Promoting personal recovery has become the guiding principle in any mental health services in the UK (Premal and Mountain 2008; Wallcraft et al,. 2010).Part of the reason is the treatment success rate,including the satisfaction from individuals and carers using the service (Kinderman and Tai 2009). There is also the economic advantage of adopting the recovery approach which the UK politicians clearly support (Expert Group on Mental Health Policy, 2006; Scottish Executive, 2006) .However, there are criticisms of the success and practices of recovery as depicted in Davidson et al,. 2006 and Shepherd et al, 2008, despite the fact that available evidences suggest that individuals with various mental health diagnosis, such as schizophrenia can actually recover(Spence,2005;Warner, 2009, 2010).Nevertheless , the key to its success has been the collaboration between experts, the individual and their families (Wallcraft et al,. 2010).
This paper examines the contemporary mental health nursing policy and practices in the UK, and how it embraces the recovery philosophy. It begins by briefly reviewing the historical development and transformation of mental health services in the UK. It highlights the arguments surrounding the social and biological views of mental illness, and examines the differences between personal and clinical mental health recovery. This paper discusses the personal recovery philosophy in an acute inpatient hospital setting, and examines the barriers surrounding its implementation. The paper concludes by reflecting on the author’s views regarding the subject matter. References will be made to the four Nursing and Midwifery Council (NMC) domains of professional practice (NMC, 2015) when reflecting on the author’s experiences during the three years of the nursing course, but more focus will be on the NMC communication and interprofessional skills. The terms “the individual”, the individual in recovery” have been used in this paper interchangeably when referring to the person in recovery instead of the term “person with mental illness” The formers are believed to be more recovery-oriented (Smith, 2010).Where applicable, references will be made to Appendix A, B, C, B, E and F respectively to depict an event, scenario or reflective practice.
Brief Historical Context
Over the past century the mental health services in the UK have passed through various stages of development and transformation (Gilburt et al,. 2014). Treatments have moved from institutions to the community, and with more emphasis now laid on the promotion of recovery in all mental health services (Premal and Mountain 2008; Wallcraft et al,. 2010). Up to the 18th century the care of people with mental health problems in UK was solely the responsibility of the family (Gilburt et al,. 2014). Further into the 19th century, and as a result of the industrial revolution, scandal of the notion of the “madhouse” (Gilburt et al,. 2014), and coupled with the inability of the work force to manage people with mental health problems, the care was moved into publicly owned county asylums (Barham, 1997). Lawton-Smith and McCulloch,(2013) highlighted this era as the “dark ages” of psychiatric development in the UK. These periods showcased the dairy of barbaric and archaic mental health treatments in the, and how people with mental health problems were abused and treated in undignified manners (Lawton-Smith and McCulloch,(2013).
However, with advances in psychiatry, greater emphasis on human rights, including the development of antipsychotic medications, the second half of the 20th century saw a radical shift in the way people with mental health problems were care for (Gilburt et al,. 2014). Community based treatment was introduced, and the introduction of the Mental Health Act also meant that more people had to be treated in the community. The 1961 famous speech ‘water tower’, of the then minister of health Minister, Enoch Powell set the stage for the subsequent closure of the first asylum in 1986(Gilburt et al,. 2014).
The transformation of mental health services in the UK has been a nonlinear process (Gilburt et al,. 2014). Whilst the financial drivers cannot be ignored, some of the therapeutic aspects have been recommendations from the public, individuals using service, and lessons learned from failings highlighted in reports (Ritchie, 1994; Gilburt et al,. 2014). Notable among them was the 1993 Ritchie report into the killing of Jonathan Zito by Christopher Clunis in 1992 (Ritchie, 1994). In the report Ritchie attributed the killing to failures in community care treatment, and stated that although community care had improved the lives of some it has also allowed too many unwell people in the streets (Ritchie, 1994). It is believed that some of the comments echoed in Ritchie reports including other subsequent reports led to the amendment of the 1983 mental health act ,and the introduction of the community treatment order (CTO) in the 2007 mental health Act ( Glasby and Tew 2015) .
