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Mental health difficulties are reported globally to affect 1 in 4 individuals (World Health Organisation (WHO), 2013). Figures in Scotland are similar, where 32% of individuals surveyed in 2013 self-reported having one or more mental health conditions (Scottish Government, 2014). Scotland currently has a wide range of policies and legislation in place to protect those with mental health difficulties, extending from policies designed to reduce stigma and discrimination, to policies designed to support those who are at the risk of suicide.
This assignment will discuss the ramifications of living with schizophrenia and cannabis dependency in an individual called Stuart. There will also be a discussion on the legislative and policy framework in Scotland within which support for people with mental health needs is set.
This case study will focus on an individual, who will referred to as Stuart. This is not the service users real name, but this paper will follow the Nursing and Midwifery Council’s (NMC) Code of Conduct, 5.1 (2015), stating that a patient’s right to privacy and confidentiality must be upheld at all times Stuart is a 50- year-old divorcee .He is an electrician by trade. Currently unemployed. He has three children and an ex-wife.
Stuart has a diagnosis of schizophrenia. Schizophrenia is a long-term and debilitating condition which is characterised by symptoms such as delusions, hallucinations, low affect, and cognitive difficulties (American Psychological Association (APA), 2013). It is diagnosed using the DSM-5 diagnostic criteria, which include delusions, hallucinations, negative symptoms, disorganised/catatonic behaviour, and disorganised speech (APA, 2013).
The experience of voice hearing should not be confused with the normal inner voice that we all have in our minds when we are in good health. Voices caused by psychosis are profoundly different. They are as real as hearing a person in the same room speaking ( and indeed research carried out by scientists has shown that the parts of the brain that are activated by hearing real speech, i.e. for detecting speech and generating language, are also active when voice hearers hear the voices coming from inside their heads( Reveley, 2006).
In addition to schizophrenia, he struggles with substance dependency and has been smoking cannabis since he was 9 years old. Cannabis is the most widely used psychoactive substance in the world (United Nations Office on Drugs and Crime, 2016). It is estimated that 10% of cannabis users develop a cannabis use disorder. This can be diagnosed when a person’s cannabis use impairs their functioning in everyday activities, such as driving, over a year long period (APA, 2013). Cannabis use has high morbidity with disorders such as schizophrenia, and some experts believe that there is a casual link between early cannabis use and schizophrenia (Hartz et al.,2014).
Stuart was raised in dysfunctional family. He rarely saw his father who had been physically abusive towards Stuart’s mother. He was also an alcoholic. Stuart’s father died at the age of 42 from liver disease. Stuart’s relationship with his mother is strained. He blames her for allowing him to witness the domestic violence as a child.
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When you grow up in a dysfunctional family, you experience trauma and pain from your parent’s actions, words, and attitudes (Boyd, 1992).Because of this trauma you experienced, you grew up changed, different from other children, missing important parts of necessary parenting that prepare you for adulthood, missing parts of your childhood when you were forced into unnatural roles within your family (Boyd, 1992).
Impact of Conditions
Cannabis use is associated with lower educational attainment and the increased use of other drugs (MacLeod et al., 2004). There is mixed evidence for the link between cannabis and impaired neurological functioning. There is some suggestion that any impairment in function is not permanent and resolves when use is stopped (Schreiner and Dunn, 2012).
Schizophrenia impacts negatively on both physical and psychological health. Research suggests that patients with schizophrenia often have health problems due to low levels of exercise, poor diets, and other drug use (McNamee et al., 2013). The social effects are also considerable. Individuals typically avoid social interactions and become isolated as their relationship with family and friends disintegrate (Castle and Buckley, 2015). In addition, they can experience significant developmental difficulties, with their ability to work impaired as a result (Lauriello and Palanti, 2012).
When Stuart’s delusions are most extreme, Stuart finds that he cannot leave the house, which is difficult for his children to cope with. This is likely to negatively impact on his chances of recovery as family support is important for recovery (Mueser and Gingerich, 2006).
There continues to be a stigma around mental illness (Thompson, 2007). This is particularly true in Scotland where stigma and discrimination have been identified as a widespread concern (The Mental Health Foundation, 2016).
Stuart was fired from his workplace for his number of absences. He believes the real reason was that he had mental health problems. This negatively impacted on his emotional wellbeing at the time, and he began to experience self-stigma and low mood. He experienced discrimination when he went to the job centre to seek employment. He revealed that he was a regular cannabis user and felt that his case worker judged him, and did not offer him any viable training or employment offers as a result.
Two Contrasting Approaches
Two approaches to mental health which have widely influenced perceptions have been the biomedical model and the anti-psychiatry model. The biomedical model views illness as an aberration to be treated (Thompson, 2007). Mental illnesses are diagnosed based on observable behaviours. This is also known as the labelling theory (Thompson, 2007). The biomedical view continues to be the prevailing view of mental illness in the Western world. An opposing view of mental illness comes from the anti-psychiatry movement. This movement has maintained a stance that mental illness should be viewed as a sane reaction to the insanity of the modern world (Thompson, 2007).
