Monday December 18th 2017

Overcoming stigma

Education and advocacy can make a difference in mental health care and services

Many people don’t give a second thought about the state of mental health services in this country until tragedy strikes – or they or a loved one needs treatment. And while recent media coverage of the Tucson shootings, military personnel with PTSD, and the suicide of a college student may raise public awareness of potential mental health issues, it doesn’t naturally translate to more care or a better understanding of these disorders.

But that’s where nurses come in. No matter the role or the setting, nurses can pursue strategies to help their individual patients and advocate for a comprehensive mental health system, according to psychiatric and mental health nursing specialists.

Nurses already have worked with the American Nurses Association (ANA) to successfully promote two federal laws – the “Mental Health Parity Act,” which expands insurance benefits to cover mental health care under certain plans, and the “Affordable Care Act” (ACA), which includes some mental health-focused provisions as part of greater health system reform.

The American Psychiatric Nurses Association (APNA), an organizational affiliate of ANA, also has heightened its work around one of the biggest barriers to mental health care: stigma, according to APNA President Carole Farley-Toombs, MS, RN, NEA-BC, also the director of Clinical Operations for Acute Psychiatric Services at Strong Memorial Hospital in New York and an ANA member.

“Mental health is a critically important issue for the entire country, and probably the most poorly understood,” Farley-Toombs said.

And that lack of understanding often extends to health care professionals, who are more accustomed to treating conditions in which they can identify an illness-causing organism or can look at an X-ray, said Faye Gary, EdD, RN, FAAN, professor of nursing at Case Western Reserve University and executive program consultant/director of the SAMHSA Minority Fellowship Program at ANA.

“The state of mental health services has never been equal to that of services available for other conditions, such as cardiovascular disease and diabetes,” said Gary, a national board member of Mental Health America, Inc., and a member of the Greater Cleveland National Alliance for the Mentally Ill. “Like diabetes, mental illness can be treated successfully with ongoing care.

“As a world community we need to focus on mental health, because without it, there is no health.”

The mental health disconnect

One might think that all the commercials advertising drugs for depression or anxiety signals a growing acceptance of mental illness-related diagnoses or an uptick in available care.

That’s not the case for several reasons, according to Gary and other nurses.

“There is a difference between the ‘worried well’ and those who have difficulty to function well,” Gary said. “Those TV ads also are targeting people who have money, who have access to a primary care provider, and who have the ability to get care – not the vulnerable people who have no resources, who have problems with ADLs, and who distort reality.”

Further, people with mental health issues may benefit more from psychotherapy, cognitive behavioral therapy, medications, or some combination, she said, which means they need to see mental health specialists who can better determine the root cause of a problem. Once again lack of access or the ability to take steps to seek treatment come into play for vulnerable individuals.

According to the National Alliance on Mental Illness’s (NAMI) Stigmabusters fact sheet:

•  One in five people worldwide have a mental or neurological disorder at some point in their lives.

•  Some 450 million people currently suffer from such conditions.

•  Almost two-thirds of those with a known mental illness never seek help from a health professional.

“People tend to think that if they are diagnosed with a psychiatric disorder, it’s a death sentence,” Farley-Toombs said. “They often are afraid of getting labeled, or they are afraid of ‘coercive’ care. If they do seek help, oftentimes it’s not until their symptoms are so acute that their judgment and behaviors are affected to the point that they may require hospitalization or treatment over their objection. Such experiences continue the spiral of stigma, and reduce their trust in the mental health system and potential for ongoing engagement in treatment.”

To diminish the power of stigma, APNA members are working on a project that promotes the use of the “recovery model” throughout mental health practice, Farley-Toombs said. That model is based on principles that foster hope, patient empowerment, respect, patient and family-centered care, and the potential for recovery.

APNA’s work is being funded through a five-year grant from the federal Substance Abuse and Mental Health Services Administration (SAMHSA) and is part of an effort being tackled by four other behavioral health care provider associations.

Currently, APNA’s Recovery to Practice Task Force is assessing the state of the discipline and how recovery principles are implemented in psychiatric nursing practice, education and research, said Mary Moller, DNP, APRN, PMHCNS-BC, CPRP, FAAN, a task force member, APNA’s representative on ANA’s Congress on Nursing Practice and Economics, and APNA’s immediate past president. The task force then will develop a curriculum aimed at teaching all nurses how to use the recovery model in educational and practice settings.

APNA also is about to revise its mental health scope and standards of practice to include the recovery model principles, Farley-Toombs added.

On the practice front

“Every nurse is a mental health nurse, but it takes skills, training, and specialization to become a psychiatric nurse,” Moller explained.

That said, she added, “[non-psychiatric specialty] nurses need to get rid of their fear of working with patients with psychiatric disorders, and one way is through education.”

APNA President-elect Marlene Nadler-Moodie, MSN, APRN, PMHCN-BC, agreed, noting that, “general nurses do tend to feel like working with patients with mental illness is out of their scope of understanding. But the more they learn, the more comfortable they will be.”

Unfortunately, many entry-level nursing programs have eliminated psychiatric-mental health content from their coursework, as well as graduate programs in psychiatric nursing. So nurses must be willing to track down resources to gain a better understanding of mental illness, including bipolar disorder, schizophrenia, and anxiety-panic disorders.

“All nurses also need to understand trauma-informed care,” Moller said. (This involves being aware that a medical procedure or hospital stay can trigger earlier trauma, such as childhood abuse.)