Although the introduction of psycho-pharmaceuticals, community mental health were positive approach, many of them fell short of their expectation to provide permanent solutions as well as provide the ideal support for patients and their family (Rogers and Pilgrim, 2001; Healy, 2002). Frank and Glied, (2006) referred to these services as “better but not well”, It is in these contexts that led care providers and policymakers to the gradual movement towards the recovery approach as the ultimate goal of any mental health services.
Overview of the personal recovery philosophy
Although there is no single universally accepted definition of recovery in mental health (Repper & Perkins 2003;Glasby and Tew 2015) , perhaps because recovery can be conceptualised broadly in different narratives, for example, clinical, personal or social recovery(De Jager et al., 2015). Nonetheless , for personal recovery, its underlying principles are well documented (Whitley and Drake 2010; Barker et al., 2011;Slade et al., 2012), and is based on hope, beliefs, optimism (Ramonet,. al 2007;Shierset al,. 2009), taking ownership and the determination that an individual can reclaim control of their lives despite experiencing severe mental illness( Glasby and Tew 2015) . This recovery-oriented paradigm is what is often referred to as the recovery model (Whitley and Drake 2010), although some NHS trusts argued that it should instead be referred to as a “concept”( South London and Maudsley NHS Foundation Trust and South West London and St George’s Mental Health NHS Trust ,2010 ).Personal recovery is a journey because it is non-linear (Slade, 2009), hence why people are often referred to as “in recovery” (Davidson and Roe, 2007) rather than “recovered”( Doukas and Cullen,2009).
Clinical recovery requires the individual to return to their original state of functioning (Carlton and Bradstreet). In Clinical recovery, wellness is a function of symptoms and cure (Barber, 2012), and results are measured on symptom elimination in response to drug reactions (Barber, 2012). In contrast, personal recovery focuses on the individual positive qualities, to help them live a meaningful life alongside the symptom (De Jager et al., 2015). Put simply, personal recovery explores the positive attributes on the individual in order to promotes independence, encourages autonomy, to enable them live a fulfilling life in the community, in spite of disabling conditions or experiences (Carlton and Bradstreet, 2006; Bellack, 2006; Slade et al., 2012).
Personal recovery is indeed a personal journey, and can mean differently to different people (Brown, 2008; Huiting,2013). What work for one individual may not necessary work for the other person (Brown, 2008), thus, further suggesting that personal recovery is person centred (Laura et al., 2010).Recovery is different from rehabilitation, because the latter is provided and controlled by the professional (Davison, 2003).
Biological and Social Viewpoints
Mental health is influenced by the biological viewpoints(Ahn et al., 2009), where every mental health problems is given a psychiatric diagnosis, which focuses on cure or illness remission using antipsychotic medications (Drake et al,. 2009; Read et al., 2009) For example, broadly, the medical model suggests that mental illnesses may be the result of neuropathological changes to the Brain (Farkas, 2007), and that one way of altering the change and or reducing symptoms is the use of antipsychotics (Read et al., 2009). Whilst such narratives may be valid in medical research (Premal and Mountain 2007), such narratives have also been shown to stigmatised an individual, and affect their self-esteem (Huiting ,2013). . People perceive mental health diagnoses to be “life sentences” (Roberts and Wolfson, 2004 p.4) that diminishes their identity. An individual with such a label can see themselves different from others which may affect how they seek treatment, therefore impeding their recovery. Huiting ,(2013) went further to suggest that low self–esteem compromises quality of life and correlates very well with high rate of relapse in patients diagnosed with schizophrenia .
In contract, the social model emphasizes the strength model by acknowledging that every individual possesses unique strengths, and that by focusing on those set of strengths they can overcome their mental health problems (Brun and Rapp, 2001). Saleebey, (2006) suggest that positive attributes and strengths lie in every individual, and that such attributes can easily be found around what interest that individual.
