This assessment task covers learning outcomes 3 and 4:

• Demonstrate safe, interprofessional and therapeutic practice when planning health care for people with mental health issues and their carers;

• Utilise critical reflection and self-reflexivity to enhance clinical practice.

Task

A consumer from a vulnerable population has been referred to you, in your role as a mental health professional, for case management. This consumer has a complex mental illness profile, including comorbidity, and is currently in your local acute inpatient unit.

Part 1 (500 words)

Choose the vulnerable population and the particular case study that you want to focus on. Research this area and create a case presentation of a client.

Your case presentation should include the following:

• At least one major DSM-V psychiatric diagnosis.

• At least one environmental and social issue, along with a description of this.

• A description of the consumer’s social context, including family and carer involvement.

• Identification of a substance use issue, in addition to the mental illness that you have identified.

Part 2 (1000 words)

Due to the complexity of the consumer’s situation, the inpatient unit has requested your input, as a mental health practitioner, as to how they should best proceed with treatment whilst they are managing the consumer’s care. Provide a list of recommendations for the inpatient unit to use in the treatment plan. Your list should include:

• Any cultural considerations relevant to treatment of the client;

• Any psychosocial considerations that may be necessary when making decisions around pharmaceutical or therapeutic interventions;

• Any issues that need to be addressed prior to discharge and suggestions for how they could be addressed.

You should also identify:

• Any key family members or carers who should be included in decision making and any interventions they may need.

• Any other factors that the inpatient unit may need to consider in the treatment of this consumer.

Part 3 (500 words)

The consumer is approaching discharge. Create a care plan for this consumer (see Module 4 (3) for an example of one type of care plan format). With reference to the evidence-based literature, provide a rationale for your decision making in relation to this plan’s creation.

A note about this section:

Referencing

Use chapters in your text books that describe specific mental conditions to ensure your clinical health interventions are evidence-based.

You must use the APA referencing system. Follow

3. Early intervention, illness management and recovery

When vulnerable individuals succumb to mental health issues, what are the principles, practical implications and challenges associated with providing care for them? Are there ‘one size fits all’ solutions? What happens at different stages of mental illness? How does the consumer’s context and environment influence diagnosis, treatment and outcomes?

• 1. LISTEN to this discussion between Dr Sally Hunter and Dr Mary Ditton about the complexities of interventionURL

• 2. NOW LISTEN to some further points about medication for consumers with mental illnessURL

• 3. Principles of early interventionPage

• READ & REFLECT: Guiding principles of interventionForum

• EVALUATE: Measure of a mental health serviceForum

• 4. Putting principles into practicePage

• 5. The first step: assessmentPage

• 6. Managing complex mental disordersPage

• 7. Crisis management: involuntary interventionPage

• 8. Medication and ethics of carePage

• 9. Managing comorbidity and complex casesPage

• 10. Planning care for diverse consumersPage

3. READ Australia’s National Preventative Health strategy

This strategy is worthwhile for you to read, especially considering the impact alcohol has on so many aspects of individual, community and family life, for example: violence, injury, depression etc.

Australia: The healthiest country by 2020

(National Preventative Health Taskforce, 30 June 2009)

In 2010 the Federal Government responded to this taskforce report in the document Taking Preventative Action: A Response to Australia: The Healthiest Nation by 2020.

The Taskforce identified seven strategic directions underpinning the effective implementation of health promotion and preventative action, which are:

1. shared responsibility – partnerships at all levels of government, industry, business, unions, the non-government sector, research institutions and communities;

2. act early and throughout life – working with individuals, families and communities;

3. engage communities – act and engage people where they live, work and play;

4. influence markets and develop connected and coherent policies – for example the use of fiscal strategies to complement other arms of action;

5. reduce inequity – by targeting disadvantage;

6. Indigenous Australians – contribute to ‘Close the Gap;’ and

7. refocus primary health care towards prevention.

These principles apply equally to physical health and mental health promotion programs.

