The Handbook of Community Mental Health Nursing

Michael Coffey, Ben Hannigan

• Publisher: Routledge
• Year: 2005
• eBook ISBN: 9781134464487
• Subtopic: Health Care Delivery

This handbook brings together authoritative contributions from leading mental health researchers, educators and practitioners to provide a comprehensive text for community mental health nurses in training and practice. In thirty-three chapters it covers a wide range of topics, from the history of the profession to current approaches to specific client groups, organised around three linked themes:

• professional context
• practice issues
• education and research.

Each chapter includes a summary of key points and suggestions for further reading, and also includes useful appendices listing key professional and voluntary organisations, journals, Internet and mailing lists.

The handbook reflects the diversity and scope of the role of the CMHN and recognizes the multidisciplinary and service user context in which nurses work. It is an essential text for CMHNs and mental health nurse educators, and offers a useful source of reference for allied professionals.

PART 1

CONTEXT

INTRODUCTION

It is now almost half a century since mental health nurses first began leaving the psychiatric hospitals to ply their trade in the community. Much has changed in the intervening years, and more change lies ahead. In this opening section, contributions address important historical, social, political and professional issues which have relevance for all community mental health nurses, whatever their particular field of practice.

In his chapter, Peter Nolan provides a lively account of the origins and early development of community mental health nursing. He writes about how, from the 1950s onwards, the work of nurses was increasingly acknowledged as being a therapy in its own right. From this, Peter writes, ‘it was only a small step to recognising that they might be equally effective outside the hospital’.

Paul Godin also starts his chapter in the 1950s, and offers a sociological analysis of the development of community mental health nursing. Whilst Paul sees some evidence of professionalisation, he argues that CMHNs continue to be characterised by a willingness to put themselves in the ‘frontline’ of mental health care.

Chapter 3 is an analysis of the policy and legal context. Here, Ben Hannigan considers the components of mental health care ‘modernisation’, including work launched in the late 1990s to introduce national standards of care and treatment, and work to review the UK's mental health laws. Ben argues that, taken together, emerging mental health policies reveal both tensions and inconsistencies.

In his chapter, Chris Chaloner urges CMHNs to engage in ‘ethical reflection’. Chris makes the point that the everyday practice of community mental health nurses is shot through with ethical dilemmas, and that – for example – even if something can be done, it may not be ‘right’ that it is done.

In their chapter, Rachel Perkins and Julie Repper point out the many ways in which people who use mental health services experience social exclusion and discrimination. The aspirations that people with mental health problems have are no different from the aspirations that everyone has, and Rachel and Julie suggest ways in which CMHNs can assist people to achieve these.

It is now a commonplace that community mental health nurses work in teams alongside members of other professional groups. However, as Edward Peck writes in his contribution, the multidisciplinary community mental health team model has never been free from criticism. New solutions to the difficulties of delivering multiprofessional community care include a move away from ‘locality’ teams in favour of ‘functional’ teams.

In her chapter, Elizabeth Armstrong begins by highlighting the extent of mental health need encountered in primary care, and makes the point that the majority of people with mental health problems are cared for in this setting. Elizabeth urges community mental health nurses to forge close links with their primary care colleagues, and suggests a number of strategies to accomplish this.

Peter Campbell writes about how, despite changes in policy and practice which have brought mental health users and providers of care together in a spirit of collaboration, there is still much that has to be done. Peter writes that, whilst the status of service users within the mental health care system has improved, the position of people with mental health problems in wider society has diminished.

Men and women experience mental health problems differently, and are treated differently by mental health service providers. In her chapter, Anne Fothergill offers some explanations for this, and makes a case for community mental health care which is more sensitive to the particular needs of women.

In his contribution, Suman Fernando argues that mental health services are failing to meet the needs of black and Asian people. He makes a powerful case that the mental health care system is institutionally racist, and ends his chapter by suggesting ways in which this major problem might be addressed.

