To be covered this week

Introduction and aims Differentiate mental health from mental illness Conceptualise the mental health continuum Recognise your own mental health needs Develop awareness of stigma, discrimination, stereotypes & labelling Understand what is person-centred/recovery-oriented mental health nursing? Understand the therapeutic use of self Understand the role of professional boundaries Understand cultural safety Develop awareness of the Safewards Model


Aims of NSB204

• to provide you with fundamental knowledge about mental health & mental disorders across the lifespan

• to enable you to recognise and take care of your own mental health needs

• to provide you with the skills to assess, plan for and work with people experiencing various mental health problems & disorders

• to increase your self-awareness, openness to others, compassion, acceptance, and communication skills

• to enable you to apply the principles of cultural safety to person-centred, recovery- oriented care


Mental health and mental illness

• We all have mental health and all of us experience mental health challenges

• The two terms do not have the same meaning. See page 123 of your text for further elaboration.

• Mental health nursing skills enable us to help others with mental health concerns and also to help ourselves to consciously care for our own mental wellbeing

Mental Health

‘A state of well being in which an individual realises his or her own abilities, can cope with

the normal stresses of life, can work productively & is able to make a contribution to his or

her community’ (WHO, 2010 cited in Happell, Cowin, Roper, Lakeman & Cox, 2013 p. 183).

‘A state in which an individual has a positive sense of self, personal & social support with

which to respond to life’s challenges, meaningful relationships with others, access to

employment & recreational activities, sufficient financial resources & suitable living

arrangements (Elder et al. 2013, p. 477).

Mental Illness

• Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (2013)

• International Classification of Disorders (ICD-10)

• Mental Illness is defined legally and is regulated by relevant Mental Health Acts in each Australian State.

• Mental illness – is characterised by a clinically significant disturbance of thought, mood, perception or memory

• a person must not be considered to have a mental illness merely because of any one or more of the following:

(a) holds or refuses to hold a particular religious cultural, philosophical or political belief or opinion (b) member of ethnic or ‘racial’ group (c) economic or social status (d) sexual preference or sexual orientation (e) sexual promiscuity (f) immoral or indecent conduct (g) takes drugs or alcohol (h) intellectual disability (i) antisocial behaviour or illegal behaviour (j) involved in family conflict (k) previously been treated for mental illness or previously subject to involuntary assessment or

treatment (Queensland Government 2017, p. 5).

Definitional dilemmas

Recognise that ideas of health and therefore, definitions of health and illness, are social constructs (i.e. created by people).

Social, political, economic, cultural and historical factors influence definitions of illnesses (diagnosis) and treatment

Definitions and treatment are susceptible to changes in values in society (e.g. homosexuality as a mental illness).


Mental Health Continuum

Wellness Illness

when becoming unwell or not coping we begin to lose function in one or several of the following areas – occupationally, intellectually, socially, psychologically, physically

when we are well we function at our usual levels or in our usual way occupationally, intellectually, socially, psychologically and physically

The mental health continuum

• minor symptoms to severe psychotic disturbances

• shades of human experience that lie between extremes

• the capacity for health status to shift between mental health and mental illness

• we all shift along the continuum

• any one of us could develop a mental illness at any time

• our own experience helps us to empathise with others …health professionals, including nurses, are of course also service users

• challenges ‘us and them’ ideas

• those diagnosed with a mental illness can become well


Prevalence of Mental Illnesses – (Slade et al. 2009)

• 45.5% of the total population experienced a mental disorder at some point in their lifetime • 20% of Australians aged 16-25 experienced a mental disorder in the previous year (i.e. almost 3.2

million people) • 14.4% suffered anxiety disorders • 6.2% suffered mood disorders • 5.1% suffered substance use disorders – men represented twice the number of women. • The prevalence of mental disorders declines with age from 26.4% in the 16-24 year age group to

5.9% in the 75-85 years group. • 11.9% of the population used health services for mental health problems in the previous year and

almost 20% had lifetime disorders • Women are much more likely to access services than men

The Stress Vulnerability Model

• A theory of causation of mental illness (Zubin & Spring, 1977) • the interaction between a person's vulnerability, their coping ability, and the

stressors they are exposed to will determine whether a mental illness will develop or not.

Harmony, calm, peacefulness

What are vulnerabilities?

