Mental health articles

OF mental health care and mentally ill

The development of mental health services for older people

The history of mental health care is long and complex, but it is important to understand the legacy that current services have inherited as some influences from this remain today. Some of the earliest documentation refers to the founding of the BethlehemHospital in London in 1327 for the mentally distracted. One of the first attempts to legislate in the field of mental health care was the 1774 Madhouses Act; this act introduced the concept of inspection of madhouses by commissioners.

The development of the lunatic asylum can be attributed to the 1845 Lunacy Act. This legislation led to the compulsory founding of asylums in every county borough in the UK. While with hindsight we tend to see the old asylums as very unpleasant places, in 1845 the idea of care for ‘lunatics’ was seen as very progressive and innovative. In 1957, the Percy Report claimed that there needed to be a much more therapeutic approach to mental health and monitoring of asylums. This report led to the 1959 Mental Health Act, which is often regarded as setting the foundations for modern mental health care. The development of neuroleptic drugs in the 1950s also played a revolutionary role in the development of mental health care. While there are without doubt many issues around the use of neuroleptic drugs, and clear evidence exists that they have at times been misused, there remains little doubt that they did revolutionise care. They brought about the demise of regular use of straitjackets and locked wards in ‘mental hospitals’. They also slowly led to the development of community mental health care. It took nearly 50 years for the old psychiatric hospitals to close their doors, but it is now unlikely that people entering mental health care now will spend the rest of their lives in institutional settings. Kitwood  highlighted that the historical approach to older people in institutions was to ‘warehouse’ them. The suggestion was that they were cared for in places of safety where their basic human needs were provided for, but little else. Even today, institutional care can persist in any environment where staff do not focus upon the needs of the individual or do not question rituals. As the move towards community care developed in the 1970s, community services developed in an unstructured and disorganised way, and health and social services saw the needs of those with mental health conditions very differently.

Despite the fact that there were some areas of excellent development, there were nonetheless a number of tragedies involving those with mental health needs, the most well known being the death of Jonathan Zito, who was murdered by Christopher Clunis on an underground station for no apparent reason. The enquiry into Jonathan Zito’s death concluded that poor communication between health and social services and a lack of effective care coordination were contributing factors. As a result, an emphasis upon joint local services for people with mental health needs became a government priority, and thus the Care Programme Approach came to fruition.

The Care Programme Approach should ensure that all older people with mental health needs, living in the community: have a key worker; have regular reviews of the care package undertaken by the multiagency team; have all care assessed and that care is reviewed in a systematic way. A further requirement of the Care Programme Approach was to make the person’s perspective central to any plan of treatment or care. This has been affirmed as a central component in the Review of the Care Programme Approach 2006. The notion of person-centred care has become well established within both health and social care professional frameworks and is an idea associated with the groundbreaking work of Tom Kitwood. Person-centred care aims to break the traditional approach to care, which often involved ritualised approaches. It aims to ensure that each person is cared for in an individualised manner. It is a concept that is now well established in care provision and underpins many government documents produced by the four countries of the UK. At the start of the millennium, there was a shift in the focus of person-centred care. The Institute for Health Care Improvement  broadened the remit to ‘care that is truly person-centred considers the persons cultural traditions, their preferences and values and their family situation and lifestyle’. This shift has been accepted as progression, involving a radical movement from a highly individualised therapeutic approach to a social and political strategy. It would be hard to disagree that person-centred care is an important way of looking to develop standards of care for older people. The challenge is to actually ensure that it is a reality and not rhetoric. Some researchers among others have begun to explore the notion of Relationship-Centred Care; this approach suggests that to achieve person-centred care for older people, there needs to be a consideration of the needs of relatives and care staff as well as those of the person themselves. It is suggested that if there is a sense of well-being for all involved in care, then the outcome for the person being cared for will be much more person-centred in nature. The rationale for this change is based on increased recognition of the need to develop a systematic approach towards care. The foundation for change is that interaction in health and social care frequently requires the involvement of three or more people. It is less common to be dealing with only one individual in care. Where this triangle of care exists, various authors have commented on the risk of alienating the least able person where the focus is upon just one person. Relationship-centred care needs to consider the whole picture. There are risks associated with this, specifically where the person receiving care is unable to communicate their wishes and needs. The risk of losing the person in the development of relationship-centered care is recognised by Nolan et al. He is explicit in identifying that the inner subjectivity of the individual remains core, but in addition to these, others must be considered. Nolan et al. argues that there are prerequisites for good relationships, and he terms them as the ‘senses framework’. The six senses are security, continuity, belonging, purpose, fulfillment and significance. The need for security includes feeling safe in both the receiving of and delivery of competent and sensitive care.

The sense of continuity is both that of personhood, of having a history in life with positive past experiences that are recognised and valued. The sense of belonging is reciprocal, with opportunities to form meaningful relationships or feel part of a team, whereas a sense of purpose is found in the agreement of clear goals that are inspirational to the practitioner, the client and their carer or family. The achievement of meaningful and valued goals brings satisfaction or the sense of fulfillment, without which the relationship is empty; and in recognising the person, be that client, carer or professional, there is a feeling of significance in the role.

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