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'Why are we so scared of mental health?'

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9 January, 2012

As a student nurse, issues surrounding mental health are never far away.

Even when studying adult nursing you are encouraged to have an awareness of concepts related to mental health and mental illness.

But still, even though everyone studies it, there seems to be an element of uncertainty around caring for patients with mental health problems.

In my own experience I can think of of a good example. Let’s call her Danni. Danni was admitted to hospital after taking an overdose of painkillers and excessive alcohol. It was felt that her vulnerable state of mental health was significantly worsened by the anniversary of the death of a close family relative.

The trained nursing staff attended to her immediate medical needs and the health care assistants checked her observations and changed her bed in the morning. I wanted to be active in all aspects of her care but felt restricted by my anxiety and lack of experience with patients who had mental health problems.

If Danni had been admitted with a physical illness you could expect to see a fairly logical series of events taking place.

Give Drug A to cure disease B: it would be a set routine or pathway that you could follow to make that patient medically fit.

But with mental health, you’re faced with a greater degree of uncertainty. You become more aware of what you’re saying and how you’re acting; conscious that even the slightest intonation or vocal inflection could have an undesirable effect.

For me this is still one of the barriers that student nurses have to overcome when dealing with mental health. The perceived fear over what you should or should not be saying is ever present.

It lurks in the background and can stifle a students’ ability to feel fully engaged and able to play a proactive role in a patient’s care.

As students, we should try not to feel restricted when caring for mental health patients. We should feel a sense of empowerment in fulfilling an important caring role as part of the entire multi-disciplinary team.

Students are in a privileged position, by engaging with patients we can make important contributions to mental well-being.

No matter what branch of nursing you chose, you will encounter mental health patients so it is vital that you become fully involved with this essential aspect of modern nursing.

Readers' comments (41)

  • I totally agree. I am a 2nd year student and am currently in an MH placement. I am on the LD branch for my training. I am really enjoying the constant challenges that this environment is throwing (sometimes literally) at me. I find, as you say, more awareness of my body language, facial expression and communication with patients. However, whenever I do successfully interact with the more challenging patients and provoke no escalation of behaviours, I do feel I have achieved something and hopefully the patient feels our interactions have been positive ones.
    I intend, through an updated action plan to continue to do my best to overcome the hurdles I still feel are ahead of me and help towards the improved mental health and wellbeing of the people I care for.

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  • George Kuchanny

    Hi Adam,
    Another good subject tackled by your article.

    Here is a recent article put up by a policeman who looks at mental health from his own job's perspective:

    ------------ http://mentalheathcop.wordpress.com ----
    This week a man went to an A&E department to seek help in crisis. He is a known mental health service user and had become unwell after 3 weeks of not taking medication – he had run out. Arriving at A&E at 10am, he was triaged and they rang for the crisis team to come and assess him.

    By 4pm, he was starting to get frustrated with the wait. He had already started protesting about the length of time it was taking and staff were becoming anxious about him and his behaviour. So they called the police claiming, “He’s threatening staff” and “about to kick off”. Five cops on a blue light run across the city later and they were there within 8minutes. The man appeared controlled and calm enough, albeit vocalising his frustration at the waiting times. He used a few naughty words, but not directed at anyone, just in the anxious parlance of someone who is fed up of waiting.

    A&E staff indicated that crisis were on their way, that they want the man removed from the department. The attending sergeant asked who the man was fighting and what threats had been made. He indicated that he wanted to arrest the man for the threats and violence. No member of staff would confirm any threats or violence were made at all.

    “So he’s frustrated with waiting and said so, perhaps in a grumpy or even belligerent fashion?” That appeared to be so. “and you want him arrested for this because he’s got mental health problems?” Yes. The police contacted the s136 suite: if they arrested him MHA would they assess him? No, apparently not. Why not? Because they wouldn’t, that’s why not. He should be removed to the cells and assessed there. Why?!! Because he’s been threatening and violent towards NHS staff. No, he hasn’t. Yes he has. NO – HE HASN’T. We’re not dealing with him.

    The sergeant took the view that it was not necessary to detain the man s136. He wasn’t attempting to leave A&E; to the extent that a police sergeant can tell, he doubted whether the man would be sectioned; he wasn’t posing a risk to himself or others. The decision not arrest was treated with opprobrium by the NHS staff in both A&E and MH camps.

    But the law requires that it be necessary, to exercise s136. If the detention is only going to coerce the man through a process with which he is willing to comply if only it gets realised this side of bed-time, then what is the utility? We are probably agreed that there is none.

    So he went unarrested and I’m telling the tale of the man who the NHS wanted to see arrested because he vocalised his frustration at a six-hour A&E wait.

    -----end of http://mentalheathcop.wordpress.com --

    As you can see it is not only student nurses who need to consider best interaction practice!

