THE IRISH STATE OF MENTAL HEALTH- PRIVATE PSYCHOTHERAPY PRACTICE
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THE IRISH STATE OF MENTAL HEALTH-PRIVATE PSYCHOTHERAPY PRACTICE
The Irish health care sector is now becoming aware of the problems faced by mental health care. A report in 2009 stated that Irish mental institutes are deteriorating with a decrease in the quality of care. Some of the problems stated by the report found in the mental institutes include poor state of the facility with very low maintenance, “dysfunctional management”, untrained staff carrying out complicated procedures unsupervised, lack of proper services for emergency management etc. (O’Brian, Psychiatric Wards Unfit for Human Habitation ,2009). The option to sell various mental health assets in order to improve the situation is neither a long term nor feasible solution. Therefore, it is important to identify this matter as one of urgency and steps taken to improve mental health care (O’Brian, Psychiatric Wards Unfit for Human Habitation, 2009).
These issues are not only related to the conditions of the hospitals, which are stated “unfit for human habitation” (O’Brian, Psychiatric Wards Unfit for Human Habitation, 2009). Rather, these are the manifestations of the deeper policy issues that are flawed in many areas, with little interest in the past to improve them. These include the absence of proper community based mental health services despite centralization of the health service sector, inequity in the division of the resources, finances and staffing, and lack of initiative to stop restrictive work practices that have been banned, but are still being carried out. All these point towards a lack of direction in creating a vision for improved mental health care (O’Brian, Progress in Mental Health Services Still Painfully Slow, 2009). These issues will remain unless efforts are undertaken to address them.
DIFFERENT SOLUTIONS PROPOSED FOR IRISH MENTAL HEALTH
Although the situation of the mental health care system still faces difficulties, the initiatives to improve and change them have been in the working for some time. The Mental Health Commission in 2004 proposed the utilization of the recovery model as a new change in the mental health sector (A Vision for a Recovery Model in Irish Mental Health Services, 2005, pp 5). This model was based on the need to create a better mental health care plan, which can provide the patients with best services along with long term outcomes (Mental Health Act, 2001, pp 10). This model also allows for research in this area. Such initiative was itself a sign that mental health in Ireland is indeed taking a new turn for the better (A Vision for a Recovery Model in Irish Mental Health Services, 2005, pp 5, Hall, 2006, pp 32).
These initiatives come at a time where the Irish Mental Health care setup is divided between leaving the older versions of mental health care behind and integrating newer systems, which mean completely changing the mental health care setup. Although such an initiative is valued among the nursing community, there is still much pondering and planning to take place in order to convince all. This change comes at a time when the de-institutionalization of the Irish mental health care sector is taking place, creating all the more tension, and questioning the true efficacy of these initiatives in the long run.
Inclusion of other institutions and social sectors in improving mental health is another aim in the new reforms. Inclusion of institutions such as volunteers, support groups, academic institutions, media, politicians, and the general public will have many benefits. By increasing awareness and personal contribution and responsibility in the overall mental health of the society, the incidences of mental illnesses are likely to decrease and will be accepted readily (Hall, 2006, pp 60). These integrated pathways will allow for unification towards a single purpose and will help in achieving better results than through traditional medical approach alone (Hall, 2006, pp 60).
THE VISION FOR CHANGE: A NEW PERSPECTIVE
In many ways the vision for change model is not a new concept. It is still based on the older versions of mental health care provision. Mostly, this means the utilization of the medical model in mental health care provision. It aims to modify the already placed policies, and aims to organize the mental health care system on the national level. At the same time, it aims to provide autonomy to the local mental health facilities by coordinating local catchments via the Mental Health Catchment Area Management Teams. This means that the hierarchy developed will be HSE, under which the National Mental Health Service Directorate falls in, which in turn, manages the Mental Health Catchment Area Management Teams (A Vision for Change, 2006, pp 10). The players remain the same; however, their roles and attitudes are now much different. For example, the vision of change now aims to encompass all those who come in contact with it in order to gain the result it desires, which is the reduction in the number of mentally ill patients by treating them completely. For this, the vision of change is now trying to include all those who seek mental health care facilities, and include them in the treatment plan. This includes the patients as well. The vision of change also aims to work on all age groups, in order to achieve preventive and therapeutic effects simultaneously (A Vision for Change, 2006, pp 11).
A common problem that is usually faced by patients is the change in residence and consequently, the loss of the service provider. The new Community Mental Health Teams have been created just for this purpose (A Vision for Change, 2006, pp 12). These teams are involved in providing mental health care and facilities at the hospitals, care centres as well as at the patients’ homes. By having one continuous caretaker or caretaking team, it is hoped that the results achieved will be better (A Vision for Change, pp 12).