FURTHER READING: Meadows et al (2012) Chapter 4 Delivering Mental Health Care – provides further background and understanding of mental health care delivery systems and processes

Last modified: Wednesday, 25 February 2015, 11:54 AM

2. Mental illness prevention

Is it possible to prevent mental illness from developing or escalating in different individuals or populations? What are the strategies and approaches which serve to maximize mental wellbeing and minimize the risks of succumbing to mental illness for vulnerable consumers?

• 1. Social determinants of health: REVIEWPage

•

1. Social determinants of health: REVIEW

Understanding the social determinants of health: a little revision

Let us briefly revisit the diagram by Turrell and Mathers (2000, p. 436) introduced in an earlier module, which shows the factors influencing mental health:

Source: Turrell & Mathers (2000a, p. 436) in Carson, B., Dunbar, T. and Chenhall, P.(2007). Social Determinants of Indigenous Health. Crows Nest, Sydney: Allen & Unwin.

It is important to note that this representation implies a composite view of health, and there has been much theoretical change in our view of health, health promotion and public health over the last forty years to arrive at this understanding.

Keleher and MacDougall (2009) in the first three chapters of their book Understanding health: A determinants approach provide a good overview of the evolution of the social model of health.

The social model of health

The social model of health complements the biological view of health that was consistent with the medical model and the functionalist perspective dominant in medicine and health services until recently.

Not only does the social model of health incorporate the notion that an individual’s health status is influenced by his/her genes and biological substrate but also that this biological substrate is influenced by social factors structurally determined in the communities in which we live. For example, global trade influences national economy, which influences employment, health services, education, community networks, family relationships and so on, impacting eventually on the health and wellbeing of the individual.

Starting with the Alma-Ata Charter on Primary Health Care in 1978 and the Ottawa Charter in 1986 there have been successive declarations by the World Health Organisation about the importance of changing social factors in order to improve the health and wellbeing of individuals. (You are encouraged to source and read more information about Alma Ata, the Ottawa Charter and other WHO conferences targeting global public health reform.)

The rationale for this is that if the arrangements in society change so that an individual can more easily make better choices for health, then the individual will make these better choices. For example, if government policies are more inclusive of diversity, then governments will try to develop services that accommodate difference, thus, for example, developing education and health policies that are more suitable for indigenous populations.

The figure from the Commission of Social Determinants of Health in Keleher and MacDougall (2009, p. 52) is another diagram similar to that presented to you in Module 1, but in this one Intermediary Determinants of Health are also mentioned.

The essential messages from these diagrams and readings that you need to recognise are:

• Health is a multidimensional concept incorporating a social model that impacts on a biological substrate;

• Individual and population health can be influenced by society factors;

• The importance of ‘difference’ to health status and access to health services;

• A multidimensional view of health means that there are opportunities to improve health and wellbeing for individuals and populations and these opportunities may be at a distance from the individual;

• The evolution of health rights and consumerism as forces in health services;

• The model expands the importance of social interventions in health and mental health services;

• Those people lower in the social gradient (lower income, less education, fewer social relationships etc) have the poorest health.

•

• FURTHER READING: Meadows et al (2012) Chapter 9 Mental Disorders in Australia considers interesting information regarding access to mental health services.

Last modified: Wednesday, 25 February 2015, 11:59 AM

• 2. Preventing mental health issuesPage

2. Preventing mental health issues

Health promotion, as a means of achieving ‘Health for all’, is seen as a process of enabling people to increase control over, and improve, their health. Because of the composite view of health mentioned above, there exists a continuum of health promotion approaches, as represented in this diagram from Talbot and Verrinder (2005, p. 35):

Some health promotion approaches target whole populations and have a community focus (for example, drink driving public health initiatives), whereas other approaches (for example, increasing the tax on Alcopops) have a regulatory and economic focus (in this case, to make drinking alcohol more expensive and therefore inhibitory).

Information about bowel and prostate cancer aims to increase individuals’ knowledge about health and changes in health so that the individual can make more beneficial decisions about his or her health-seeking behaviour.

