in the medical model would assume that mental illness is completely biologically based, and therefore recovery would mean that a person is cured. Recovery in this definition means a return to a former state of health (Whitwell 1999).
– Second, the rehabilitation model holds that although the illness cannot be cured, with training and support the person can achieve a life approaching what might have been without the illness (Fitzpatrick 2002).
– Third, recovery can refer to psychological recovery from the effects of the illness, whatever its aetiology, and whether or not mental illness is still present. That is, ‘the development of new meaning and purpose as one grows beyond the catastrophe of mental illness’ (Anthony 1993).
– Fourth, the empowerment model of recovery is based on the premise that mental illness does not have a biological foundation, but is a sign of severe emotional distress. Social and psychological approaches can therefore eliminate the illness completely and the person returns to their expected role in society. The strong version of this model advocates that medication is not necessary (Ahern & Fisher 2001).
The third meaning, psychological recovery, corresponds to most experiential accounts. However, the empowerment model is behind the push for greater consumer involvement in mental health services. The basic principles of recovery are otherwise shared. Whether or not mental illness has a biological basis, it is now clear that social and psychological factors can play a large part in the quality of life that consumers can achieve. It is also clear that many consumers consider the continued judicious use of medication or behavioural strategies integral to their continued well-being.

The Concept of Recovery in Mental Health
Recovery is not something that ‘happens’ or something that is done by clinicians, it is a growth process that requires hard work by the person recovering. The complete definition from Anthony (1993) is:
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 in one’s life as one grows beyond the catastrophic effects of mental illness (Anthony 1993).
What does recovery look like? A review of the consumer-oriented literature has revealed hope, identity, meaning and responsibility as essential elements of the experience of recovery:
Hope. The importance of hope permeates the experiential literature on recovery (e.g. Adams & Jenkins Partee 1998; Bassman 2000; Crowley 2000; Deegan 1997; Marsh 2000; Mead & Copeland 2000; Murphy 1998; Schmook 1996). Finding hope is the catalyst of the recovery process; it can come from within, or can be triggered by a peer or significant other. Hope also maintains the momentum of recovery. Snyder, Michael and Cheavens (1999) have identified hope as the common factor in all successful therapeutic endeavours. Although the beginning of hope is usually described as a realisation of the possibility of a brighter future, Snyder’s definition of hope comprises three distinct elements: awareness of a goal, envisaging pathways to the goal and the belief in one’s ability to pursue the goal. Clearly these three elements can be incorporated into rehabilitation approaches.

Self Identity. An horrific impact of mental illness is the loss of one’s identity. To go from having a socially accepted role in society, to being labelled as ‘crazy’, and to doubt one’s own mind, completely destroys a person’s sense of self. Pettie and Triolo (1999) explored the struggle to redefine oneself during the recovery process, and described two ways of reconciling the self with the illness. One way is to accept the illness as part of the self in a spirit of growth. Alternatively, the illness is seen as something separate from the ‘real’ self, that has to be lived with. Curtis (2000) illustrated recovery as a process of moving from being engulfed by the illness, to accepting the illness as just a part of the whole self.

Meaning in Life. The reestablishment of meaning in life is central to the concept of recovery. (eg. Curtis 2000; Ridgway 2001; Tooth, Kalyanansundaram& Glover 1997; Young &Ensing 1999). Descriptions of recovery almost always include the discovery of new meaning and purpose in life. Often a person’s life goals are no longer available to them, and they face the task of reassessing their values and goals in life. Alternatively, a person may find different ways of attaining their ultimate goals.This theme is strong in accounts of all types of recovery, not solely from mental illness (Emmons, Colby & Kaiser 1998).

Responsibility. The fourth important dimension is taking responsibility for one’s own recovery, including self-management of medication and well-being (eg. Curtis 2000; Deegan 1994; Tooth et al. 1997). Responsibility involves having autonomy in one’s life choices, being held accountable for one’s behaviour, and being willing to take informed risks in order to grow (Mead & Copeland 2000; Bassman 2000; Tenney 2000). It involves taking control in one’s life, and being in control of the illness (Williams & Collins 1999).

A common factor in these four elements of recovery is personal goals. The importance to motivation and psychological well-being of pursuing meaningful, autonomous goals is well documented in the non-clinical literature (eg. McGregor & Little 1998; Sheldon &Kasser 2001).

Although the four elements represent aims of recovery, they also imply a sense of continuation. Some people prefer to think of recovery as an ongoing process, rather than an end-point, and so prefer to see themselves as recovering rather than recovered.
Andresen, Oades&Caputi (2003) identify four processes involved with personal recovery:
•Finding and maintaining hope
•Re-establishment of positive identity
•Building a meaningful life
•Taking responsibility and control
Glover’s (2012) model of recovery reflects the efforts that people undertake in their personal recovery journeys through a set of five processes:
*From passive to active sense of self
*From hopelessness and despair to hope
*From others’ control to personal control and responsibility
*From alienation to discovery
*From disconnectedness to connectedness
The U.S. Deparment of Health and Human Services (2012) identified ten guiding principles of recovery. These are:

Image from SAMSA, Deparment of Health and Human Services (2012)
Characteristics of a recovery-oriented service

Service Level
ƒ The recovery vision is the mission of the service
ƒ Staff training focuses on the needs of consumers
ƒ Consumer-designed measures of satisfaction included in evaluation of service
ƒ Consumers actively sought for participation at all levels of the organisation
ƒ Consumer-led self-help and services available
ƒ Consumers and families integrally involved in service design and evaluation
ƒ Access to services is by consumer preference
ƒ Access to environments outside the mental health service is expected
ƒ Education for consumers in relapse prevention and crisis planning
(Anthony 2000; Jacobson & Curtis 2000)

Clinician Level
ƒ Believes that all people can learn and grow. Communicates expectation of success
ƒ No assumptions are made based on diagnosis or symptoms – focuses on skills and strengths
ƒ Recognises the right of the client to information and choice
ƒ Develops a healthy therapeutic relationship with the consumer
ƒ Planning and treatment is truly collaborative
ƒ The person is viewed as an equal in making decisions
ƒ The person is autonomous in their choice of life goals
ƒ Personal choice is at the core of all interventions

Client Level
ƒ Believes in the possibility of recovery
ƒ Takes responsibility for own recovery
ƒ Takes responsibility for own life course
ƒ Asserts rights to information and choice
ƒ Becomes active participant in own rehabilitation
ƒ Is willing to take informed risks

(Compiled from Curtis 2001; Fisher 1994; Mead & Copeland 2000; Bassman 2000; Davidson 1999)