DIFFERENT MODELS OF SERVICE DELIVERY IN MENTAL HEALTH SECTOR
THE BIOPSYCHOSOCIAL MODEL
As the name implies, this model focuses on understanding the interconnection between the various factors and people in the patient’s life, and utilizing them to make a cohesive treatment plan. The three different areas include the biological factors and illnesses, the psychological issues the patient may be facing and the social functioning and how to manage it with the illness (A Vision for Change, 2006, pp 20). In many ways, it aims to harness the traits, qualities and the positive aspects of the person and his life and use them to treat the patient. This concept is not new, for it is well known how mental illness is a complex combination of the various factors, experiences, and associations that are made by the person of his experience. By understanding and identifying these factors, the patient can be guided to use these facts to their advantage and improve their outcomes (A Vision for Change, 2006, pp 20).
THE RECOVERY MODEL
Much of the psychiatric treatment options used in the past did not engage the patient into actively taking part in his own recovery process. This passive role of the patient in his recovery led to higher rates of relapse, which meant increased burden over the mental health care sector over time. The emerging concepts now look into the different methods through which the person is engaged in his own treatment plan, and encouraged to take a more active role in reclaiming his life. The recovery model works on these principles. This model states that by helping self and gaining control over self a person can improve his mental health and become a more productive member of the society (A Vision for a Recovery Model in Irish Mental Health Services, 2005, pp 5 and 6).
This model works by acknowledging biological, psychological as well as social components of mental illness and therefore, aims to combine all these three areas in the treatment regime. The positive comments for this particular model can be found in many of the international seminars, researches and studies. The increased implementation of this model in the various mental health systems of the world is in itself a sign that recovery model may be the next level of mental health care (A Vision for a Recovery Model in Irish Mental Health Services, 2005, pp 7).
The theme of recovery model includes the following areas
- Living well under the circumstances
- Full participation in the activities of the community
- Self management and responsibility
- Personal growth
- Person centered services
- Resilience and
- Empowerment (A Vision for a Recovery Model in Irish Mental Health Services, 2005, pp 12)
In the same way, different programs to improve the patients’ confidence and helping them in their re-employment are some of the ways better mental health outcomes can be achieved (Promoting Mental Health, 2004, pp 40). The JOBS initiative which is being carried out in Ireland along with other countries has shown good outcomes for mentally ill patients in terms of quality of job, self efficacy and mastery. Such programs have shown to decrease depression among the patients as well, and integrating them as models among others in mental health care practice may translate into better long term outcomes (Promoting Mental Health, 2004, pp 40).
Many programs have been developed based on this recovery model, which include the WRAP or the Wellness Recovery Action Plan, the Recovery Workbook, the BRIDGES program and the Anxiety and Phobia Workbook among a few (A Vision for a Recovery Model in Irish Mental Health Services, 2005, pp 25).
THE MEDICAL MODEL
The medical model in psychiatric illness may be viewed as the traditional concept of treating mental ailments. It is however, much more than that and therefore, should be appreciated for its contribution towards complete mental health. In comparison to the recovery model and other such initiatives, the medical model seems outdated and even in opposition. Even the terminologies applied to address the same situation differ, as shown in the table 1 (A Vision for a Recovery Model in Irish Mental Health Services, 2005, pp 16). However, medical research and treatment is among the most important contributors towards health in mental illness. The aim should be to create a blend of treatment which is able to use the positive aspects of all kinds of mental health models.
Table 1 (A Vision for a Recovery Model in Irish Mental Health Services, 2005, pp 16)
THE ADMIRAL NURSE MODEL
The admiral nurse model is a specialist nursing competency framework, with eight core competencies. These nurses are specialists in managing dementia, and work with families and caretakers of the patients (The Admiral Nurses’ Competency Framework, pp 1, nd). In this way, the admiral nurses are involved in improving the quality of life of the patients. The eight competencies of the admiral nurses include therapeutic work and interventions, sharing information about dementia and carer issues, improving assessment skills, prioritizing work, carrying out preventive work and health promotion, creating a health care system which is ethical and person centred, creating a system whereby the needs of both the carer and the patient with dementia are met and promoting best practice (The Admiral Nurses’ Competency Framework, pp 2, nd).
This new system has provided much improvement in the management of dementia patients. The system is specially created around the patient with dementia, which makes it easier for the clients to access services, and improves partnership. The nurses are able to focus on the patient along with carrying out research, thereby improving their professional skills (The Admiral Nurses’ Competency Framework, pp 3, nd).
