For some people, recovery in mental health means gaining hope, improved health and wellness.
So what is recovery in mental health?
Recovery in mental health means developing an insight into one’s disabilities, understanding one’s abilities, having personal autonomy and a positive outlook on life.
In this article, I will show how I analysed mental health issues in relation to a case scenario (made up case scenario) involving a young woman I have named Sarah.
Features of depression will be identified, and an exploration of its impact in relation to Sarah’s functioning and personal recovery will be analysed.
Using Sarah’s experience, diagnosis, strengths and difficulties, I will explore my understanding using two theoretical perspectives on mental health; the recovery model in mental health and empowerment.
Consideration will be given to the structure and process issues in engagement when undertaking assessments.
The assessment process will focus on a semi-structured interview and observation. I will explore the nature and purpose of engagement in mental health practice, including issues that enhanced or hindered the engagement process.
I will highlight values and skills applied during the assessment, and the rationale for applying these values and skills using contemporary literature.
Recovery in Mental Health
Sarah is a 45-year-old White British Woman who had an Acquired Brian Injury (ABI) following a road traffic accident 10 years ago.
Sarah lives alone after her partner of 10 years passed away following a stroke.
Sarah lost her job shortly afterwards. These recent events placed a significant strain on Sarah’s relationship with her mother and financial circumstances.
Sarah’s mother was concerned about her mood as she was feeling sad, not sleeping at night, was overweight and most significantly
Sarah was losing her ability to cook for her family as she could not remember her recipe’s.
Sarah had neglected her personal care and had not showered or brushed her teeth for weeks.
As Sarah’s symptoms were present for over two weeks, her mother arranged a GP appointment. Sarah was willing to engage with health professionals to make her feel better.
The GP diagnosed Sarah with depression and prescribed some anti-depressants.
Sarah was later found unconscious after taking an overdose of anti-depressants. She was subsequently admitted into hospital.
What is mental illness?
Mental health illness refers to any disorder that affects an individual’s mood, thinking or behaviour. Mental distress happens on a spectrum with varying severity.
Diagnosis is based on symptoms a person displays with some individuals displaying more than one disorder at a time.
A person’s mental health is affected by their current and experiences and this will also affect their willingness or ability to engage with services and interventions.
It was essential for me to keep in mind the current social and personal circumstances which have contributed to the development of Sarah’s mental health problems.
According to the World Health Organisation (WHO) (2017), the proportion of the global population with depression in 2015 is estimated to be 4.4% with depression being more common in females (5.1%) than males (3.6%). In addition, the overall rates of depression in England steadily increased in women and remained steady in men.
Sarah presented a depressed mood nearly every day and had gained weight rapidly, which was a concern to her mother.
What are the symptoms of depression?
The International Disease Manual (2017), listed these symptoms as signs of depression.
A recent report by the Department of Health (2018) highlight a close link between depression and weight gain.
Due to this, Sarah would refuse to engage in activities with her friends/family and would report of constant fatigue or loss of energy.
There was evidence of a diminished ability to think or concentrate on tasks, and Sarah was losing her ability to remember recipes she used to follow to prepare meals.
This frustrated Sarah as cooking was her hobby. Grey (2015) reports that losing functional abilities because of memory loss can have a massive impact on an individual’s ability to feel a sense of who they are.
Twigg and Burgener (2007) assert that the stigma of changes in mental abilities affects an individual’s ability to continue with previously known tasks and may lead to a tendency to withdraw or just give up on trying to do things. It should be noted that Sarah’s memory impairment may be associated with her ABI.
According to Lindsey and Perfect (2013) ABI can present problems of delayed recall and memory disorder in some cases. However, prior to Sarah losing her partner and her job, the effects of ABI on her memory were not clear.
Shortly after her partner’s death, Sarah lost her job and now lives alone. Loneliness according to Bridget (2014) may affect an individual’s recovery from a depressive state.
In addition, loneliness and loss have both been associated with depression.