Practitioners, families and communities together create the resources the individual reply on to develop their strength (Saleebey, 2006). The strength model does not disregard the individual’s pains and suffering but it challenges lapse in the sole focus of pathology (Huiting, 2013).
Although the medical model postulate mental illnesses as the results of neuropathological changes to the Brain (Farkas, 2007), Neuroscience does support this assertion, and suggests that the brain structure and function respond to changes in biological, social and psychological functioning (Premal and Mountain 2007).Which may well explain why antipsychotics are needed to regulate the level of neurotransmitters in the brain cells when they exceed the appropriate levels (Lieberman el al,.2008).
Further, following the personal recovery approach does not mean the medical approach is completely irrelevant. In fact, Barber, (2012) argued that both personal recovery and medical recovery compliments one another. Personal recovery helps the individual stay on track with clinical treatment by engaging in work and other activities to maintain good mental health and wellbeing (Deegan, 2005). Deegan, (2005) referred to these activities as “personal medicine”.
Acute inpatient Services and coercion practices
Treatment under coercion practices is common in inpatient mental health hospitals (O’Brien and Golding, 2003), however, this raises questions about concordance and the recovery principle (Davoren et al,.2005). A systematic review on the quality of care given under coercion practices reveal little evidence of the effectiveness of the care in terms of social functioning and quality of life (O’Brien and Golding, 2003).Moreover, compulsory treatment work in direct opposite to the principles of personal recovery, because such atmosphere does not create the necessary condition for nurses to promote growth, self-determination, independence and citizenship(Cahn, 2008).A majority of patients in an in-patients secured unit believed their involuntary admission and treatment were the key to their recovery(Mezey et al,.2010). When treatment is coercively administered collaboration is hardly achieved, if not impossible (Karen,2010).Wallcraft et al,. (2010) argued that the best care in acute hospital setting is achieved when done in collaboration between the user, the family and the clinicians.
In addition, an individual with high risk of self-harm, and to others may result in undesirable recovery outcome (Wallcraft et al,. 2010) .This thus raises further question about risk and recovery. The case of Eric highlighted in Appendix A1 and A2 is very significant because Eric is being supported to recover in the hospital, however, there is also the risk to women and from Eric’s exploitation. Nevertheless, risk is a dynamic construct (Morgan, 2004), and by allowing Eric some escorted leave one can identify and measure any foreseeable risk that could be used to develop a positive-risk-taking plan for Eric.
Power of Lived Experience
Although science hypothesises about the causes of mental illness (Farkas, 2007), understanding and accepting the lived experience of the individual is central to any successful mental health treatment (Clarke and Walsh, 2009).Listening and understanding the individual lived experience in a non–judgemental manner can help nurses practice emphatically with the individual in order to support them through their recovery journey (Clarke and Walsh, 2009).
The active participation of service users, family and friends, as well people with lived experience of mental ill health is vital to the development of mental health recovery-oriented programmes (Wallcraft et al,. 2010). People with lived experience of mental illness can provide critical roles in sharpening the recovery services, and act as a support network to others (Bradstreet, 2006), either through self-help or formally through peer support services (SAMHSA, 2011). Organisation like Alcohol Anonymous (AA) was created, and resolves, around peer support (McCrady and Miller,1993).The experience and views of members helped others with similar problems cope with their problems (Bradstreet, 2006). There unique perspective can help service providers assess the relevancy and value of the care being delivered. Further , the story of lived experience can steer the tide towards changing the public opinion that people with mental health problems can indeed recover from their illness. Wallcraft et al., (2010) argued that one way of changing societal views is to promote partnership between professionals and people with lived experience of mental ill health, and for them to work together to challenge stigma, prejudice and stereotyping.
