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Why is Australia’s vision for mental health rehabilitation so shy of the international benchmark?

Image: Marino González, Flickr (CC BY-NC-ND 2.0)

Image: Marino González, Flickr (CC BY-NC-ND 2.0)

Nurses provide frontline patient-centred, holistic and best-practice care. Their ability to prevent adverse events and respond with agility to changes in patients’ statuses relies on accumulated skills and experience. The frontline is a privileged, often intimate place, where each bed behind its flimsy curtain becomes a world unto itself of fears, hopes and dreams, where stories are shared and where nurses witness violent abuse and the quiet miracle of recovery. The keys into this world are excellent communication skills and empathy that build the necessary therapeutic relationship required to support patients through their care journeys.

Comfortably entrenched in a rich and varied career in academia, I was keen to reorient myself to deliver patient care whose evidence base was derived from the kind of research projects I supported. I had trained as a public health specialist, and after almost two decades working in primary health care, I enrolled to study nursing.

Whether a recent high-school graduate or a mature-entry student like myself, we were attracted to nursing’s fundamental core of caring. We would be exposed to caring approaches through the embedded 800-hour minimum of clinical practica that transitioned gently from residential and subacute to acute care over a standard three-year undergraduate degree. Throughout, we would learn the importance of prioritisation and communication. We would find ourselves obliged to act when patients’ expectations collided with clinical guidelines, and when understaffing impacted patients’ safety. Nurses’ failure to care would prove most confronting of all.

Mental health practica are typically offered in the latter half of a nursing degree. One of seven students placed in a psychiatric unit at a suburban hospital, I found rapport with Elliott, a patient I regarded as a gentle giant, early into my three week-long placement.

Brain injured after his bikie father smashed his head in a drug-induced rage, he viewed his home with a passive smile, spent an hour happily licking honey from his breakfast toast, and had to be encouraged to be moved on from the dining room. He carefully arranged his coloured pencils after a lengthy period of admiration, stopping only to ask for a cigarette stored in the nurses’ station from nurse Ronan.

Ronan, sporting a navy polo and a casual attitude, seemed equally unassuming. After receiving a cigarette, Elliott didn’t move his foot from the station doorway. ‘Move away!’ Ronan shouted. ‘Move away!’ Elliott stood immobile. ‘Move away!’ Ronan cried, and with swift shoves battered the door against Elliott’s foot. Elliott shuffled to the courtyard, shoulders slumped in dejection. Neither the nurses nor the patients reacted for, as I came to learn, this stupefying act was typical.

Elliott shuffled to the courtyard, shoulders slumped in dejection. Neither the nurses nor the patients reacted.

Nursing students often commence their degrees at the tender age of 18, and their ability to process the emotional and physical challenges within clinical practica is reliant, in part, on their university clinical facilitator’s capabilities.

On our first day, I was immediately put at ease by the maternal warmth and exuberance of our facilitator, Deborah. She welcomed us, introduced us to the hospital, and initiated a discussion about mental illness and how it affects the way we think and feel.

Depression occurs most commonly in our society, and we named anxiety, schizophrenia, and bipolar, personality and eating disorders. One in five Australians has a mental health problem, but none of us had experience in its specialised care.

The student group was separated and shown our places of work: three to Hamilton Ward, a short-stay acute unit; and four to Fitzgerald Ward, a longer-term rehabilitation unit that had the gloom of a submarine. Watery light filtered over the kitchen area with its plastic chairs and tables where three nurses stood sentry over lunch, counting knives and forks.

Surrounded by bare, sterile white walls, we passed an unused activities room. We paused in an empty, uninviting lounge by the nurses’ station. Its super-sized television roared the discount price of dishwashing liquid and the necessity of aged pensioner insurance at the empty plastic seats bolted to the linoleum.

Continuing past the seclusion room were 18 locked doors with metal hatches and, beyond them, the blessed light of a grassy courtyard ringed by eucalypts.

‘You will see difficult things,’ Deborah warned us. ‘We must always have hope.’

*

Legally, two kinds of patients receive psychiatric care in Australia: voluntary and involuntary. Each state and territory’s Mental Health Act list the four criteria by which patients can be involuntarily detained in a psychiatric facility, the crux of which being that patients must have a mental illness necessitating immediate treatment regardless of their refusal or ability to consent, in order to prevent deterioration and to protect the safety of patients and the public. The psychiatrist must next determine that a treatment order is necessary as there is no less restrictive way than to compulsorily provide the instantaneous care. Patients have the right of appeal through a Mental Health Tribunal.

I had this in mind when I arrived for my first shift. What would illness necessitating a locked psychiatric ward look like? How would it feel to have a legal status that stripped you of your agency?

