Pocketbook of Mental Health 3rd Edition

3RD EDITION
POCKETBOOK OF MENTAL HEALTH

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3RD EDITION
POCKETBOOK OF
MENTAL HEALTH
Eimear Muir-Cochrane
Patricia Barkway
Debra Nizette
Elsevier Australia. ACN 001 002 357
(a division of Reed International Books Australia Pty Ltd)
Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067
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Foreword
Mental illness is not something that affects just a few Australians and New
Zealanders. As highlighted in the revised first chapter of this third edition
of Pocketbook of Mental Health, mental ill health is common, with one in
five Australians and New Zealanders experiencing a mental illness within
a 12-month period. Almost half (45%) of Australians and New Zealanders
aged 16–85 years will experience a mental illness at some stage in their
lives. That means that 55% of Australians and New Zealanders who don’t
experience mental illness will in some way care for and be affected by
those who do.
It is an honour to be invited to provide the foreword for this edition
of Pocketbook of Mental Health. As South Australia’s inaugural Mental
Health Commissioner and lacking a clinical background, I have found
Pocketbook of Mental Health an invaluable resource and reference to
grow my knowledge and understanding of mental health and wellbeing.
Knowledge is empowerment; it enhances an individual’s capacity to
deal with issues with confidence. Pocketbook of Mental Health empowers
clinicians and non-clinicians alike with the knowledge and understanding
of mental illness that enables them to positively contribute to the mental
health and wellbeing of Australians and New Zealanders. By raising
awareness and educating through mediums such as this book, we can
break down the stigma associated with mental illness and work towards
growing the mental health of our nations.
It is impressive to see that the authors of this third edition have
included new chapters on assessing risk and addressing behaviours of
concern. They also provide much more in-depth detail on trauma-
informed and person-centred care. With a focus on social inclusion,
recovery, culture and the promotion of consumer rights, this book acts as
a pivotal guide for holistic modern health care practices.
In offering the foreword for this book, I would like to compliment its
authors, Eimear Muir-Cochrane, Patricia Barkway and Debra Nizette,
for their commitment to and professionalism in delivering an invaluable
hands-on and user-friendly guide to strengthening the mental health and
wellbeing of Australians and New Zealanders.
Chris Burns CSC

South Australian Mental Health Commissioner
v
Contents
Foreword v 11 Co-occurring Medical

Problems 113
Preface vii
12 Loss and Grief 120
Authors viii
13 Law and Ethics 130
Reviewers viii
14 Settings for Mental Health
1 Mental Health: Every Health
Care 138
Professional’s Business 1
Appendix 1 Surviving Clinical
2 Working in a Recovery
Placement 147
Framework 8
Appendix 2 Who Does What in
3 Essentials for Mental Health
Mental Health? 149
Practice 19
Appendix 3 Abbreviations
4 An Overview of Mental Health
in Medication
Problems 29
Administration 152
5 Mental Health
Appendix 4 Supporting People
Assessment 47
With Mental
6 Assessing Risk 61 Illness Taking
Medication 154
7 Behaviours of Concern 69
Further Reading and
8 Mental Health Talking-Based
Resources 155
Therapies 80
Glossary 158
9 Managing Medications 85
Credits 162
10 Culture and Mental
Health 103 Index 165
vi
Preface
Approximately 450 million people worldwide have a mental health

problem, with about 20% of the adult Australian population and 15% of
young people having a mental illness. For these reasons, mental health
and illness awareness are fundamental to all those working in health and
health-related areas. This handy, readable text is intended to provide easy
access to immediate advice for a range of health professionals and
workers including general nurses, general practitioners, paramedics,
police, mental health workers, drug and alcohol workers and allied health
professionals who encounter people with mental health problems in their
daily work. This text will also be useful for mental health support workers
and those in consumer care roles. We have distilled the core elements of
engaging and working with people with mental health problems into
practical skills and approaches that can be applied to a range of settings
for care.
This third edition has been comprehensively prepared to provide the
latest evidence about mental health care and includes new chapters and
more detail in the areas of co-occurring physical and mental health,
behaviours of concern and risk assessment.
At the core of mental health practice is a focus on social inclusion,
person-centred care and recovery, cultural understanding and respect for
and promotion of consumer rights. Accordingly, we have included
chapters that reflect these foci and associated ‘hands on’ strategies. We
have used text boxes to provide practical tips about what to do in
commonly encountered situations and give handy, practical quick guides
for practice. Revised and extended appendices serve as an aide-mémoire
or checklist for quick reference in relation to, among other things, tips
about how to survive clinical placement, what roles health professionals
have in the workplace, and a brief guide to help consumers manage
medication. We have included extensive web-based resources to provide
the latest bibliography of reliable electronic resources for ease of access.
In writing this book we set out to ‘cut to the core’ in terms of which
practical, do-able and helpful strategies would be of use to health
professionals who don’t have formal mental health qualifications. We
believe that this is what we have achieved and trust that readers will find
this book to be a vital, practical and useful adjunct to their professional
practice.
Eimear Muir-Cochrane
Patricia Barkway
Debra Nizette
vii
Authors
Eimear Muir-Cochrane BSc(Hons), RN, CMHN, GradDip—Adult Ed, MNS,