Working in community mental health care is stressful, and in her chapter Deborah Edwards reviews the evidence which has demonstrated this. However, as Deborah argues, knowledge about the causes of stress has not been matched by an awareness of how stress can be managed, at both the ‘primary’ and ‘secondary’ levels.

This first section of the book ends with a chapter by John Cutcliffe on clinical supervision and reflective practice. John makes the point that the work of CMHNs is inherently isolating, making opportunities for a ‘reflective space’ vitally important for both personal support and professional development.

CHAPTER 1

THE HISTORY OF COMMUNITY MENTAL HEALTH NURSING

Peter Nolan

SUMMARY OF KEY POINTS

This chapter focuses mainly on early developments in community psychiatric nursing. By the end of the chapter, the reader will:

• be aware of the multiple complex factors that led to the emergence of community psychiatric nursing in the late 1950s;
• understand the types of work undertaken by the first community psychiatric nurses;
• appreciate the problems now confronting community mental health nurses.

INTRODUCTION

The birth of community mental health nursing in the late 1950s took place during a troubled period in mental health care. The asylum system, a highly ambitious attempt to manage mentally ill people, which had been founded almost one hundred years previously, was close to collapse. The therapeutic optimism that had produced it and the ardour which had driven its chief architect, Lord Shaftsbury, had become muted. In the mid-nineteenth century, the magnificence of some of the asylums and their superb facades had been symbols of civic pride and social concern; one historian remarked that in France such buildings were used to house royalty, not pauper lunatics (Porter 1987). However, by the 1950s, the system that had once held out hope to the marginalised and the stigmatised had been undermined by overcrowding, bureaucracy and loss of the original vision of providing compassionate accommodation for the mentally ill away from the prisons, workhouses and private madhouses.

Overcrowding meant that 155,000 patients were being accommodated in buildings designed to cater for less than half that number (Shorter 1997). In 1956, Claybury Hospital near London admitted 1,360 patients (560 males and 800 females) compared with 215 in 1937 (Pryor 1993). Overcrowding stifled efforts to create a therapeutic environment. Griffiths (2001) contends that over-diagnosis of psychiatric conditions, coupled with the belief that compulsory institution-alisation was the only solution to mental illness, contributed largely to this glut of patients. In their role as guardians of social order, psychiatrists operated with relatively inclusive nosologies of psychopathology; yet many of the problems with which clients presented were no more than normal reactions to difficult life events. Also contributing to overcrowding was the fact that psychiatric hospitals tended to admit disruptive patients whom relatives and support agencies were very reluctant to re-assume responsibility for on discharge. The burden shouldered by the mental hospitals was only matched by the burden on primary care professionals, relatives and carers of people with mental health problems, who struggled on, receiving little or no statutory assistance (Freeman 1999).

Morale amongst psychiatric staff was further depressed by criticisms such as those made by Peter Townsend in The Observer of 5 April 1964. Townsend described how conditions in the hospitals degraded both staff and patients. He did not blame the staff, but suggested that society should take responsibility for the care provided for its mentally ill. Echoes of Townsend were heard at the 1964 Annual Conference of the Chief Male Nurses Association when attendees were told that the psychiatric nursing profession was ‘despondent’. Delegates heard that approximately 70 per cent of student nurses left before completing their training, not because of the nature of the work but because of the way in which they were treated. Split shifts, long days, scant notice of ‘off-duty’, and ‘heavy-handed and insensitive management’ contributed to low morale. The conference also heard that training was largely irrelevant to the work nurses were being asked to do on the wards, and yet nurses were being blamed for low standards. One delegate asked:

What can nurses do about the appalling conditions that still persist in mental hospitals? Nurses are asked to remedy the situation, but how can they when they have no power in the organisation and have no presence on any decision making committee?