They further must understand the role stigma plays, and that mental illness is “as real and valid” as any medical condition, Farley-Toombs said. “And they need to embrace the idea that people with mental illness are working toward recovery and can live meaningful lives.”

Nadler-Moodie, who has written extensively on the issue of non-specialists caring for patients with mental illness, said there are other strategies nurses can apply to their practice – some of which are core nursing skills. (See her continuing education article, “Are you prepared for psychiatric emergencies?” in the May 2010 issue of American Nurse Today.)

“It’s important that nurses be open to the fact that they are going to have psychiatric patients in their care, because they break legs and have heart attacks,” said Nadler-Moodie, a clinical nurse specialist at Sharp Mesa Vista Hospital and Scripps Mercy Hospital in San Diego, CA, and an ANA/California member.

“Nurses also need to be good communicators, which includes being aware of their own communication style and taking the time to listen, which can be challenging on typical med-surg units. When I walk into a room to talk with a patient, I sit down and start the conversation by saying, ‘How can I help you?’”

Nurses also should be cognizant of the language they use – for example say a “person with schizophrenia” and not a “schizophrenic,” she said.

Added Gary, “Every nurse needs to be grounded in the basic principles of communicating with patients and providing patient-centered care in a culturally sensitive way. And mental health needs to be part of the routine nursing assessment, like taking a blood pressure or temperature, so at-risk patients can be identified and the appropriate care provided.”

Another strategy is knowing the key person on staff who can be called in for a consult or referral, as well as being knowledgeable of resources in the community, such as shelters and free clinics.

“Nurses don’t need to know all the ins and outs of the mental health system, but they should do research on community and facility contacts before they need help with a patient,” Farley-Toombs said.

Additionally, nurses must trust their assessment skills and judgment.

“If you suspect something, such as a psychotic breakdown or clinical depression, you probably are right,” Nadler-Moodie said. “So don’t hesitate to call [for a consult], or fear stigmatizing the patient if you make a referral.”

Moller also recommends that nurses advocate for ongoing educational activities at their facilities so they are better prepared to provide solid care.

And finally, there are online resources available to nurses and patients through consumer organizations, such as; government agencies, such as; and professional associations, such as

Nadler-Moodie added that the Emergency Nurses Association, another ANA-affiliated organization, invited several APNA members to collaborate on an online educational product focusing on working with mental health issues and psychiatric disorders. That project is in development.

Big picture advocacy

Just as they routinely advocate for individual patients, psychiatric-mental health nursing specialists encourage all nurses to engage in broader efforts on behalf of this population who often can’t advocate for themselves.

“The system is very overburdened,’ Moller said. “And nurses need to advocate at state legislatures for more funding and community services that were supposed to be provided under the “Community Mental Health Act of 1963.” That law led to increased deinstitutionalization of people with mental illness.

With few community resources available, many people with mental illness and psychiatric disorders again are ending up in the nation’s prisons and jails without treatment – not unlike the times before 19th century mental health care reformer Dorothea Dix crusaded for humane, hospital-based care, she said.

Adding to the problem are tight federal and state budgets.

Moller also noted that the mental health parity law does not apply to Medicaid and Medicare recipients and those employed in businesses with 50 or fewer employees.

However, provisions in the ACA, which also needs nurses’ ongoing support, may help.

“The ACA provides significant steps forward in mental health,” said Cynthia Haney, JD, senior policy fellow in ANA’s Department of Practice and Policy. “A major step is the understanding that mental health and physical health are linked, so a sensitivity to this link and the potential need for mental health referrals should be integrated into primary care.”

Nadler-Moodie knows that strong advocacy is important, because good mental health services work.

She offered the example of the A-Visions program at Scripps Mercy, where she works.

Clients in recovery, some of whom were former inpatients, are initially placed in non-paying hospital jobs in three areas, such as the cafeteria, for a three-month trial while providing them with job coaching and ongoing mental health and social skills support.

“If they do well, they are given paid jobs at the hospital,” Nadler-Moodie said. “Some of the people who are in this program I saw in the hospital when there were very sick. Now they are working and functioning well.

“And there are many success stories like this around the country.”

The health care reform law and mental health

The Affordable Care Act (ACA) includes several mental health-related provisions that are rolling out over time. Among them are:

•  Creating more incentives to coordinate primary care, mental health, and addiction services, as well as providing grants and Medicaid reimbursement for the creation of “health homes” to identify, treat and prevent chronic health conditions, including mental illness.

•  Including “mental health and substance abuse disorder services, including behavioral health treatment” in an “essential benefits package” (EBP). The EBP is important because it defines the minimum acceptable coverage for all insurance plans that participate in the state Exchanges (insurance marketplaces) that are coming into effect in 2014. This requirement will also affect Medicaid plans.

•  Medicare annual wellness visit (at no charge) includes screening for cognitive impairment and other mental health conditions.

•  Grants for school-based health centers to provide primary health services, to include mental health and substance abuse; grants selection preference include communities where there are barriers to mental health and substance abuse prevention services.

•  Establishing a network of Centers of Excellence for Depression that will engage in research, professional training, data collection, and coordinating and collaborating to provide comprehensive health for people with depression and related disorders. Supporting research on postpartum depression.

•  Including mental health and behavioral health in national priorities being developed by the new National Prevention, Health Promotion and Public Health Council.

•  Providing specialty loans to medical and nursing professionals who focus on child and adolescent mental and behavioral health care, and grants to train primary care providers in the care of vulnerable populations and in the integration of mental health into primary care services.

Sources: ANA and SAMHSA materials

— Susan Trossman is the senior reporter for The American Nurse.

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