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This essay discusses a case study of a patient with schizophrenia who the student author worked with on a practice placement. The theme of the essay is the social model of mental health. It has been observed that nurses are being pulled in different directions; towards the social model of understanding mental health and illness and in the other direction towards a medical model of treatment and care (Coffey and Hannigan, 2013). This essay highlights the tensions created in practice by these competing approaches. The essay starts with a description of the social model of mental health. This is followed by an introduction to the patient. The main section describes how this model influenced the student author’s therapeutic engagement with the patient and being reflective, it is written in the first person in accordance with academic convention (Lillyman and Merrix, 2014). Finally, recommendations for future practice are made before the main issues are drawn together in the concluding section.
The social model of mental health is rooted in a significant body of empirical research that shows that mental disorders are not uniformly distributed across society but are more likely to affect those in the lower levels on the socio-economic spectrum (Davidson et al., 2015). It therefore follows that there are socially constructed risk factors for mental ill health and mental disorders. The social model of mental health therefore advocates a treatment approach that focuses on social inclusion and recovery (Repper and Perkins, 2003). It has been suggested that clearly articulating the social model is important for the contemporary NHS because this model underpins partnership working and collaboration; service user involvement and evidence for the effectiveness of holistic interventions that are designed to tackle the root causes of mental ill health and inequality (Duggan, Cooper and Foster, 2002).
To clearly articulate the social model of mental health, it is necessary to understand the social model of disability which forms the basis of the model. The social model of disability draws a distinction between impairment and disability. Some individuals have physical or mental impairments, but it is the way in which society is organised that causes disability rather than the impairment itself (Wallcroft and Hopper, 2015). The barriers that people with impairments face that cause disablement are environmental, economic and cultural (ibid.). For example, for those with schizophrenia, stigmatisation within society is a significant barrier to full participation (González-Torres et al., 2007) and this stigma can be internalised leading to self-stigma (Brohan et al., 2012) which in turn can negatively affect patient engagement which can hinder recovery (Fung, Tsang and Corrigan, 2008). This was a key issue in the case study that will be discussed. Utilising the social model was at times useful for fostering a therapeutic alliance but in other respects it was less helpful, and this will be critically discussed.
The patient is a 24-year-old male of mixed heritage (his mother is Iranian, and his father is white British). The patient will be referred to using the pseudonym Mark to protect patient confidentiality (NMC, 2018). Mark was diagnosed with schizophrenia at the age of 19. Mark is estranged from his family of origin and lives in a hostel. He drinks alcohol heavily and uses illegal drugs, mainly amphetamines. He has a very poor insight into his illness and does not accept his diagnosis. Mark had historically been non-compliant with his oral antipsychotic medication and therefore attended the outpatient clinic for a monthly depot injection of paliperidone palmitate. Mark failed to turn up for his monthly depot injection and shortly afterwards he was detained under section 2 of the Mental Health Act (Department of Health, 2007) when his support worker at his hostel accommodation called the police due to his increasingly erratic behaviour.
Mark was brought to the inpatient unit (where I was working) in handcuffs and leg restraints and was clearly distressed. The social model of mental health recognises the importance of trust in building the therapeutic alliance and working collaboratively with the patient (Williams and Heslop, 2005). This was challenging given that Mark was being detained against his will and was experiencing psychosis. The social model also focuses on a person’s needs rather than their diagnosis and therefore takes into consideration social and practical support as well as medical interventions (ibid.). Therefore, when we had administered an intramuscular injection of olanzapine, I stayed with Mark and spoke to him in a reassuring manner and explained where he was and that he needed to stay in hospital so we could help him get better.
After a few hours on the ward, Mark was less agitated. I made him a hot drink and sat down with him and explained the role I would have in his care as his named nurse and that I was there to help him. Mark’s hostel accommodation provides supported housing and his support worker sent over a copy of his current care plan. The support worker also informed the ward staff that he believed Mark had been using amphetamines. Amphetamine use can cause or worsen psychosis (Bramness et al., 2012). The social model of mental health influenced my therapeutic engagement because it enabled me to look at Mark’s substance misuse in context. Once I had established a rapport with Mark, I was able to get him to give a urine sample for drug testing by assuring him that he would not be in trouble. The urine sample tested positive for amphetamines confirming the suspicions of the professionals involved in his care. I asked Mark why he used amphetamines as they can make people very unwell and he stated that lots of people in his hostel accommodation were taking this drug and it was very easy to get hold of and they ‘lifted’ his mood.