    Regards George

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  • George Kuchanny | 9-Jan-2012 7:53 pm

    It's unsurprising that the police did not want to invoke the S136 'place of safety' until a mental health assessment can be done. In theory the police should remain with the person until this is completed, but usually they just leave them in a room with a nurse until it happens, not realising until they are made aware. Now that we insist they remain with them until it has been decided whether or not further input is required they are reluctant to take the matter to this point as it is very time consuming calling out an oncall psyche and all the hoops that need to be jumped through just to get a mental health assessment done and then find there might not be any call for the person to be detained if they are unprepared to remain voluntarily if deemed to be in need of mental health input at all. Then they are stuck with them.

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  • if that is the respect and treatment offered by the NHS to a patient who has a mh problem - I am speechless!

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  • tinkerbell

    It is sad and i have been left speechless as a RN(MH) on many an occasion to see a situation escalate that could have been brought under control with just a few kind words. Once when i worked inpatient on young adults psyche ward we had a regular young chap who use to present for admission, ?mental health/learning difficulties. On this particular day he came onto the ward but before he could even chat with anyone about his distress our ward manager called the police to have him escorted off the ward. His anxiety mounting, frog marched from the ward by our staff, police arrived took over and frog marched him to the glass entrance of our building. What could possibly go wrong? As he was ejected from the front doors i watched on with sinking heart at his treatment and guessed what he would do next. He picked up one of the big cobble stones at the entrance and hurled it through the windows and shattered the main entrance glass doors, was frog marched back into the main entrance and i sat down with him whilst he cried and told him i was sorry. He was then arrested by the police. I know we shouldn't give people false expectations of being admitted (as was told me on occasions by my management) but come on at least give them the chance of a cup of tea and a chat until they calm down. All the cobble stones were later removed from the entrance but they weren't really the problem to start with. Hopefully things have moved on as that was many years ago.

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  • "All the cobble stones were later removed from the entrance but they weren't really the problem to start with."

    That is exactly the problem, people do not take the time, show the interest or perhaps even have the experience or training, to find out what the problem was to start with, sometimes leading to severe or even tragic consequences. Just ignoring patients' problems, symptoms and difficulties, declaring zero tolerance, letting them escalate out of control, calling the police or having the patient arrested doesn't solve anything or help the patient at all. Whereas kind and gentle attention and trying to understand the situation may help the patient a whole lot more. Nurses after all are supposed to be able to show genuine compassion and empathy.

    I feel sad and angry in the case cited above by George Kuchanny that many nurses are working in areas such as A&E where they do not have the relevant experience to cope with people with MH problems, fail to recognise the signs and do not understand them, and that many staff and health care providers do not always act in the best interests of their patients no matter what group they have been classified into whether it be MH or the elderly or anybody else and these individuals are not being treated with respect. In a general setting we are not free to choose which patients we wish to treat or which not so what is the point of discriminating against them. Far better to exercise our clinical judgement, skills and expertise. All this is may be as much the fault of the organisation and management as it is with the healthcare staff themselves for not attending to the adequate provision of human and other resources.

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  • from Anonymous | 10-Jan-2012 0:01 am

    I could go on and on, but at the risk of stating the obvious, I would also like to point out the it is also sometimes the attitudes of the staff, the perception of the patient of their attitudes (as Adam points out in the article) and how they treat the patient or handle a particular situation that can be the cause of the problems. It often takes two and the patient may have an impulse control disorder and less degree of control than one would expect professional staff to have so it is up to them to try and act as appropriately and respectfully as they possibly can, but obviously without putting themselves or anybody else at risk, which can in some instances be a very fine line and requires training, experience and good skills in assessing the situation.

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  • Thanks for the mention, above: I just wanted to correct the misunderstanding that the police are or can be obligated to remain at a Place of Safety because the NHS would prefer that to be true. There is no obligation in the MHA for the police to remain and the only obligation to do so, is where other legal duties exist to prevent crime or protect life.

    I often ask A&E staff to understand that if it took too long for the police to turn up to violent drunks in A&E, it may be because the MH trust up the road are busy holding officers against their will in a mental health unit PoS when there is no reason to do so.

    It is up to the NHS to commission, operate, staff and train their people to deliver upon healthcare responsibilities. Plugging gaps in provision by inappropriate use of the police, strips officers away from their legal duties and prevents them fulfilling statutory obligations to the public.

    Using the police for non-police purposes comes at a cost to the public and the public includes the rest of the NHS who need policing services.

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  • Catherine Lowe

    I'm a 3rd year mental health student nurse and must say that when my peers who are studying adult nursing went on their mental health experience placements they were all very dismissive of the role us MHNs do. Lack of importance is often expressed by people and it seems to be an overlooked area which frustrates me greatly. I have also had a recent experience on placement were, when doing an escort to a hospital appointment, adult nurses in the hospital made inappropriate comments about "all that money spent on nutters" as i'm working on a brand new purpose built acute mental health ward. So i guess the question i feel the need to ask is, are general nurses scared of mental health or do they simply not care? I love my area of work however often get frustrated at peoples views on mental health nursing.