Screening services for breast cancer, for example, are the application of the medical model to the individual to improve outcomes by early detection of cancer and therefore early intervention with treatment.

Keleher and MacDougall (2009, p. 54-57) discussed the five key determinants of health:

• Class and socio-economic gradient

• Early childhood development

• Poverty deprivation and social exclusion

• Health literacy

• Gender

When we consider these key determinants of health, many groups of people are disadvantaged structurally in relation to several of these determinants: for example, indigenous people in Australia, new arrivals to Australia, gay and lesbian people, foster children, people with disabilities, people who cannot speak English, second generation migrants, people of various occupations (e.g. police officers, undertakers), poor people, ex-criminals etc, etc. In fact the degree of tolerance exercised in society towards ‘difference’ is sometimes very small, so it is not hard to feel an ‘outsider’. Sometimes people who are divorcing feel they are failures in society, and unemployed or people made redundant feel they do not have a ‘legitimate’ role. Housewives sometimes feel like second-class women – ‘not doing everything modern women should do’. Also at various times in the lifespan it is hard to feel part of society. The young and the elderly are sometimes outside the mainstream concerns of society.

Consequently, when trying to prevent mental health problems we are often working to improve income and education, to support families so that children receive love and stability in early childhood, to reduce poverty and improve social inclusiveness, to increase understanding of health and signs of ill health, to enhance accessibility to health services, and to remove gender-related discrimination.

Primary, secondary and tertiary prevention

In the text by Meadows, Singh and Grigg (2007, p. 33), Singh defines primary, secondary and tertiary prevention:

Primary prevention aims to reduce the incidence of new cases through intervention before the disorders occur. Health promotion programs to support vulnerable new mothers are primary prevention for the children in those households to assist the mothers to provide ‘good enough’ mothering during early childhood.

Secondary prevention aims to reduce the prevalence of disorders through early identification of problems with intervention before the disorder becomes severe. Health promotion programs that help families identify signs and symptoms of early drug taking behaviour in adolescents is secondary prevention assisting families to intervene with their children before the drug taking behaviour is entrenched.

Tertiary prevention aims to reduce the prevalence of the disorders by reducing their duration through treatment and prevention of relapse. Severe mental health conditions, for example schizophrenia and clinical depression, require active intervention and ongoing intervention to prevent relapse.

FURTHER READING: Meadows et al (2012) Page 56-59 explores "The Preventaative Model".

Last modified: Wednesday, 25 February 2015, 12:03 P

• 3. Managing stress and life/role transitionsPage

3. Managing stress and life/role transitions

What is risk?

Risk factors are characteristics associated with an increased probability of a particular event, usually an injury or illness occurring (Murray, Zentner & Samiezade-Yard 2001:53). Risk assessment is part of the process of weighing up health problems and trying to be effective and efficient with interventions to benefit the individual and community. The regulation of risk involves attempts to control risk by setting and enforcing behavioural and product standards.

According to the Australian Bureau of Statistics report on the Social Trends for Health: Risk Factors among Adults (2003), the risk factor responsible for the greatest disease burden in Australia is tobacco smoking. Another common risk is excessive alcohol consumption. Excess alcohol consumption is linked to some cancers, liver disease, pancreatitis, diabetes and epilepsy. Smoking and drinking together account for about 17% of all disease (Australian Institute Health Welfare 2000:146–148). The risk factors of smoking and excessive alcohol intake have been studied extensively.

Beck’s Risk Society (1992) offers fair warning about the deceptive simplicity of the concept of risk in modern society. According to Beck (1992:3) risk is an ‘intellectual and political web’ cast by modern industrial society, in terms of problems (or risks) for the individual. These risks for the individual are conveyed in scientific language that ignores social rationality. Risks seem to concentrate in society at the lower end of the socio-economic spectrum. For example, lower socio-economic groups or those who are less powerful consume more tobacco. Also in the workplace, the least well paid workers not only operate in more hazardous environments, their amenities (e.g. tea rooms, wash rooms, etc.) are usually more limited than workers who attract higher wages. Their opportunities to have a break from work and refresh themselves, as well as their opportunities to move to better work environments, are also constrained. Beck (1992:35) makes the point that ‘risks seem to strengthen, not abolish the class system’, on the other hand [the] ‘wealthy [i.e. those with high incomes, power and education] could purchase safety and freedom from risk’.

