Primary Care Guide to Mental Health

• Publisher: M&K Publishing an imprint of M&K Update Ltd
• Year: 2012
• ISBN:
  9781907830105
• Topic: Medicina
• Subtopic: Psiquiatría y salud mental

One in three or four patients seen in primary care has a mental health problem. There are straightforward and effective treatments available for many of these conditions and the primary healthcare clinicians themselves can treat some successfully. Many secondary care services for mental health are working towards earlier discharge, making primary care an important place for delivering mental healthcare. This has been recognised in the Quality and Outcomes Framework, giving clinicians in primary care responsibility for recognising and treating a certain number of mental illnesses. Clinicians in primary care need to work closely with those in mental health services to ensure the patient receive the most appropriate treatment.This book aims to provide an uncomplicated guide to the mental health problems that are routinely managed in primary care. It is suitable for students and for clinicians working in primary care.

Chapter 1

Recovery

We are sure you have heard colleagues and patients talking about ‘recovery’ when discussing mental illness. The term has been popularised over the past decade and many mental health services promote themselves as being ‘recovery focused’. For colleagues who work in primary care with patients who have both mental and physical disorders, talk about recovery may be a little confusing if not perplexing. It will be helpful, therefore, to discuss what is meant by recovery within a mental health context and how you as a primary care worker can support this approach.

Many mental health practitioners perceive that the functioning and quality of life of patients with severe mental illness (SMI) will inevitably decline over the course of the illness. Patients, it is argued, do not recover from SMI. Objectively there is a certain truth to this; psychosis is toxic and the longer people spend experiencing symptoms (for example, hearing voices, feeling paranoid, manic or depressed) the worse their functional outcomes. But this misses the point about how the concept of recovery is used in mental health. You may be thinking if a patient has a bout of influenza, they have recovered when the virus has run its course and the patient has returned to normal life. Patient groups have argued that recovery in mental health is different. Mental illness does not go away; to recover patients have to learn to work around or live with the symptoms they are experiencing. So much as you might like to help a patient with diabetes live with their condition (although you probably would not say they had recovered), by helping a patient with SMI work around their symptoms you may have helped to promote their recovery. This leads us to our second key observation about recovery; it is considered an ongoing process, not an outcome. So you can never say that a patient has recovered from mental illness; rather you have supported them in the process.

The concept of recovery in psychiatry emerged from patients writing about their experiences of living with mental illness in the early 1980s. Most famously Pat Deegan (1988) talked about how she had developed skills in coping with her experiences, but perhaps most importantly about how to regain an identity beyond mental illness.

So in a mental health context you should consider recovery a process, an attitude, a guiding principle if you like. You may want to take some time to reflect on how comfortable this construct feels to you. Certainly there are many authors who have been very critical of the recovery concept and movement, lambasting it as no more than a marketing term used by mental health services to promote themselves. We consider that the message of hope and positive collaboration that the recovery concept imbues is an important consideration for professionals, patients and their carers.

How do I promote recovery?

Using a recovery approach places an increasing emphasis on self-management and a strengths approach, focusing on what people can do, rather than what they can’t, and looking at social, as opposed to medical, outcomes. Housing, employment, education and participation in mainstream community and leisure activities become the central objectives.

Geoff Shepherd (Shepherd et al., 2008) offers us ten top tips for recovery oriented practice. He suggests that after each consultation, you should ask yourself, did I…

1. actively listen to help the person to make sense of their mental health problems?

2. help the person identify and prioritise their personal goals for recovery, not professional goals?

3. demonstrate a belief in the person’s existing strengths and resources in relation to the pursuit of these goals?

4. identify examples from my own lived experience, or that of other patients, which inspire and validate their hopes?

5. pay particular attention to the importance of goals which take the person out of the ‘sick role’ and enable them actively to contribute to the lives of others?

6. identify non-mental health resources – friends, contacts, organisations – relevant to the achievement of their goals?

7. encourage self-management of mental health problems (by providing information, reinforcing existing coping strategies, etc.)?

8. discuss what the person wants in terms of therapeutic interventions, e.g. psychological treatments, alternative therapies, joint crisis planning, etc., respecting their wishes wherever possible?

9. behave at all times so as to convey an attitude of respect for the person and a desire for an equal partnership in working together, indicating a willingness to ‘go the extra mile’?

10. while accepting that the future is uncertain and setbacks will happen, continue to express support for the possibility of achieving these self-defined goals, maintaining hope and positive expectations?