Prymachuk (2011) shares similar views with Bridget (2014) and highlights that the risk for depression for people who live alone is almost 80% higher than for people who live with others.
Sarah appeared to experience recent loss due to the death of her partner and losing her job. In addition, Sarah showed symptoms such as sadness, insomnia, isolation and withdrawal.
Nonetheless, Sarah was willing to engage with health professionals and had a desire to work towards achieving goals set.
Using the recovery model mental health
The recovery model of mental health provides a holistic and person-centred approach to mental health care (Jacob, 2015).
The recovery process provides a holistic view of people with mental illness that focuses on the person, not just their symptoms.
The process argues that such recovery is possible and that it is a journey rather than a destination (Repper & Perkins, 2014).
One strength of this model according to Stickle and Wright (2014) is that it allows the nurse to view the service user as an individual who has control over their lives.
It supports an individual to achieve their own goals, aspirations and dreams. Mental health professionals are encouraged to focus on an individual’s strengths and resources (Xie, 2013). In Xie’s view, we should place attention on helping an individual develop confident to embark on the journey of recovery.
When using the recovery model, I could provide Sarah with opportunities for change, reflection and discovery of new skills and experience.
According to Jacob (2015), such personal factors could aid the recovery process. However, Farkas (2007) argues that lack of mental health resources coupled with large caseloads creates a major challenge to creating individualised strengths-based service plans.
Despite this, I realised that using the recovery model, allowed me to consider supporting Sarah to develop good relationships, doing the things she wants to do, and building her self-esteem using the Wellness Recovery Action Planning (WRAP) model.
The aim of using the WRAP model was to support Sarah to identify upsetting events, early warning signs that things have gotten too much, list of things to do every day to stay and possible and crisis plan (Jaffe, 2018).
Sarah had lost her job as a Chef, she had no financial security and this resulted in an added strain on her life. However, Sarah’s family believed in her, listened and understood her situation.
They were willing to support in any way possible. In addition, Sarah was happy to be supported to work on her memory issues in order to take on basic cooking tasks.
Empowerment model in practice
Zimmerman’s concept of empowerment looks at 3 essential components for change, which include individual, organisational and collective empowerment (Wilson et al., 2011).
On an individual level, when working with Sarah, consideration was given to what needs to change within her and what she needs to do to change.
One of Sarah’s strengths was her willingness to improve her life, and this was an excellent step in achieving her goals. On an organisational level, consideration was given to services which provide opportunities for people to become empowered.
For instance, Live, Independence, Voluntary and Employment (LIVE) is a service available to help support individuals back in employment. This service was willing to support Sarah get back into employment. As part of LIVE activities, Sarah will be working together with other individuals who are also working towards improving their own lives (collective empowerment).
Kensit (2000) argues that all three components of empowerment are inter–connected and true empowerment occurs when all three elements work together to achieve a balance in society.
Furthermore, Beresford (2014) asserts that empowerment shifts power from the professionals to the individual.
In contrast, Rapp and Goscha, (2006) points out a limitation. Rapp and Gosha argue that such approaches result in a false sense of power transfer as professionals remain in control. Despite this, I found it useful to use this model because it allowed me to understand Sarah’s situation better by including her in all decisions made around her care and support.
Using this approach also helped improve Sarah’s self-esteem.
Structure when undertaking assessments?
The assessment method I used for Sarah’s case was an observation and a semi-structured interview using the Trusts’ initial assessment proforma as recommended by the local Trust’s protocol on undertaking an initial assessment.
Prior to using any of the assessment methods, consent was sought from Sarah to allow me to gather information about her. The use of a semi-structured interview was to gather information to understand the nature, extent and severity to which Sarah is affected by her depression. In addition, it was to help identify which services or therapeutic interventions might best fit Sarah’s needs.
According to Barker (2004), semi-structured interviews offer a flexible and a two-way conversational approach to assessments. However, Mitchell and Jolley (2010) assert that this approach does not guarantee honesty of participants. Using this method helped me to effectively engage with Sarah.