• Genetic predisposition • Country of birth? • Family of birth (as an adverse interpersonal environment; learned behaviour) • Presence of physical conditions/disease • Learning difficulties • Substance use/abuse

The Stress Vulnerability Model • Stressors challenge our ability to adapt. • Internal factors – developmental challenges, toxic substances, infection

responses, pregnancy, physical responses to external stressors; and • External factors – for example, bereavement, promotion, marriage,

work/study pressure • Holmes & Rahe Social Readjustment rating Scale (1967). e.g.

The Stress Vulnerability Model

• The more vulnerability, the less stress is required to trigger the symptoms of a mental illness.

• Zubin & Spring (1977) argue that episodes of psychosis can arise for anyone under the right conditions (e.g. refugee detention).

• It is important that we consider all of the factors interacting to potentially cause illness for a person (including ourselves).

The Water Tank Metaphor

The water tank represents our genetic makeup, which is predetermined. Some people are born with bigger tanks than others and they therefore have the capacity to hold more water and greater influxes before overflowing. ned/Risk_and_protective_factors/risk_objective_2/ind ex.html

The Water Tank Metaphor

The inflow pipe represents the external stressors (risk factors) which are often beyond our control. For example, rain often falls heavily and gutters fill quickly during a storm. This is equivalent to being overwhelmed by stressors - lots of stress all at once. At other times rain is minimal - not much stress. At other times rain may be regular and predictable - chronic but manageable stress.

The Water Tank Metaphor The outflow pipe represents personal (protective) factors such as habits and learnt coping strategies, or external protective factors like social support and employment. People with good coping strategies or strong external supports can control their outflow effectively to manage the water level in the tank, even when inflow is rapid and unpredictable. Others, particularly those with smaller tanks, might not be able to control their outflow and water levels will rise and cause overflow.

The protective factors differ for all of us

• Good physical health • Social support • Strong family relationships • Problem solving skills • Mindfulness skills/stress management skills • Sense of belonging • Internal locus of control • Little or no community violence • Also see p. 502 of your text for a comprehensive list of risk and protective factors.

Perspective is everything

Stop. Think. Respect. Racial discrimination and mental health.

• (2 mins 7 sec)

Stigma and Discrimination

Stigma, stereotyping and labelling

• negative attitudes, shaming & discrimination from others - experienced by most people with mental illnesses

• being treated by others as if one is disgraced

• an attitude that is deeply discrediting

• people get labelled by their illness and are stereotyped

• people accept the world view and engage in self-stigma

Labelling and disempowerment

• Feeling diminished by the diagnostic label (2 mins 40 sec)

How society contributes to distress

• What are some common stereotypes of those experiencing mental health problems?

• What are some myths about those experiencing mental health problems?

• Stereotyping is often revealed in insulting names & terms.

• Can you think of any?

Perceptions/attitudes to mental illness might be shaped by...

• personal experience

• ignorance, misinformation, no information, misunderstanding information

• modelling by family, peers and society such as through media – social; digital, electronic and print; film; music

• personal and societal values


What is person-centred mental health care?

The person is central to the process of mental health care

Recovery from mental illness is always possible

Recovery as a philosophy for practice

• “is a person-centred approach, underpinned by principles of social justice and equity, which

challenges an exclusive biomedical model of focusing mainly on symptom identification and

treatment” (Muir-Cochrane, Barkway & Nizette, 2014, p9).

• Provides a way of organising your thoughts about working with people with mental illness.

• Opens up possibilities for people with serious mental illness that were never understood only 30-

40 years ago.

Critical Factors in Recovery

• “Just one person who believed in me” • Friends • Pets • Medications (for some) • Personal goals • Self-will • Professionals (Curtis, 1997).

Core Elements of Recovery

• Hope – the belief that change and a better way of life is not only possible, but also attainable. • Personal Responsibility – not counting on others to solve one’s problems or cure the disorder,

but relying on one’s self with help from others. • Self-Determination - re-establishing control over one’s personal life, rights, and responsibilities. • Relationships - assistance from friends, family and professional health/mental health care givers. • Understanding - learning about the disorder, one’s self, what can be done, what is available to

help (Stanton, Tooth & Champ, 2017). • Identity – developing a sense of self beyond a diagnostic label (Palmer & Halpin, 2017).

A Recovery Focused Mental Health System

• Professionals do not hold the key to recovery, people with mental illness do. The task of professionals is to facilitate recovery while the task of people who are unwell, is to recover.

• Recovery can occur even though symptoms reoccur. The episodic nature of severe mental illness does not prevent recovery.