PRIVATE PSYCHOTHERAPY PRACTICE
Private mental health services have grown as an alternative to national mental health services, and continue to provide important contributions and services in their areas. In 2003, the number of admissions in private psychiatric institutes was 18 % (A Vision for Change, 2006, pp 55). Private mental health consultation is also availed by many people in Ireland. Approximately 52% of the population holds private insurance (A Vision for Change, 2006, pp 55). Many of the patients go to the private practitioners on fee pay basis (A Vision for Change, 2006, pp .61).
Over the years, the private sector has been able to provide somewhat better quality of services to the patients. This sector has been able to work towards creation of multidisciplinary teams, which has given it an edge over public mental health care sector. The private sector also employs a large share of the nurses in mental health care provision. The private sector also has seen a good organization level, with managers coming from different backgrounds (A Vision for Change, 2006, pp 66).
This contribution of the private sector in the mental health care setup would not have been possible without the Griffith’s report into community care (Hall, 2006, pp 42). At the time, this report was given much criticism since it allowed the entry of free market economy in the NHS.
However, it also paved way for an alternative and a choice for the patients. The above mentioned statistics reveal how private mental health care is catering to the needs of many patients, and how it may be of some hope to patients when the public sectors are facing such tremendous challenges (Hall, 2006, pp 42). This sector has been able to introduce much more than another option for treatment in the mental health care sector. The private psychotherapy practice allows the patients to refer themselves to another psychiatrist, which helps them decide their own service provider (Irish Mental Act, 2001, pp 15). Such an option is not readily available in the NHS, where the people get service from the doctors within their own location (Hall, 2006, pp 60). Such private practices have been criticized for taking their own initiatives and ignoring some of the policy guidelines set by NICE and NHS in mental care. However, it is with these initiatives that mental health sector has been able to allow new concepts and ideas into itself (Hall, 2006, pp 78). The new recovery model, although was accepted in the NHS, may not have gained such vote of confidence without independent implications by some of the private mental institutions (Hall, 2006, pp 78).
In all this, psychotherapy distinguishes itself by placing high emphasis on the “therapeutic relationship” and believes in psychodynamic psychotherapy. Supporters claim that it remains one of the leading areas of improvement in mental health care, which was not attainable in the public sector (Burns, 2004, pp 77). This concept however, still remains critically acclaimed and therefore, require more understanding and research to gain widespread acceptance. This concept of “assertive outreach” claims that it allows the mental healthcare teams to work closely with the patient, and therefore helps them identify fully the different factors that contribute towards his mental condition. Through regular contact and connection, the patients are able to get full time access to mental health care, which translates into successful outcomes (Burns, 2004, pp 78).
This system has identified the contribution of each member in its ultimate success. Therefore, in order to operate fully, there is need to have nurses, psychiatrists, social workers fully integrated into the system (Burns, 2004, pp 79). Depending on the need of the area, the teams should be made large or small. The need for full time as well as part time staff is another aspect that needs addressing (Burns, 2004, pp 79).
The mental health care system in Ireland is in need of serious reforms and introduction of new policies and ideas, which can improve patient outcomes. So far, the private sectors have shown more inclination towards change than the public ones. In order to achieve substantial results, the public and the private sectors both need to identify their areas of weakness and work upon improving them.
The Admiral Nurses’ Competency Framework, nd. Site last accessed on October 2nd, 2010 from http://www.dementiauk.org/assets/files/what_we_do/admiral_nurses/comp_frame_sum.pdf
Burns Tom, 2004. Community Mental Health Teams: A Guide to Current Practices. Oxford University Press, 2004.
Hall Julie, 2006. Integrated Care Pathways in Mental Health . Elsevier Health Sciences, 2006.
Irish Mental Act, 2001. Site last accessed on October 2nd, 2010 from http://www.mhcirl.ie/Mental_Health_Act_2001/Mental_Health_Act_2001.pdf
O’Brian Carl, 2009. Progress in Mental Health Services Still Painfully Slow. The Irish Times, Monday 28th, 2009. Site last accessed on October 2nd, 2010 from http://www.irishtimes.com/newspaper/ireland/2009/1228/1224261300804.html?via=rel
O’Brian Carl, 2009. Psychiatric Wards Unfit for Human Habitation, Report Finds. The Irish Times MondayDecember 28, 2009. Site last accessed on October 2nd, 2010 from http://www.irishtimes.com/newspaper/frontpage/2009/1228/1224261302831.html
Promoting Mental Health-Concepts, Emerging Evidence, Practice, 2004. Summary Report by World Health Organization, Department of Mental Health and Substance Abuse in Collaboration with the Victorian Health Promotion Foundation and the University of Melbourne.
A Vision for a Recovery Model in Irish Mental Health Services, 2005. A discussion paper by Mental Health Commission.