Communication and interpersonal skills is one of NMC competency domain, and it require nurses to use a range of communication skills to support patients(NMC, 2015).Good communication and interpersonal skills are central to building therapeutic relationships with patients (Elder, Evans and Nizette, 2005), and evidence based studies suggest that good therapeutic relationships between practitioners and patients predicts positive outcomes (Safran et al., 2009;Staemmler, 2012).
Over the course of my training my communication and interpersonal skills have been improving. Firstly, from the communication and interprofessional module I had in 1st year, and also from experiences gained from placements. Working with patients and their families, including staff in a ward and community settings has exposed me to real world applications of the use of verbal and non-verbal communication skills. In one placement my mentor used role-play to observe and enhance my communication skills. Kesten,(2011) suggest that the use of role-play can improve communication skills in nursing students. This is because role-play can be used to mirror a real life interaction between the student and the patient (Babatsikou and Gerogiann 2012).
Further, my microteach presentation helped me improve my self-confidence. Moreover, it enabled me evaluate my presentation, including receiving feedbacks, and giving feedbacks to others (see Appendix C)
During one of my placement I conducted several bio-psycho-social assessments(Appendix E and F) using semi-structured form to stimulate information gathering in order to support patients’ .During the assessments I acted in a professional manner in line with the “NMC Professional Values competency domain”(NMC,2015). I make sure I was polite, courteous, and seek consent from patients before conducting assessment. During assessments, I also make sure I identified patients that were vulnerable, and at imminent risk to themselves and the public, and recommended appropriate actions to maintain their safety. I also ensured my work was in accordance with the role and responsibilities of nurses, and within the NMC code. Feedbacks from patients and carers were encouraging and I hope to maintain this practice when I become registered. The reflective practice in Appendix E and F highlights my reviews and analysis of the knowledge and experienced gain during therapeutic sessions with the patients.
The nursing process is a cyclic one, and begins with assessment, then planning, implementation and evaluation (Clarke and Walsh, 2009). One of my coursework in second year was to prepare a care plan for a patient on section 3 of the mental health Act in a simulated hospital ward scenario. I did the care planning with my team which I believe was very significant in two-folds.One, it enabled me to prepared a care plan for the patient using the nursing process (NMC Nursing Practice and Decision Making competency domain), and ensured that the patient essential needs were meet, and that there were room for changing needs (NMC, 2015) .Two, it promoted team working and self-management, and this relates to the NMC Team Working and Self-Management Competency Domain.(NMC, 2015).
Overall, it appears to me that at the heart of the recovery approach lie three interconnected variables; nurses’ effective communication and interpersonal skills, the nursing environment, and the individual mental state, motivation and willingness to engage. These variables compliments one another and neither may function in isolation. For instance, an individual recovering from alcohol addiction may have low self-esteem and find it difficult to build a healthy relationship with the practitioner. However, if the practitioner shows empathy, unconditional positive regard and congruence (Clarke and Walsh, 2009), the individual may feel reassured and be willing to collaborate with the practitioner. Although this also depends on the individual mental state. Clarke and Walsh,(2009) suggest that nurses’ effective use of the recovery language can give hope and optimism to the individual in recovery.
The nursing environment is equally crucial to the success of any recovery programme. Although care under coercive may be useful for patients not cooperating with their care and discharge plan (Pilgrim, 2005), research studies suggest that such practice opposes the recovery principle, and the concept of co-production (Cahn, 2008).
There is also the factor of the individual motivation and willingness to engage, which Swift and Greenberg’s (2012) and Frei and Peters’ (2012) study clearly suggest are necessary in any process of change and therapeutic engagements. Although, in the recovery approach the individual decides and take the lead whilst the practitioners supports them, and foster independency (Clarke and Walsh, 2009), but what if the individual chooses not to engage? Recovery becomes difficult to implement.
It is difficult for me to predict my career path at the moment because of the diverse opportunities I can perceive. Although, much of this paper focused on acute inpatient services, because I have also done some jobs in this area, I tend to lean toward community mental health nursing. Obviously, going this direction means I may have to take further courses to specialise in this area.