My classmate Cara and I stood in the nurses’ station during 0700 handover. Our belts hung heavy with keys, security cards and duress alarms. We were forbidden from working alone.

Nurses were allocated their roles: Cara was assigned to assist nurse Charity with medications, I to comfort with nurse Susie, and nurse Gene to security. Patients’ legal statuses and ground access eligibility were recorded on the journey board; 15 out of 18 held involuntary status.

Outside the station, patient Gloria waited for Susie, her dark eyes downcast. ‘Cigarette,’ she mumbled, wearing a stained pair of scrubs. Her hair held a pillow’s imprint.

‘No cigarettes before eight o’clock,’ Susie replied, her small frame vibrating with vital energy. Her smiles and positivity threw Gloria’s lethargy and cautiousness into blunt relief.

‘You getting cigarettes for me?’

‘Yes. It’s Tuesday. So take off your bed sheets and put them in the linen skip. But first go have your breakfast.’

The comfort role ensured that patients were toileted, had clean clothes, access to personal belongings and a listening ear. Surely therapeutic communication was a normal part of what nurses did? Susie withdrew patients’ daily allowances of up to $27 at the cashier and spent it at the kiosk. She knew from 25 years of practice which cigarettes and snacks to buy for each patient as most weren’t permitted to leave the ward. Carl, a patient on ground leave, gleefully showed us the toy ponies and glittery bangles he’d bought with his allowance.

‘Fitzgerald Ward’s been my home for 30 years,’ he told me.

*

I spent the next morning in the nurses’ station doling out cigarettes every half-hour. Nurse Christopher, focused on his online shopping, explained, ‘Give them a pack of smokes and they’ll smoke them all at once. They have to learn to wait. That’s how things work in the real world.’

After a few days, patients Rani and Gloria would incline their heads towards us, indicating they wanted to talk. Rani, grateful to have an audience, was so keen to speak that his words came out in a stuttering rush. He’d been studying law when he first tasted speed, his ‘oxygen’. After a diagnosis of schizophrenia four years ago he’d become an inpatient. He dreamed of being released, but since he felt that a life on drugs was superior to compulsory treatment he held no hope that it would happen.

Had he seen a drug and alcohol counsellor? Never. The hospital did not employ one despite two-thirds of patients having a dual diagnosis of mental health and substance-abuse issues.

‘Beware of Rani,’ Ronan warned me. ‘He’s dangerous. You’re fresh blood to him.’

By the week’s end, it was evident that the daily ward rhythm was marked by medications and meal times. There were no nurse-initiated activities, although nurses arranged patients’ medical appointments and weekly external activities including massage, animal handling, woodworking, and day leave with carers.

The most animated patient discussion was about which take-away to order on Friday nights. Few patients had formed friendships with one another, and even fewer had family contact. They spent the majority of their time alone. Each lunchtime Deborah gathered her students to debrief and discuss issues including the conditions we thought our patients had, which mostly consisted of schizophrenia, schizoaffective disorder and depression.

The following week Deborah permitted us to read patients’ files and these confirmed our proposed diagnoses. The files revealed chaotic childhoods, abuse and neglect, teenage symptom onset, drug and alcohol abuse, homelessness, and cycling hospitalisations. They’d been shunted between various accommodations and the streets, and finally onto Fitzgerald Ward where their florid symptoms had been stabilised.

Gloria’s file recorded parental abandonment, numerous violent relationships, and an inability to cope with the demands of everyday life. A voluntary patient, she felt ‘safe’ entrenched in the ward’s routine. She found the world beyond it chaotic and filled with people whose behaviour perplexed and hurt her. She shrugged when I asked, ‘What do you like to do here?’

‘Dunno. There’s not much to do.’

‘What would you like to do?’ Cara asked.

‘Dunno.’ After another minute she said, ‘I like to read. Well, look at cooking magazines. But the activities room is always locked.’

‘Could you ask a nurse to open it?’ I suggested.

‘They don’t like it if you keep asking them for things.’

Would the occupational therapist cook with her?

‘We never see her,’ Gloria reported. ‘We only ever learn pikelets, anyway.’

In the nurses’ station I asked, ‘Could I teach patients how to cook?’

Charity scoffed. ‘You must be joking! There are knives in the kitchen.’

One morning patient Marlon sobbed in the lounge area. He went through two boxes of tissues. While Cara comforted him, Ronan, who had been watching from the nurses’ station, remarked to her, ‘Don’t waste your time with him. He only cries for attention. He’s a manipulator.’

Cara glanced at me. The disappointment and dismay crystallised in her eyes matched my own.