Psychiatrists such as Laing contended that psychotic episodes were instead expressions of extreme stress on the part of the individual in response to societal expectations (Thompson, 2007).
Stuart has recently heard that his ex-wife is moving away with their children. This has been a huge setback for Stuart, who is likely to feel even more isolated than before.
Legislative and Policy Framework
Scotland has a strong legislative and policy framework in place to support people with mental health needs. The Mental Health (Care and Treatment) (Scotland) Act 2003 provides the backdrop to policies such as Delivering for Mental Health (Scottish Government, 2006), Towards a Mentally Flourishing Scotland (Scottish Government, 2009 b), and Mental Health Strategy for Scotland: 2012-2015 (Scottish Government, 2012). In addition to these, there have been accompanying developments such as the See Me programme which aimed to reduce stigma around mental health (Scottish Executive, 2002), and the Suicide Prevention Strategy (2013-16) which was developed to target suicide rates (Scottish Government, 2013). The Mental Health Division was set up in 2003 by the Scottish Executive and has been responsible for some of the above policies (The Mental Health Foundation, 2016). The impact of the Division and the Mental Health (Care and Treatment) (Scotland) Act 2003 will be discussed here, and their relevance to the care that can be provided for Stuart explored.
The Mental Health (Care and Treatment) (Scotland) Act 2003
The Mental Health (Care and Treatment ) (Scotland) Act 2003 set out provision as to how and where individuals could receive treatment, and how they could be treated without their consent should that be necessary. It also set out the rights of individuals when receiving treatment. The background to this legislation was the growing awareness in Scotland in the 1990’s that the previous legislation, the 1984 Mental Health (Scotland) Act, was outdated. New legislation was required that reflected the changing landscape of mental health, with its greater focus on human rights and on supporting individuals in community, as opposed to hospital-based care (The Mental Health Foundation, 2016). The Act was an ambitious piece of legislation, and was recognised as one of the most forward-looking pieces of legislation in the world at the time. Of particular importance was its emphasis on the human rights of those with mental health illnesses. It was informed by the Millan Principles (Millan, 2001). These included an emphasis on participation and non-discrimination. Advance statements relate to the principle of participation and mean that an individual can produce a written statement when they are well which specifies how they would want to be treated when they are unwell from mental health perspective, and are unable to make decisions for themselves, Stuart has produced an advance statement which specifies that he is to be administered anti-psychotic medication If he is too unwell to make that decision for himself. Advance statements are useful in forming a therapeutic alliance between the practitioner and the patient (Mental Welfare Commission for Scotland, 2014).
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The McManus Review (Scottish Government, 2009 a) assessed the Act’s progress and found that the implementation of the Act was proceeding well, but that areas for improvement remained. The review highlighted areas such as the limited use of advance statements, and take up of independent advocacy services.
Mental Health Division
The second important development that I will discuss is the Mental Health Division and the policies that this body has been responsible for. The Mental Health Division was established by the Scottish Executive in 2003, and its aim was to improve the quality of mental health provision in Scotland. It has been responsible for policies such as Delivering for Mental Health (Scottish Government, 2006), Towards a Mentally Flourishing Scotland: Policy and Action Plan (2009-2011) (Scottish Government 2009b), and the Mental Health Strategy for Scotland : 2012-2015 (Scottish Government,2012). The Delivering for Mental Health policy set out health improvement, efficiency, access and treatment (HEAT) targets which were to be achieved within a certain timeframe. The HEAT targets relevant to mental health included decreasing the number of antidepressants the population was taking, reducing psychiatric readmissions, and decreasing suicide rates.
Of relevance to the present case study is the publication of the Mental Health Strategy for Scotland: 2012-2015. This policy aimed to improve the treatment options available for people with mental health needs and their carers. The Mental Health Strategy however, has been criticised by professionals and service users like, for trying to address too many areas for placing less emphasis on health promotion and prevention than previous (The Mental Health Foundation, 2016).
Gaps in Service Provision
An area where there are some gaps in service provision is in the provision of crisis support for individuals with mental health difficulties. Crisis provision is ‘’designed to provide support to individuals with or without prior diagnoses of mental health conditions in instances of acute distress as an alternative to hospitalisation ‘’ (The Mental Health Foundation, 2016, p.88).
Another area where further funding is required is around the evaluation of policies (The Mental Health Foundation, 2016). Most mental health evaluation focuses on measuring ‘hard outcomes’ such as patient waiting times, the number of psychiatric admissions, and the take up of services (The Scottish Government, 2006b).
In Scotland, there is a strong legislative framework to support individuals with mental health concerns. However there continues to be gaps in service provision with respect to measuring progress, and the delivery of crisis services. In this way, Scotland is not unlike other developed countries, however greater efforts must be made to address these gaps. In addition, service users such as Stuart continue to experience stigma and discrimination in daily life and this does not appear to have lessened greatly in Scotland since the publication of the Sandra Grant Report (Scottish Executive, 2004)
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