These tips are helpful in guiding our overall practice towards a more recovery oriented approach to working with people with mental health problems. Other authors have described different stages of recovery. Knowing which stage in the recovery process your patient has reached, will enable you to target your interventions more effectively. Table 1.1 shows Andresen and colleagues’ (2006) five stage model of recovery. To work out which recovery stage your patient is at, you can use the Stages of Recovery Instrument (STORI) also developed by Andresen et al. (2006). The STORI is a fifty item self-report measure; each item is rated on a five point scale. You can find out more about this measure by going to the following website: http:​//www.uow.edu.au​/health​/iimh​/stori​/index.html (last accessed: 24.4.11).

Table 1.1 Five stages of recovery

1. Moratorium	A time of withdrawal characterised by a profound sense of loss and hopelessness
2. Awareness	Realisation that all is not lost and that a fulfilling life is possible
3. Preparation	Taking stock of strengths and weaknesses regarding recovery and starting to work on developing recovery skills
4. Rebuilding	Actively working towards a positive identity, setting meaningful goals and taking control of one’s life
5. Growth	Living a meaningful life, characterised by self-management of the illness, resilience and a positive sense of self

Source: Andresen et al. (2006).

At each of the five stages it has been argued that different therapeutic techniques may be particularly helpful. We have listed some below under the five stage subheadings.

Moratorium

At this stage, the professional:

• demonstrates hope and the potential for achievement when interacting with the patient;
• promotes acceptance as first step to recovery;
• explains illness, symptoms/distressing experiences, courses of treatment;
• informs the patient about benefits of active treatment;
• engages family and/or significant others and refers them to available community supports and education.

Awareness

At this stage, the professional:

• ensures the patient and family/significant others are educated about the choices/resources available to them;
• provides activities that will increase the patient’s readiness to make choices in selecting life roles, environment, and goals;
• educates the patient about mental illness and recovery;
• continues to use hope-inspiring strategies.

Preparation and Rebuilding

At this stage, the professional:

• assists the person in connecting with ordinary community services based upon their needs;
• works with the person to review and monitor status of their goals;
• assists the person in contacting agencies and services that will help them achieve life goals and support recovery-enhancing activities (i.e. recovery groups, housing options, volunteer opportunities);
• refers to employment agencies to learn about how to use work incentives;
• supports and assists the person in developing personal coping skills.

Growth

At this stage, the professional:

• provides support/assistance in maintaining recovery;
• advocates use of community resources;
• encourages and supports the person in becoming more involved in community activities;
• keeps patients/family/significant others up-to-date about new medications, alternatives and complementary treatments.

Having set out some fairly general therapeutic techniques for promoting recovery, it might now be helpful to focus on Wellness Recovery Action Planning, a specific clinical tool that is increasingly used by mental health practitioners working within a recovery framework.

Wellness Recovery Action Planning (WRAP)

Mary Ellen Copeland has personal experience of mental illness that she has used in developing the WRAP. The philosophy that underpins the WRAP is that prevention is better than cure. The WRAP is an individualised workbook that aims to enable the patient to take control over the problems or difficulties they experience in their day-to-day lives. There is no particular way in which the workbook has to be completed. Some WRAPs are short and sweet, some contain pictures, and others are detailed personal accounts of lived experiences. Patients can work on their WRAP on their own; many, however, say that they find it valuable to have someone they trust to work on it with them. The thoughts and reflections that patients have written in their WRAP serve to remind and guide and also as a resource and source of comfort when times are difficult. Each WRAP will be individual and unique but in our experience we usually find included:

1. Taking each day at a time – the patient will identify what they are like when they are well and what they do to keep feeling well. They will also identify some of the things they may wish to work on to keep themselves well.

2. Understanding triggers – the patient will explore their personal triggers and consider what they can do to avoid and control them.

3. Identifying warning signs – early warning signs are the subtle signs of changes in the patient’s thoughts or feelings or behaviour, which indicate that they may need to take action to avoid a worsening of their condition or situation.

4. Supporters – the patient will list the people who could provide some additional support when things get difficult. They can be family members, work colleagues, friends or healthcare professionals.

You can find out a lot more about WRAPs by visiting the following website: http:​//www.mentalhealthrecovery​.com/ (last accessed: 2.1.12).

Summary

Recovery is a process not a goal. In this chapter we have considered how you as a primary care practitioner can work within a recovery framework in your consultations with patients. At the core of the recovery approach to working with patients with mental health problems is the fostering of hope. We have discussed the Stages of Recovery Instrument as a tool to identify which stage of recovery the patient is in to guide more focused intervention, and Wellness Recovery Action Plans to help patients deve...