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  • I can't understand why adults and professionally qualified nurses can make such discriminatory comments about patients. why do they find their remarks so clever. mental health is a pathology like any other and people do not choose it. There seems to be a lack of awareness possibly due to inadequate training and placements.

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  • tinkerbell

    Anonymous | 11-Jan-2012 8:50 pm

    The answer's in the dictionary under the word 'ignorance'. Wrong knowledge or lack of knowledge. Ignorance causes fear of the unknown.

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  • tinkerbell

    not all mentally ill people are 'bad,' same as not all 'bad' people are mad.

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  • "... "all that money spent on nutters"..."

    nurses with such unprofessional attitudes towards some patients, or members of the public, should carefully analyse their motives to see what leads them to such inappropriate and unacceptable behaviour, why they have chosen a career in healthcare and what measures they need to take to remedy the situation. they need to recognise and take responsibility for their own actions!

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  • Adam Roxby

    As always, I thoroughly enjoy reading and responding to comments and this one seems to have got quite a few.

    So here I go with a few responses.

    Ruth – I am pleased that I am not alone. It's reassuring to see that others share the anxiety. However it sounds like you are making real positive contributions to your patient's health. Thanks to your comment and good luck in your training.

    George – Thanks for sharing the article. It is interesting to see these issues reflected in another profession. Since reading the article I decided to subscribe to see how he gets on.

    Tinkerbell – That really is a sad example. Sometimes staff get a little bit of "boy who cried wolf" syndrome. Looking back at that situation it is easy to see how a slight change of approach at the beginning could have worked out so much better for him. I also hope that things have improved.

    Anonymous 10-Jan – What more can I say, I agree. Great comment.

    Michael – Welcome to the site. I have often wondered what the view of some of the police officers are when they get called out to deal with various patients at hospital.

    Catherine – I would say that there are some who simply don't care about mental health. There is still a view among some that a mental health problem isn't as serious or somehow isn't as real as a physical condition. As antiquated as that view is it can still be found among staff and patients alike.

    Could it be that as general nurses go through their training there isn't enough exposure to mental health patients? So when those students qualify the fear and anxiety that has developed during their training isn't challenged? I'm not sure know the answers, in fact I know I don't but I am determined not to let the fact that I can't see a problem being an obstacle to treat the problem.

    So I would like to say thank you to everybody that has commented so far. The writing of the article is really only half of the equation. The biggest award is to know that people are reading, discussing and ultimately getting something positive out of the interaction.

    So thank you very much and I'll speak to you all really soon.

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  • Many thanks for a great article, as always, Adam and your excellent and encouraging comments.

    Another of my many experiences while on the subject:

    In the mid-70s, when I trained as an SRN, we had to do a three month compulsory assignment on the psychiatric wards during our third year along with a theoretical module. Although I found it interesting at the time my real experiences and interest developed later on in my career.

    For these assignments I was sent to the private clinic attached to the London Teaching Hospital where I was training and also to a high dependency locked ward. Both wards, which offered me experience with very different groups of patients, have stood me in good stead throughout my career in general nursing where one sees patients with a variety of MH problems. It has had a positive effect on my attitudes towards these patients as well as giving me the feeling that I had a head start over some of my younger colleagues who may have had fewer opportunities in this area. However, I am very well of my limitations when I work alongside the real MH nurse experts.
    Unfortunately complications with training programmes and acquiring a placement with the relevant psychiatric experience hindered my chances of taking up MH training later on in my career, but I have kept up to date with my experience and theoretical knowledge.
    Recently I came across my student notes on psychopathology and was surprised how out of date they now are and how limited some of the thinking was at that time but it is interesting to see how care and treatment has evolved and progressed towards far greater understanding of the patients and their problems and which has influenced their care.

    However, by filling in a little of my background I have strayed totally from the brief anecdote I wanted to relate. It was on the high dependency ward which was in a grotty old hospital belonging to my teaching hospital but some distance away and in an unattractive and rather unsavoury area of SE London.

    I was so shocked and have never forgotten the patient in his 40s who was brought into us by the police having brutally kicked him in the kidneys causing considerable pain and damage. The reason being that he suffered from Huntingdon’s Chorea and was in a phone box where the police found him and accused him of masturbating! Even if he had been he certainly did not deserve the brutal treatment he had received. Ever since this experience I have never been able to understand why those working in public service do not have a greater understanding and adequate training on how to handle individuals and especially those who are suffering from some mental health disorder. After all, like doctors, nurses and other health care professionals they are there to perform services to the public and not to brutalise them when they need their help.