Whilst a traditional medical model of mental health would focus on getting Mark to stop using drugs and perhaps pharmacological interventions to improve his mood, the social model enabled me to look at the social factors behind his substance misuse. It was clear that his current accommodation was not conducive to his recovery. I told Mark that I would speak to his social worker and enquire about supported housing. I knew there were several housing projects locally where people with mental health issues received support that would foster recovery. Crucially, Mark would not be in close proximity to others using or dealing illegal drugs. In this respect, the social model of mental health was very useful in promoting therapeutic engagement and helping me to deliver person-centered care.
Using an expanded medical model (like the biopsychosocial model) would have perhaps given more prominence to medication adherence alongside the social factors (Wallcroft and Hopper, 2015). Medication is crucial and adherence to anti-psychotic medication is associated moved with better outcomes including a reduced chance of relapse fewer hospital admissions (Morken, Widen and Grawe, 2008). A focus on the social model meant that in my initial discussions and care planning, less emphasis was put on medication. Therapeutic engagement should include ensuring that holistic person-centered care treats the whole person and the social model that looks only at broader social factors hindered engagement in this regard. In fact, the tension between the medical and social approach did not compromise Mark’s care as the ward psychiatrist carefully reviewed Mark’s medication regime and on discharge, Mark’s monthly depot injection was changed to risperidone which can improve symptoms of depression in patients with schizophrenia (Kjelby et al., 2011). Mark’s social worker was also successful in securing a place for Mark in a supported housing project for men with mental health issues and he was discharged into a safe, pro-recovery environment. This is a strength of the social model in that Mark’s wider social needs were met.
Mark spent a total of 8 weeks as an inpatient in the unit where I worked. We put together a comprehensive care plan and the social model of mental health meant that this included Mark’s social needs. The fact that we collaborated on the care plan meant that mark was fully involved in his care planning and this participation is well supported by the social model (Duggan, Cooper and Foster, 2002). Shared decision making is central to person-centred care (Barry and Edgman-Levitan, 2012) and so the social model of mental health supports this.
Mark also stated that he often felt bored and isolated and he would like to return to work. Mark enjoyed his part time Saturday job in a hardware store – a position that he had held between the age of 16 and 19 and said he enjoyed the company of colleagues and the work. Mark said that he felt ashamed that he had been given a diagnosis of schizophrenia and felt any prospective employer would not want to give him a chance. In fact, this perception was not entirely unfounded as research shows that people with schizophrenia often face employment discrimination (Seeman, 2009). Additionally, anticipation of discrimination like that expressed by Mark can negatively affect self-esteem and can lower self confidence that in turn can lead to a poorer performance at job interviews (Üçok et al., 2012).
The supported accommodation that was secured for Mark organised work placements for residents and when Mark this learned towards the end of his stay in hospital, he became more engaged. I explained to Mark that he would need to remain engaged with treatment and compliant with his medication if he was to remain well enough to be able to work. I also said that if he relapsed on amphetamines, this would likely prevent him from working. The social model was useful to engage with Mark because although he struggled to accept his formal diagnosis, he was able to understand that medication compliance and abstinence from illegal drugs would enable him to reach his personal goals.
My professional experience of working with Mark and the lessons I learned have enabled me to formulate some recommendations for future practice. It is important to consider the wider social circumstances of a patient who is not treatment compliant and/ or is using illegal drugs. I recommend that these vulnerable service users are treated with compassion in a non-judgemental way (Lubman, King and Castle, 2010) and it must be considered that there may be wider social factors contributing to substance misuse. Additionally, the patient might be trying to ‘self-medicate’ as Mark was trying to counter his depression. Safe and secure accommodation can be key to facilitating recovery and another recommendation for practice is that accommodation issues are addressed through liaison with other health and social care agencies.
Another recommendation for future practice is that adequate attention is given to medication adherence. Research shows that poor insight into the illness is correlated with poor medication compliance (Beck et al., 2011). This was clearly demonstrated in Mark who had a poor insight into his schizophrenia and therefore could not see the need for antipsychotic medication. As discussed in this essay, the medical model is perhaps better than the social for stressing the importance of medication, but the social model was more effective in engaging with Mark and helping him see he needed his medication to be able to achieve his goals. An extended medical model such as the biopsychosocial model would foster a more holistic approach.
One final recommendation is that wherever possible, service-user’s families are involved in treatment planning and care (NICE, 2009). This was not possible for Mark as he was not in contact with his family, however, this meant he had no family support. Supported housing would hopefully reduce Mark’s social isolation but wherever possible, care planning should involve significant others (Corsentino et al., 2008).
In conclusion, the social model of mental health considers that mental impairment does not cause disability but rather disability is caused by the way in which society is structured. This case study shows how discrimination and stigma are one of the barriers to social inclusion that is experienced by patients with schizophrenia. This case study also shows that the social model of mental health can be very useful for encouraging therapeutic engagement for patients with schizophrenia and addressing the underlying risk factors for relapse.
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