Lupton (1995:77–105), Nettleson (1996:37, 53) and Petersen and Lupton (1996:18–20) comment on the pervasiveness of risk in literature of health and lifestyles and the limited ability that people have to control the social circumstances of their lives. These authors agree with Beck that more advantaged people have more control over socio-economic, environmental, living and working conditions. Therefore concentrating on lifestyle factors only, rather than on cultural and socio-economic factors, may contribute to increasing health inequalities because advantaged people will gain doubly—from their own power base to control external factors influencing their health, and from the renewed push of society as a whole to enhance better lifestyle choices.

Stress

Stress is an imprecise term, but in spite of this it has a significant place in the literature that deals with work and health. Semmer (1996:53) defines it as denoting states of ‘tension’ that are experienced by the individual as aversive and may have psychological and/or physical components. ‘Psychological stress[es]’ according to Kaplan (1996:3–4), are ‘the socially derived conditioned and situated processes that stimulate any or all of the many manifestations of dysphoric affect falling under the rubic of subjective distress’. Stress conveys negative emotional states such as anxiety, frustration, anger and guilt and/or physiological states such as racing heart, sweaty hands, dry mouth and increased respirations. Stress has to do with the appraisal of threat and/or loss. This definition implies that stress has to do with anticipated or experienced thwarting of goals. Stressors are characteristics in the environment that tend to elicit these emotional states in a given population. Stress is influenced by various environmental, psychological and social factors, but it is uniquely perceived by the person and intensifies when environmental change or a threat occurs (internally or externally) to which the person must respond (Murray, Zentner & Samiezade-Yard 2001:257).

A certain degree of stimulation for people is considered positive and motivating. The pattern for stimulation/stress and performance is shown in the figure below. This figure shows that while too little stress can cause apathy, excessive stress leads to unhealthy states and poor performance.

Stress/stimulation and performance (Source: Peterson 1990:23)

Work is often a significant source of stress. Cooper (1998:1–2) states that there is a ‘mountain of research in the cognate area of occupational stress’ and has developed certain principles in considering the effects of various stressors (Cooper & Payne 1988; Cooper 1998). These are summarised by Murray Zentner and Samiezade-Yard (2001:258) thus:

• the primary response to a stressor is behavioural, and the physiological impact is secondary;

• the impact is cumulative;

• circumstances alter the impact or harm done by the stressor;

• people are remarkably adaptive;

• various psychological or social factors may ease or exacerbate the effects of the stressor;

• there are definite low points when stressors are poorly tolerated;

• conditioning is an important protector;

• responses throughout life are local and general—local responses attempt to wall off and control the stressor, whereas general responses are characterised by alarm and resistance and when body resistance is not maintained, the end stage is exhaustion.

Risk and workplace stress management

Theories of workplace stress management vary from individual approaches that support individuals’ coping abilities, to more integrated strategies. The basic difference in the two approaches is that, in the former approach the individual is responsible for employee health, whereas in the latter approach, there is a synergy between individual and collective responsibilities for employee health in the workplace. Integrated strategies target the organisational demands and stressors, together with stress responses in individuals. The basic beliefs behind these integrated strategies are elaborated by Quick, Quick and Nelson (1998:247) and include:

• the interdependence of individual health and organisational performance;

• managerial participation in employee health and organisational performance;

• non-acceptance of individual and organisational distress as inevitable;

• unique reactions of individuals and organisations to stress;

• the ever-changing nature of organisations.

Protective factors

Just as health promotion programs focus on promoting mental health, they also try to reduce risk and they also try to increase protective factors against mental illness.

