In reading an article regarding co-production of services, it led me to consider co-production in the context of the therapeutic relationship in mental health nursing.
Recent personal experience with a patient who challenged the boundaries of that co-production and the meaning of that therapeutic relationship created opportunities in the team for reflection on how we participated in that relationship. It wasn’t a particularly easy journey I think for us or the patient. Personally I found it taxing and frustrating with moments of joy and sadness as we jostled and jogged our way along this road. “It’s my life” the patient would scream at us, obviously frustrated by our attempts to be therapeutic.
The text which follows is a brief summary of my research into that therapeutic relationship and how legislation both affects and enables it.
The relationship between nurse and patient seeks to co-produce a plan of care and treatment that leads them back to “their life”. The context of this co-production is a continually shifting balance between autonomy that permits the patient to “travel their own path and make decisions and, paternalistic control that removes decision making from the patient until such times as they are able to retake control and have the capacity to make decisions.
Nurses working in mental health are often faced with working out the right thing to do, and when and in what context it is acceptable for us to limit someone’s freedom, or make choices for them. Sometimes these decisions are made easily because people are either a risk to themselves or others. But there are times when matters are less clear cut
Scotland has been seen as a beacon of good practice in the field of mental health care and has been proud of its legislative approaches in providing humane person centred care, however in the last few years there have been changes in international law that now finds Scottish legislation wanting.
Human rights legislation, in particular aspects of legislation covering care, treatment, capacity and consent within the Mental Health (Care and Treatment)(Scotland)Act 2003 and Adults with Incapacity (Scotland) Act 2000 and Adult Support and Protection (Scotland) Act 2007 now appear at variance with aspects of human rights legislation. In particular the UN Committee on the Rights of Persons with Disabilities that oversees the United Nations Convention on the Rights of People with Disabilities (UNCRPD) has adopted a radical critique of mental health and capacity law. It argues that the justification for any form of non-consensual intervention based, even in part, on a diagnostic label such as ‘mental disorder’ and the use of capacity assessments is inherently discriminatory.
Discrimination against those who are diagnosed as mentally ill has been a significant issue and has led to a focus on reducing that stigma through education and awareness programmes such as the “See Me “campaign but impact has been poorer than expected. Therefore a revised approach is now in place and is recognition of the substantial impact that stigma attached to mental illness has for people in society. Potentially this stigma has affected perceptions of how competent people with mental illness are to be involved in decisions around care and treatment.
A patient’s ability to contribute to the decision making around their care and treatment has been enhanced through the use of advocacy support and advanced statements.
The Scottish government is currently reviewing both mental health and capacity legislation to ensure it meets with the criteria stated above. There is some evidence from public responses that indicate the review does not go far enough (see SG)
“While the Mental Health Bill has provided an opportunity to revisit the Mental Health Act ten years on, it was felt that it did not appear to have fully explored the issue of how human rights can be further supported within law and practice.
‘I think there’s really interesting challenges ahead in terms of the noises the UN are making about the Convention on the Rights of Persons with Disabilities and what that means for compulsory treatment in mental health and suggesting that it’s discriminatory and that’s raised a lot of useful discussions which I think we should have been having a long time ago about the acceptability and prevalence of forced treatment.’
– Expert Interview (A Review of Mental Health Services in Scotland: Perspectives and Experiences of Service Users,
Carers and Professionals-Report for Commitment One of the Mental Health Strategy for Scotland: 2012 – 2015)
However the UNCRPD believes that current legislation around detention and non consensual treatment needs to change in favour of a supported decision making model. It therefore seems likely that this will impact significantly on Mental Health professionals and will be a paradigm shift in how we relate to those entrusted to our care. Mental Health Nurses will need to consider how this impacts on their practice and how their fairly unique position as potential advocates might develop. Patillo (2011) notes that “Nurses seem better placed as advocates because they are constantly interacting with patients”. How then might this position develop in terms of a supported decision model?
In considering this we can think about how relationships between mental health professional and patients have been described
Pelto-Piri, V. et al, talk about 3 styles of working with people who have a mental illness:
Sandhu. S et al (2015) suggest that “reciprocity may be conceptualized and incorporated as a component of mental health care, with recurrent and observable processes which may be harnessed to promote positive outcomes for service users.”
Positive outcomes thus may result from Mental Health nurses reflecting on their role as advocates and treatment partners in which reciprocity is the mode of interaction, enhancing the therapeutic relationship whilst discharging our professional responsibilities both as nurses and as members of the Multi-Disciplinary Team, and enabling consideration of changes to practice and education that would make this a reality of mental health care and treatment rather than a desired state.
Euan McLeod is a Mental Health Staff Nurse at Mid Park Hospital, NHS Dumfries and Galloway