• Recovery changes the frequency and duration of symptoms. Symptoms interfere with functioning less often and for briefer periods of time.

• Recovery involves growths and setbacks, periods of rapid change and little change. The recovery process feels anything but systematic and planned.

• Recovery from the consequences of the illness is sometimes more difficult than recovering from the illness itself (e.g. stigma and discrimination) (Anthony, 1993).

Recovery From Schizophrenia

Sample Size Length of Study (years) % Recover or significantly improve

Bleuler (1972) 208 23 53-68

Huber et al (1979) 502 22 57

Ciompi & Müeller (1976) 289 37 53

Tsuang et al (1979) 186 35 46

Harding et al (1987) 118 32 62-68

Recovery from mental disorders – Pat Deegan

• (4 mins 8 sec) • The full Pat Deegan story – Recovery vs rehabilitation (49 mins) can be viewed at:

Pat Deegan

“Normal people get to make many stupid choices over and over again in their lives.

Nobody tells them they need a case manager. How many times has Elizabeth

Taylor been married? At last count it was seven or eight times. The poor woman

lacks insight! She exercises poor judgment! She is making the same dumb

choice again! How come they don’t get her a case manager?” (Deegan, 1993, p9).

“Those of us who have been diagnosed are not objects to be acted upon. We are

fully human subjects who can act and in acting, change our situation. We are

human beings and we can speak for ourselves. We have a voice and can learn to

use it. We have the right to be heard and listened to. We can become self-

determining. We can take a stand toward what is distressing to us and need not

be passive victims of an illness. We can become experts in our own journey of

recovery” (Deegan, 1996, p92).

Therapeutic use of self

Fundamental to mental health nursing practice

The instrument of therapy is ourselves

Skills and qualities for the development of therapeutic alliance

Therapy not necessarily an external intervention – human connection is powerful


Therapeutic use of self

We bring our own personality, experiences, values, feelings, intelligence, needs, coping skills & perceptions

The goal is to establish relationships

Form a connection (rapport)

Communicate warmth, compassion & understanding


The self

Understanding ourselves involves developing self awareness, which helps us to understand others

Self awareness: Knowing how you respond (emotions) Understanding who you are (identity) Acknowledging your own worth or value (self-esteem) Appreciating your effect on others


Why do we need self-awareness?

the purpose of knowing the self is to be aware of the effects of our

experiences on who we are and how we relate to others. We

carry ‘stuff’ with us that might affect how we relate to those we

work with.


The professional self

self awareness is essential for reflective practice

self awareness is essential for critical thinking

self- awareness is essential for being authentic


Reflection on self also concerns…..

Empathy – which is related to our ability to develop therapeutic relationships

• a process of communicating your understanding

• don’t presume to understand the person

• clarify

• validate/paraphrase

• reflect


Therapeutic relationships

foundation of person-centred mental health nursing - built on the therapeutic use of self

awareness and maintenance of professional boundaries

well developed communication skills

establishes the skill to gain the trust of people in our care and their families


Mental health nursing

• mental health nursing work 4:48 mins

Therapeutic relationships

• rapport • trust • respect • genuineness - authenticity • empathic communication

Goal-oriented Focus is the person’s needs Learning and growth promoting We work with the person and their family


Professional boundaries • separate therapeutic behaviour from that which could lessen the benefit of care

• give each person a sense of legitimate control

• Identify the limits to nurse-client relationships

• laws create some boundaries and other limits are set by licensing bodies

• expectations influence how we behave

• how can nurses maintain a professional boundary and develop a close therapeutic relationship at the same time?


Cultural safety

Cultural safety defined:

“...the effective nursing of a person/family ... by a nurse who has

undertaken a process of reflection on own cultural identity and

recognises the impact of the nurse’s culture on own nursing

practice” (NCNZ, 2011, p. 7 cited in Happell et al. 2013, p. 351).


Cultural safety (Cox & Taua, 2013)

steps to cultural safety

1. cultural [self] awareness 2. cultural sensitivity 3. cultural safety

produces – an environment where people can be themselves and have their needs met without being

challenged or insulted

NB: notice how similar cultural safety is to the goals of therapeutic relationships and the therapeutic

use of self. All of these are dependent on increasing self-awareness.


Strategies for culturally safe care

• become aware of our own culture and ethnocentrism [biases & prejudices]

• know that it is counterproductive to treat all people the same or as if they are the same

• avoid stereotypes/generalisations

• acknowledge the limitations of your own expertise

• share power

• accept that people define themselves and they are able to do this as experts on their own culture and situation


Strategies in the provision of culturally safe care … cont.