Protective factors are those factors that increase a person’s ability to cope with stress in life. Common protective factors are:

• stable home and living environment;

• positive personal relationships;

• adequate income;

• suitable emergency supportive facilities;

• community cohesiveness;

• social capital

• community capacity etc.

In thinking about the prevention of mental health problems we have to understand risk, stress and protective factors that operate in the environment of the person. Keeping in mind the composite view of health, some of these risks, stresses and protective factors may be proximate and/or distal to the person involved so our interventions may be complex and varied.

Resource

Visit this Canadian website (Centre for Addiction and Mental Health) to learn more about protective factors against mental health problems for children and youth.

Last modified: Tuesday, 1 October 2013, 12:53 PM

•

• 4. Overview: Evidence-based mental health promotion and early interventionPage

4. Overview: Evidence-based mental health promotion and early intervention

Mental health promotion

Health promotion programs to reduce risk in the context of mental health are summarised in the diagram adapted from the original of Mrazek and Haggerty (1994):

As you can see from earlier definitions of primary, secondary and tertiary prevention, health promotion programs can be developed to any level of prevention. It is important to understand the nature of the health problem that you are addressing and the characteristics of population you are targeting through the health promotion strategy. Some of these concepts are covered in the diagram above and please note the definition of Universal , Selective and Indicative health promotion programs with a preventive focus.

Mental health promotion programs can be targeted to different populations in a universal, selective or indicated way. Definitions for these methods are given in Meadows, Singh and Grigg (2007, p. 34). It is important to understand these distinctions.

An example of a universal mental health promotion program is provided by Swannell, Hand & Martin (2009): The Effects of a Universal Mental Health Promotion Programme on Depressive Symptoms and Other Difficulties in Year Eight High School Students in Queensland, Australia, School Mental Health Volume 1, Number 4 / December, 2009 P 229-239.

For an example of a selective mental health program, visit the site referred to in the previous section, the Centre for Addiction and Mental Health, and look at Best practice guidelines for mental health promotion programs: Children & Youth:

I am reproducing the guidelines from this web site here because they could not be improved.

Guidelines for mental health promotion programs

These 10 guidelines define best practices for mental health promotion interventions. They are based on mental health promotion principles that have been identified through critical analysis of literature reviews. The guidelines are not intended to be used as an evaluation tool, but rather to improve existing interventions or develop new interventions. Not all components will apply in all contexts, because the guidelines are based on ideal mental health promotion interventions. Health and social service providers will have to take into consideration their own level of resources and restrictions, given the overall mandate of their organization. They should apply what is relevant for their programming needs.

1. Address and modify risk and protective factors that indicate possible mental health concerns.

2. Intervene in multiple settings, with a focus on schools.

3. Focus on skill building, empowerment, self-efficacy and individual resilience, and respect.

4. Train non-professionals to establish caring and trusting relationships.

5. Involve multiple stakeholders.

6. Provide comprehensive support systems that focus on peer and parent-child relations, and academic performance.

7. Adopt multiple interventions.

8. Address opportunities for organizational change, policy development and advocacy.

9. Demonstrate a long-term commitment to program planning, development and evaluation.

10. Ensure that information and services provided are culturally appropriate, equitable and holistic.

An example of an indicated mental health promotion in young people is provided by WHO (2010: Mental Health Promotion in Young People – an Investment for the Future By: Eija Stengård and Kaija Appelqvist )

Evidence based mental health prevention

Mental health prevention must be based on:

• Sound knowledge of the individual and social problem at a practical and theoretical level.

• This involves awareness of the extent of the problem, in its biological, social, historical, economic, and political dimensions and the theoretical concepts involved in the problem.

• Sound knowledge of practical and theoretical methodological approaches to solving the problem.

• Multidisciplinary collaboration to manage complex risk.

• Sound knowledge of prior interventions with similar problems.

Principles of early intervention with mental health

Early intervention principles are based on the same concepts as the evidence-based mental health prevention that has just been discussed, with some additional considerations.