(quoted in Nolan 1993, p. 127)

In July 1948, the National Health Service (NHS) came into being. The first Minister of Health was also the Minister of Housing, to emphasise the relationship between living conditions and health (Webster 1998). Psychiatry, which was predominantly based in psychiatric hospitals, came under the aegis of the NHS. The hospitals were encouraged to remain independent of the acute sector and were funded to provide their own pathology laboratories, X-ray departments and other investigative and medical facilities. This expansion of services elevated the standing of psychiatry within the NHS, and yet isolated it from other health services. Policy-makers appeared to believe that relatively minor changes could reform the mental health system (Rogers and Pilgrim 2001), although dissenting voices argued that the infrastructure of care had to be tackled if there were to be real and ongoing improvements in the services provided (Martin 1984).

Within a decade of its inauguration, the Guillebaud Report (1956) confirmed that the NHS was proving far more costly than originally envisaged. The Report also noted, with regret, that the NHS had become a national hospital service rather than a national health service, with pre-eminence given to the acute sector to the detriment of other areas of health care, including mental health services. By the 1960s, mental health services were in crisis, as the first of eighteen public inquiries revealed. Authors such as Szasz (1960) decried the way in which patients were excessively medicated and confined within soulless institutions. The Manchester Regional Hospital Board (1956) summarised the problems it faced when asked to take over mental health care in their area:

The Board inherited mental hospitals some of which were in the neighbourhood of 100 years old, and most of them were victims of damage and bombings during the last war. In addition, they were … generally ill adapted to the needs of patients under treatment within them. The patient population in the hospitals was predominantly composed of chronic long-stay patients in various stages of deterioration resulting from prolonged hospitalisation.

Szasz suggested that psychiatrists were colluding with the State to control nonconformist, ‘awkward’ citizens. Shepherd et al. (1966) advised that mental health care could be improved by strengthening the role of general practitioners. Treating mental health problems in general practice would reduce stigma for clients and have a significant impact on the number of patients in psychiatric hospitals. Primary care personnel were ideally placed to identify the early signs of mental ill health and to initiate treatment. Over thirty years later, the central role of primary care has been enshrined in the National Service Framework for Mental Health (Department of Health 1999).

REFORM FROM WITHIN

It would be a mistake to presume that reform of the mental hospitals was dependent on the arrival of the NHS. In 1935, the ‘kind and benevolent Welshman’, T.P. (Percy) Rees, superintendent at Warlingham Park Hospital, had embarked on a crusade against ‘locks and keys’. All the wards were unlocked including, to the horror of staff, the doors confining the suicidal patients (Shorter 1997). Rees strove to reduce the time patients spent in his hospital, recognising that there were only limited benefits to be gained from removing people from their homes and social networks. By the 1950s, attitudes were changing in line with Rees's thinking. New policies and innovative care included: adoption of the open-door policy by some superintendents (Dr MacMillan at Mapperly Hospital, Nottingham, 1954; Dr Stern at Central Hospital, Warwick, 1957; Dr Mandelbrote at Coney Hill Hospital, Gloucester, 1957); part-time hospitalisation; provision of easily accessible out-patient care; industrial therapy; hostels for people with mental health problems; therapeutic social clubs; locating psychiatric units in general hospitals; and mental health staff carrying out home visits (Shorter 1997). The discovery of powerful new psychotropic medication assisted these changes by controlling the symptoms of major mental illness. For many, the introduction of Largactil (chlorpromazine) refuted the conjecture that schizophrenia was irreversible and deterioration inevitable.

During the 1950s, it began to be recognised that nursing care might in itself be therapeutic and that nurses could be used more effectively than simply to subdue and control patients. Cameron and Laing (1955) reported the transformation that took place at Glasgow Royal Infirmary when nurses and patients started talking to each other more. Patients got to know their nurses, were able to feel relaxed with them, and, as a result of their attention, began to take an interest in themselves and their futures. ...

Table of contents

• Cover Page
• Half Title page
• Title Page
• Copyright Page
• Contents
• List of tables, boxes and figures
• Notes on contributors
• Acknowledgements
• Introduction
• Part 1 Context
• Part 2 Practice
• Part 3 Education and research
• Appendix I: Professional organisations
• Appendix II Voluntary organisations
• Appendix III Journals and magazines
• Appendix IV Internet sites and discussion lists
• Index