Shortly afterwards, Elliott called through the Perspex for a cigarette. Christopher didn’t look up from his newspaper. Elliott asked three more times, then made a rude gesture. That Christopher saw.

‘You do that again and I’ll PRN you!’ he cried.

*

Why was it not possible for a nurse to spend time with agitated patients in order to listen and counsel them, to increase their insight into their behaviour and what triggered them? I could not make myself believe that the threatened administration of PRN – which stands for pro re nata, or additional anti-anxiety or anti-psychotic medication – was dignified care.

The following week, as part of a series of studying media depictions of mental health, Deborah arranged for the students a screening of One Flew Over the Cuckoo’s Nest (1975). We empathised with McMurphy’s sense of bewilderment at the hospital environment, Nurse Ratched’s authoritarianism, cigarette rationing as a form of control, medicines as chemical restraint, and patients’ loss of agency.

Why was it not possible for a nurse to spend time with agitated patients in order to listen and counsel them?

Yet in the film the patients exercised on a basketball court and Nurse Ratched held a weekly round of open discussion with them. Fitzgerald Ward’s basketball hoop was unused, the ball having been deemed dangerous.

My three weeks presented a mere snapshot into ward life, leaving me with more questions than answers. It did, however, lead me to Wulf Rössler’s Psychiatric Rehabilitation Today: An Overview (2006), where he proposes that rehabilitation should be offered to all individuals experiencing chronically severe mental health problems to assist them to obtain ‘the emotional, social and intellectual skills needed to live, learn and work in the community with the least amount of professional support’.

Television, sleeping or smoking in the courtyard were the major entertainments permitted on Fitzgerald Ward. Patients could consult a psychologist once a year. No patient I spoke to recalled being offered financial management training, home economics, or being told about the nearby community-based mental health organisations. Most had no idea what they intended to do after discharge. They had not been encouraged to envision their future selves.

Due to insufficient exercise and anti-psychotics administration, all but three patients were overweight or obese. Rani was distressed by this, but reported that he’d given up asking the nurses to walk him to the patients’ gym as they always said they were too busy. Few patients could prepare anything more than a sandwich or remember to wash their clothes without being reminded. Under stimulated, they were becoming fatter, more insecure and institutionalised while their ability to comprehend social mores and healthy relationships diminished daily.

The ethic of nil nocere, to do no harm, underpins medical care. Fitzgerald Ward’s patients were detained to ensure they caused no harm to themselves or to society. Could its anti-therapeutic environment pose risks to them?

Observing the weekly case conference proved revelatory. The social worker outlined the difficulties of moving patients into community residential care due to stringent acceptance criteria and few beds. Patients Piers, Harry and Elliott had waited years.

I listened to the psychiatrist’s gently mocking voice as each patient sat opposite him. He asked the same questions disinterestedly: ‘How are you? How do you think things are going? What do you need? Is there anything you want to tell me? Let’s look at your ground access…’

In his presence, the ward’s dearth of dignity and therapeutic nihilism became clear. Without empathy or self-regulation, nursing and allied health professionals emulated the psychiatrist’s derisive manner that entrenched the tyrannical ‘us and them’ mentality. Therapeutic interaction, the vital core of nursing care, was devalued. Psychiatric rehabilitation existed in name only and care was dispensed in medications and privileges. For Rani and Marlon, this holding cell reverberated with silent despair. For Gloria and Elliott, it was the kindest home they’d ever known.

*

Australia’s National Mental Health Strategy 1993 was a turning point in our country’s mental health care. Deinstitutionalisation began in the 1960s, reducing psychiatric inpatient bed numbers from 30,000 to 8000. Unfortunately, while the majority of patients were transferred into the community, the bulk of funding and specialist staff remained in hospitals.

The Strategy’s funding and policy directions had by 2002 redistributed expenditure towards community-based care, which continues to date. Victoria led the nation by closing all stand-alone psychiatric hospitals and implementing 24-hour mobile crisis teams and myriad services. Victoria also leads in the use of Community Treatment Orders to detain patients involuntarily despite these being ineffective alternatives to comprehensive community treatment programs.

Victoria also leads in the use of Community Treatment Orders to detain patients involuntarily.

Overall, a sincere nation-wide investment in community-based services has not been realised. While the Prime Minister Malcolm Turnbull commendably announced greater community-coordinated mental health care through Primary Health Networks in 2015, his 2016 Federal Budget did not propose expanding community psychosocial rehabilitation facilities.

This dreadful oversight means that patients like Carl, who would best be treated in the community, occupy almost half of all hospital psychiatric beds. Psychiatric care access rates remain unchanged despite a 50 per cent outlay increase in recent years that is incommensurate with the burden of mental health disorders, the third greatest chronic illness experienced by Australians.