As I did not know of Sarah’s condition, it was important that I understood the chronology of events which lead to her admission. I read her hospital notes to gather some information on the various areas of her life such as who she lives with and circumstances leading to her admission.
With the view that Sarah is the expert of her own life, I met with her to find out her needs and preferences using a person-centred approach.
During the interview, Sarah said that “I feel I have lost everything but I really want to get better and get back to work”.
The Care Quality Commission (CQC) (2008) recommend that assessments should be person centred based on a person’s needs and preferences. Using the semi-structured interview enabled me to ask questions around the various domains of Sarah’s life such as past mental health history, family history and social relationships.
Carl Rogers developed the person centred approaches that focus on empathy, authenticity and respect (Maclean & Harrison, 2015). Adopting the Rogerian approach while working with Sarah, lead towards an empathic approach that empowered and motivated her to achieve self-actualisation (Stickley & Wright, 2014).
However, theorists like Sigmund Freud have emphasise that for self-actualisation to be achieved, a person needs direct help to solve their problems. Nonetheless, when working with Sarah, objectives were set which were SMART (s-specific, m-measurable, a-attainable, r-realistic, and t-timely) in nature. For instance, ‘for Sarah to get back into employment working at least one day a week within the next 3 months’.
An observation of Sarah’s appearance and behaviour was carried out as part of the assessment process. This was to observe any physical issues or self-care problems.
According to Barker (2004) observation continues to be one of the most common interventions in mental health care as it helps unearth hidden factors contributing towards a person’s state of mental health.
However, Page (2006) points out to a limitation of using this method of assessment. In his view, there are negative patient experiences as a result of observations due to the high level of intrusiveness.
Notwithstanding this limitation, I found it useful using the observation technique as I was able to gather some information Sarah was unable to open up about during the assessment, such as her unkempt appearance.
Using this method, I noticed that Sarah had stained clothing and was not wearing clothes which were weather appropriated. This was in line with the report received from her mother about the fact that Sarah had gone for weeks without a shower and was self-neglecting.
Communication skills in engagement
I realised that good communication was key in the process. Johnson and Wiggs (2011) highlighted effective communication as an essential skill when engaging with service users.
For most part of my work with Sarah, I felt that information was exchanged effectively and it could be argued that communication was effective because I had established rapport and used both verbal and nonverbal forms of communication. Sarah commented, “you captured all that was discussed”.
This meant that I had listened effectively. Ruch et al. (2010) highlight that the ability to listen puts the listener in connection with the direction of the service user’s world and opens the door for involvement.
For a collaborative working relationship the service user should feel that they have been understood both cognitively and emotionally.
According to Wilson et al. (2004) to show the ability to listen effectively involves the use of both verbal and non-verbal communication skills.
My nonverbal communication with Sarah included leaning and making eye contact. However, in using verbal communication, I felt that I could have varied the pitch of my voice better as Sarah struggled to hear me occasionally.
Cournoyer (2014) emphasises that “the words you choose, the sound and pitch of your voice, the rate and delivery of your speech and your use of language may suggest a great deal to clients and others with whom you interact” (p.201).
However, I summarised what we had discussed at the end of my assessment to ensure that all relevant information had been fully captured. I felt that by actively listening to Sarah, I used the values of care, compassion and competence to support her recovery.
The first need identified through my assessment was that Sarah expressed not being able to remember her food recipe’s due to her memory declining. Sarah would like to try cooking at least one meal a day.
The second need identified through my assessment was that Sarah does not have a job and this is putting a strain on her finances.
Before you go
Supporting a person with mental health involves an exploration of its impact on their overall wellbeing. This may mean working in collaboration with the individual, their family or carers to come up with the best plan to support them on the road to recovery.
Barker (2004). Assessment in psychiatric and mental health nursing: in search of the whole person (2nd ed.). Cheltenham: Nelson Thrones.