Case identification and early intervention means that the health professional must be sensitive to what is happening to the consumer and what he/she is saying. You must give the consumer sufficient time so that in a discussion or interview conducted professionally you gain an understanding of the problem. You are constantly assessing the risk that the consumer poses to himself/herself or others and the severity of mental health problem. By the end of the interview you should be able to determine whether the consumer should be treated in hospital or not and how urgent or not the consumer’s needs are. Do not hesitate to seek assistance in assessment from your colleagues and other health professionals. With a respectful approach consumers will usually be wiling to be guided by your advice.

This discussion about principles of early intervention with mental illness will be continued in the next section.

Last modified: Wednesday, 25 February 2015, 12:04 PM

Skip Navigation

3. Early intervention, illness management and recovery

When vulnerable individuals succumb to mental health issues, what are the principles, practical implications and challenges associated with providing care for them? Are there ‘one size fits all’ solutions? What happens at different stages of mental illness? How does the consumer’s context and environment influence diagnosis, treatment and outcomes?

• 1. LISTEN to this discussion between Dr Sally Hunter and Dr Mary Ditton about the complexities of interventionURL

• 2. NOW LISTEN to some further points about medication for consumers with mental illnessURL

• 3. Principles of early interventionPage

• READ & REFLECT: Guiding principles of interventionForum

• EVALUATE: Measure of a mental health serviceForum

• 4. Putting principles into practicePage

4. Putting principles into practice

Of course, it is one thing to espouse the correct principles and another thing to put these into practice. Those of you who work in large systems may have come across attitudes that are a far cry from those discussed in the previous section. You may have come across examples of racism or stereotyping of consumers e.g an indigenous Australian who is treated poorly because they have a mental illness compounded by a drug addiction. We would encourage you to examine your own beliefs and prejudices and become more aware of the beliefs and prejudices of those that you work with. It is easy to be drawn into thinking and behaving in a negative way towards people suffering from mental illness.

Here are some of the attitudes that you may meet when working in mental health:

Drug addicts don’t help themselves, so why should we help them, when our resources are so limited?

People with mental illnesses are violent and dangerous when they don’t take their medication.

You should be able to snap out of depression.

People who don’t take their medication are a menace to society.

Some people with mental illnesses should be locked up permanently.

Addictions are a choice, not a mental illness.

If you have a mental illness, you don’t suffer as much as when you get physically sick.

The families and carers suffer more than the person with the mental illness.

It’s the families who cause the person to become mentally ill.

You can never recover fully from mental illness.

Check your assumptions!

There is a website that you can go to, in order to check your own knowledge of facts/myths in mental health. It is run by Mental Health America of Eastern Missouri. See how many out of ten you score:

http://www.mhaem.org/mental-health-illness-topics.html?task=article_view&article_id=35

The reason for asking you to assess your own attitudes to mental illness is to make you aware of your own prejudices and negative beliefs. We all have these, to a certain extent, depending on our personal and professional experiences.

Reflection… You might like to write a private list of all your beliefs about people with mental illness. Try to be honest about your feelings and own up to any prejudices that you may have. Think about whether these beliefs come from your personal experiences or your work environment.

Decide if any of these beliefs will get in the way when you are working with consumers suffering from a mental illness.

Talk to a trusted colleague about how you might change any problematic beliefs that you have, or any problematic behaviours that you see around you in your work environment.

READ: Meadows (2012) pp 27-30 discussing stigmatisation – consider your perspectives and attitudes

Last modified: Wednesday, 25 February 2015, 12:12 PM

•

• 5. The first step: assessmentPage

5. The first step: assessment

Assessment as the first step towards appropriate intervention

The period of providing care, particularly in the acute phase of an illness is a complex puzzle which clinicians must piece together. Consumers don’t come with a single diagnosis or with issues that can be fixed in the same way as for the previous consumer. Every case is unique and requires clinicians to think critically about the situation and what can be realistically achieved. Assessment is the first stage of working through this puzzle and to offering the consumer appropriate care and therapeutic interventions.

Asses