The increase in hospital admission thresholds means that psychiatric patients are more likely to be involuntary, with challenging behaviours and greater treatment resistance. In highly pressured and unsupportive environments, health professionals may cope through reducing patient interactions, perceiving that behaviours are under patients’ control, and responding to patients with criticism and hostility. This is especially destructive since patients’ social ability, symptoms, violence and aggression are modulated by positive relationships between patients and health professionals.

Reform effects on the quality of inpatient care are poorly understood. In The Lost Art of Caring (2003), editors Leighton Cluff and Robert Binstock use the word caring to describe ‘concern for and responsiveness to the needs and the worth of the person receiving it’. Caring helps us to understand, express and give meaning to suffering, be it illness, disability or pain.

High-quality nursing care – including active listening, concern and advocacy – can improve patient satisfaction and health outcomes, from which nurses, in turn, derive professional satisfaction. Indeed, the greatest of reforms should be supported not only by structural and financial improvements but also by high-quality human interactions.

*

Nurse Susie’s professional satisfaction appeared evident, but what of the others? Had frustration at patients’ chronicity stifled their desire to care? If true, and if patients are not thriving, what are the alternatives?

The ‘whole system, whole community’ approach conceptualised by Franco Basaglia in Trieste, Italy, has had impressive outcomes as described by Roberto Mezzina in Community Mental Health Care in Trieste and Beyond: An ‘Open Door – No Restraint’ System of Care for Recovery and Citizenship (2014). All psychiatric ‘guests’ are cared for in community-based homelike centres that have an open-door policy even for those receiving compulsory treatment.

Guests, their families and caregivers contribute to care plans that derive from mutually trusting and continuous relationships with health professionals. Guests are expected to negotiate, be responsible, and work towards care-plan compliance. They participate in daily outdoor activities and are offered job placements, sport, art, individual and family therapies, and links to community-based health and social services.

This cost-effective approach, established from 1971, has significantly reduced social stigma as well as the number of suicides, hospitalisations and incarcerations. It has improved guests’ satisfaction, engagement in employment and community integration. Furthermore, staff have continuous professional development, remain committed to the facilities, interact positively with staff and patients, and report high morale.

In placing the person rather than the illness at its core, this model is the international benchmark in psychiatric rehabilitation. It demonstrates that most people with a mental health problem can be effectively and respectfully treated through comprehensive community services without the use of medical or chemical restraints.

Similarly, Finland’s Open Dialogue model detailed by Jaakko Seikkula in Open Dialogues with Good and Poor Outcomes for Psychotic Crises: Examples from Families with Violence (2002), demonstrates how early intervention and illness conceptualisation can profoundly influence health outcomes while avoiding hospitalisation. People with a lived experience of mental health problems are considered equal to their social network members and health professionals.

Through dialogical psychotherapy, or ‘open dialogue’, problems are discussed honestly, solutions sought, and treatment decisions are agreed upon, typically in the person’s home within 24 hours of psychosis onset. It has proven beneficial for recovery, with high satisfaction, reduced antipsychotics use and fewer relapses. Since its inception in the 1980s, no new long-stay hospitalisations for schizophrenia in Western Lapland have been recorded.

Open Dialogue demonstrates an empowering client-centeredness and recovery-oriented practice that is now permeating Australian mental health service frameworks. People experiencing mental health problems emphasise that recovery is possible, but it cannot occur without hope. Hope is relational, generated when patients trust their health professionals who believe that better outcomes are possible, even when patients themselves are unable to.

When Australia’s medical and surgical treatments are world class, its worryingly piecemeal approach to mental health care and sluggish translation of evidence-based care into policy raises serious questions about how its most vulnerable citizens are valued.

[Australia’s] worryingly piecemeal approach to mental health care raises serious questions about how its most vulnerable citizens are valued.

Why is Australia’s vision for mental health rehabilitation so shy of the international benchmark? At the very least, don’t our psychiatric patients deserve the thorough vetting and training of the health professionals employed to care for them?

*

During our last afternoon, Deborah asked what we’d learned from the practicum. We considered that providing the right help at the right time could make a significant difference in patients’ lives. We all agreed that we would never emulate the sub-optimal care we’d witnessed.

If learning this was our greatest achievement, then the practicum was worth its weight in our fears, frustration and failures, for we can become the difference we want to see. As I packed away my notebook, I reflected on some fitting words from Martin Luther King Junior: ‘Our lives begin to end the day we become silent about the things that matter.’

*All names and personal details have been changed.