Beresford, P. (2014). Personalisation: Critical and radical debates in social work. Bristol: Policy Press
Burgener, S. & Twigg, P. (2007). A personal guide to living with progressive memory loss. London: Jessica Kingsley Publishers.
Cournoyer, B. R. (2014). The social work skills workbook. London: Cengage Learning.
Department of Health (2015). Department of health annual report and accounts. https://www.gov.uk/government/publications/department-of-health-annual-report-and-accounts-2015-to-2016 Retrieved on 12th December 2018.
Farkas M. (2007). The vision of recovery today: what it is and what it means for services. World psychiatry : official journal of the World Psychiatric Association (WPA), 6(2), 68-74.
Herfordshire Crisis Assessment and Treatment Teams (HCATT) (2018). https://www.hpft.nhs.uk/media/1435/foi-2420-30-12-2016-crisis-assessment-and-treatment-team-catt-operational-policy-attachment.pdf Retrieved on 31st December 2018.
Jacob K. S. (2015). Recovery model of mental illness: a complementary approach to psychiatric care. Indian journal of psychological medicine, 37(2), 117-9.
Jaffe, M. (2018). Wellness and Recovery Action Plan. http://mentalhealthrecovery.com/ Retrieved on 31st December 2018.
Jahn H. (2013). Memory loss in Alzheimer’s disease. Dialogues in clinical neuroscience, 15(4), 445-54.
Johnson, R. & Wiggs, P. (2011). ‘Change management–or change leadership?’, Journal of Change Management. 3 (4). pp.311-17. doi: 10.1155/2011/352627
Kensit, D. A. (2000). Rogerian theory: A critique of the effectiveness of pure client-centred therapy, Counselling Psychology Quarterly, 13:4, 345-351, DOI: 10.1080/713658499
Lindsay, S. D. & Perfect, J. T. (2013). The SAGE handbook on applied memory. London: SAGE.
Maclean, S., & Harrison, R. (2015). Theory and Practice: A Straightforward Guide for Social Work Students. (3rd ed.). Lichfield: Kirwin Maclean Associates.
Meyer, J. (1998). Grief and Loneliness. London: Harrison House.
Mitchell, L. M. & Jolley, J. M. (2010). Reseach Design Explained. London: Cengage Learning.
Page, M. J. (2006). Methods of observation in mental inpatient units. https://www.nursingtimes.net/clinical-archive/assessment-skills/methods-of-observation-in-mental-health-inpatient-units/203195.article Retrieved on 20th December 2018.
Pryjmachuk, S. (2011). Mental health nursing: an evidence-based introduction. London: SAGE.
Rapp C & Goscha R (2006). The Strengths Model. N.Y: Oxford University Press
Repper, J. & Perkins, R. (2014). Why Recovery? In T. Stickley & N. Wright (Eds.), Theories for Mental Health Nursing: A guide for practice. (pp. 183 – 201). London: Sage Publications Ltd.
Ruch, G., Turney, D., & Ward, A. (2010). Relationship-based Social Work. London: Jessica Kingsley Publishers
Stickley, T., & Wright, N. (2014). Theories for mental health nursing: a guide for practice. Los Angeles: SAGE.
Stobbe, E. (2006). Social isolation and mental illness. http://brainblogger.com/2006/05/15/anti-stigmatization-social-isolation-and-mental-illness/ Retrieved on 30th of December 2018.
The International Disease Manual (2018). Retrieved from https://www.who.int/classifications/icd/en/ Accessed on 21st December 2018.
Wilson, K, Ruch, G, Lymbery, M & Cooper, A (2011) Social Work: An Introduction to Contemporary Practice, Harlow: Longman
World Health Organisation (2017). Global Health Observatory date. https://www.who.int/gho/publications/world_health_statistics/2017/en/ Accessed on 6th December 2018.
Wrycraft, N. (2015). Assessment and Care Planning in Mental Health Nursing. Maidenhead: Open University Press.
Xie, H. (2013). Strengths-based approach for mental health recovery. Iranian journal of psychiatry and behavioral sciences, 7(2), 5-10.