• assist people to use available services

• advocate for the people for whom you have a caring role

• embrace the fact that culture is not only about ethnicity – it includes gender, gender identity, class, sexuality, disability, age

• focus on your own cultural assumptions and not about learning recipes about others – this always leads to problems.


Novelist Chimamanda Adichie tells the story of how she found her authentic cultural voice -- and

warns that if we hear only a single story about another person or country, we risk a critical


Chimamanda Adichie: The danger of a single story

The Safewards Model

• Developed to address high rates of aggression in some acute psychiatric inpatient units (Bowers, 2014)

• Identified core factors that contribute to conflict and containment in these settings and then strategies to minimise conflict and containment

• There are six interacting domains that underpin the Safewards model. • There are 10 strategies to minimise conflict and containment

Ten Interventions

• Clear mutual expectations • Soft words • Talk down • Positive words • Bad news mitigation • Know each other • Mutual help meeting • Calm down methods • Reassurance • Discharge messages

The Safewards Model

• Professor Len Bowers presents the Safewards Model:

• (Full length introduction:

Positive Words • Suggestions from our service user group:

• Positively reframe, positively connote, find a positive aspect to some behaviour (doing handstands in the day room = perfect handstands, showing great agility).

• Seemed to be coping with things better. • Had a really good conversation with me. • Managed to say something to me. • Remains a complete pain in the arse but they got up for breakfast. • Had a bath; enjoyed activities. • Interacted well with named nurse/doctor. • Ate all their food. • Took meds calmly; stated meds were helping them feel better. • Enjoyed a walk. • Slept well. • Less disruptive. • Interacted more today.

• (4 mins 49 sec)

Web Sites for eMental health - free online help for distress, anxiety, depression etc. and other relevant sites

Mind Spot

Mood Gym

Beyond Blue

anxiety awareness film

SANE Australia

Black Dog Institute

Australian Government Department of Health


References Anthony, W. (1993). Recovery from mental illness: the guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal, 16(4), 11-

23. Bowers, L 2014. Safewards: a new model of conflict and containment on psychiatric wards. Journal of Psychiatric and Mental Health Nursing, vol. 21, no. 6, pp.499-

508. Cox, L., & Taua, C. (2013). Socio-cultural considerations & nursing practice. In J. Crisp., C. Taylor., C. Douglas., & G. Rebeiro. Fundamentals of Nursing., 4th Edn.

Sydney: Elsevier. Curtis, L. (1997). New directions: International overview of best practices in recovery and rehabilitation services for people with serious mental illness, New Zealand

Mental Health Commission, Wellington. Deegan, P. 1993, Recovering our sense of value after being labelled mentally ill, Journal of Psychosocial Nursing, 31(4), 7-11. Deegan, P. 1996, Recovery as a journey of the heart. Psychiatric Rehabilitation Journal, 19(3), 91-97. Happell, B., Cowin, L., Roper, C., Lakeman, R., & Cox, L. (2013). Introducing mental health nursing: A service user oriented approach. (2nd ed.). Sydney: Allen &

Unwin. Muir-Cochrane, E., Barkway, P., & Nizette, D. (2014). Mosby’s pocketbook of mental health (2nd ed.). Sydney: Elsevier Australia. Palmer, C., & Halpin, M. (2017). Pathways of care. In L. Moxham., M. Hazelton., E. Muir-Cochrane., T. Heffernan., C. Kniesl., & E. Trigoboff. Contemporary psychiatric-

mental health nursing: Partnerships in care. Melbourne: Pearson Australia. Queensland Government. (2017). A guide to the mental health act 2016. Brisbane: Queensland Health. Slade, T., Johnston, A., Teesson, M., Whiteford, H., Burgess, P., Pirkis, J., & Saw, S. (2009). The mental health of Australians 2: Report on the 2007 national survey of

mental health and wellbeing, Canberra: Commonwealth of Australia.$File/mhaust2.pdf

Stanton, V., Tooth, B., & Champ, S. (2017). Recovery as the context for practice. In K. Evans., D. Nizette., & A. O’Brien. Psychiatric and mental health nursing. Sydney: Elsevier Australia.

Zubin, J., & Spring B. (1977). Vulnerability: a new view of schizophrenia. Journal of Abnormal Psychology , 86,103-126.