    In the private psychiatric clinic I was surprised to discover that there was a whole floor dedicated to 30 patients, most of whom were healthcare personnel mainly from our hospital, and many of whom were senior nurses and doctors, and among whom was my GP and family friend who had trained in this hospital with my father many years before this. To us students, this floor was strictly out of bounds, probably for reasons of identity, but exceptions were made to allow me to visit the private room of this friend. It was very hard as he was unable to communicate and I was very inexperienced at that time.
    I note all the comments from Anon above are mine - makes it clearer when there is only one! Perhaps I should now pluck up the courage to write under my screen name as I am retired and have just removed my name from the NMC Reg. so in theory can now say what I like (well, at least within reason)!

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  • tinkerbell

    Anonymous | 12-Jan-2012 4:37 pm

    Go wild, get yourself a nifty avatar. Betty Boop, Elmer Fudd, Yosemite Sam, Pepe le Phew, Tweetie Pie, Sylvester, Speedy Gonzalez, whatever you relate to most. It's all a bit of a panto in nursing at the moment, 365 days of the year.

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  • I were thinkin' aboot Pipi Langstrumpf meself actually!

    Looks like you and I hold the record for the greatest number of comments at the moment! Is there a prize?

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  • tinkerbell

    Anonymous | 12-Jan-2012 5:34 pm

    Do we? I hope so. Just keeping the site going as best we can hey?

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  • Little One

    I think some of the fear stems, as Tink has suggested, from the unknown. At University the Adult nurses' mental health training and experience has consisted of a few lectures regarding dementia and alzheimers, DoLs, one lecture in first year about schizophrenia and other mental health illnesses and a two week mental health placement, but we weren't able to go to the really acute wards.

    I was 'lucky' that my placement was in a Hospital on a dementia unit, so I could experience and see the tailored, individual care that each patient had to ease and manage their symptoms, but I have no firsthand experience of working with anybody with a mental illness apart from patients suffering with dementia.

    I know no one who has ever suffered with a mental illness, I have never nursed anyone with a mental illness such as schizophrenia, and am not scared to say that I will be a little bit apprehensive when I eventually have a patient who suffers with a mental illness.

    It is not that I am scared, so much as worried that I won't treat them well because I don't have enough knowledge about their condition. If that makes any sense. I realise that first and foremost they are a person but I am just worried that they might need help or support that I won't be able to provide because I am not confident in my own knowledge or abilities regarding mental health illnesses because the only real training we have had regarding mental health has focussed on the conditions we are most likely to come into contact with, ie alzheimers and dementia, but even that training has not been hugely in depth.

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  • Among the most common mental health complaints encountered in adult nursing are personality disorders, and notably Borderline Personality Disorder, more common in females and often associated with deliberate self-harm, suicide ideation and threats, difficulties in controlling impulsive behaviour, anger and aggression. They frequently seek professional help, may act helpless and expect to be rescued but at the same time may have extreme difficulties with interpersonal relationships in which they display black-white thinking perceiving others as all good one moment, and all bad the next if they fail to comply to their wishes. The reasons for this are too complex to discuss in this short space.

    Individuals in this group of patients often present in A&E, or on a medical ward with other conditions, and because they are little understood by staff they are often described as a nuisance and time wasting and thus may not get the attention and care that they need which may cause their behaviour to escalate into a conflict situation. BPD was previously described by doctors and psychotherapists as a dustbin diagnosis as it was difficult to treat as patients have little trust and tend to go from one facility to another seeking help and support. Specific therapies have now improved such as Dialectical Behavioural Therapy and the condition can, over time, become manageable or burn out entirely. They can be charming but manipulative and can cause splitting in a care team by pitting one member against another, similar to the way children do with adults such as their parents or teachers, because this may be their only method of coping in a crisis. They may also have problems with identity and be very low self esteem. Some have difficulties in holding down employment and wander from one job to another. quite a number do manage to hold down a job and can also be found in the caring professions where they may be excellent at their jobs and may have a tendency towards perfectionism or obsessive compulsive type behaviour. They may suffer very painful inner turmoil and conflict as well as extreme mood swings which may change hourly or from one minute to the next precipitating serious crises (unlike bipolar disorder where moods tend to last a matter of weeks). Depression, which may be severe, is also common. they may be exquisitely sensitive to the mood, verbal cues and body language of others they come into contact with, but which they may misinterpret leading to misunderstandings and emotional reactions such as anger.

    It is important that nurses familiarise themselves with this group of disorders and especially BPD as it seems that many are unaware of the associated problems associated which is highly problematic when they encounter such patients who need highly skilled and careful handling to prevent conflict and worsening of their condition.

    Causes of BPD remain largely unknown but childhood abuse is associated with this disorder which commonly manifests for the first time in puberty and may also be triggered later on by life crises.

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