PhD, FACMHN
Chair of Nursing (Mental Health), College of Nursing and Health Sciences,
Flinders University, SA, Australia
Patricia Barkway RN, CMHN, FACMHN, BA—Psychology/Education,
MSc—Primary Health Care
Senior Lecturer (Academic Status), College of Nursing and Health
Sciences, Flinders University, SA, Australia
Debra Nizette RN, CMHN, FACN, FACMHN, DipAppSc—Nurse Ed,
BAppSc—Nursing, MNSt
Director of Nursing, Nursing and Midwifery Office, Queensland Health,
QLD, Australia
Reviewers
Paula Duffy RN, MPET, ACMHN, ACN

Director of Nursing, Mental Health/Senior Psychiatric Nurse, Ballarat
Health Services, VIC, Australia
Lisa Holmes BEd(Hons)
Mental Health Lecturer, Edith Cowan University; Chair of Paramedics,
Australasia Paramedic Mental Health and Wellbeing Special Interest
Group, VIC, Australia
Ronald Castelino BPharm, MPharm, PhD
Senior Lecturer, Pharmacology and Clinical Pharmacy, University of
Sydney; Renal Pharmacist, Blacktown Hospital, Western Sydney Local
Health District, NSW, Australia
viii
Chapter 1
Mental Health: Every Health
Professional’s Business
INTRODUCTION
More than a decade ago the World Health Organization (WHO) made two
statements that have been embraced by policymakers as core principles
of worldwide mental health policy and plans (Mental Health Taskforce UK
2016, New Zealand Ministry of Health 2014, WHO 2013). They are that
there is no health without mental health and that mental health is
everybody’s business (WHO 2004).
WHO (2014a) defines mental health as:
… a state of well-being in which every individual realizes his or her

own potential, can cope with the normal stresses of life, can work
productively and fruitfully, and is able to make a contribution to her or
his community.
Mental illness, however, is defined as the presence of cognitive,

affective and/or behavioural symptoms that are persistent and pervasive
and impair the individual’s functioning. The Fifth National Mental Health
Plan (Department of Health 2016 p 74) states that mental illness is:
A clinically diagnosable disorder that significantly interferes with an

individual’s cognitive, emotional or social abilities. Examples include
anxiety disorders, bipolar disorder, eating disorders, and schizophrenia.
Mental health is integral to health and wellbeing, yet throughout the

world mental illness is stigmatised and remains a significant health, social
and human rights concern, and the burden is growing (WHO 2013).
Furthermore, living with mental illness is also associated with poorer
physical health and shortened life expectancy; and, conversely, living with
a chronic physical condition increases the risk for mental health problems
(Department of Health 2015). In other words the disadvantage works both
ways. This chapter presents statistics on the incidence of mental illness in
the community and recommends strategies to address the needs of
people experiencing mental health problems, to facilitate recovery and to
ensure the WHO goal of health for all.
THE EXTENT OF MENTAL ILLNESS IN THE COMMUNITY

At any one time approximately 20% of the adult Australian population and
15% of young people have a mental illness (Australian Bureau of Statistics
(ABS) 2016). If you add to these figures the unknown, but significant,
1
2 Chapter 1 Mental Health: Every Health Professional’s Business
TABLE 1.1
KEY FINDINGS OF THE 2007 AUSTRALIAN MENTAL HEALTH AND
WELLBEING SURVEY
Incidence Mental Disorders in the Australian Population
45.5% Mental disorder at some point in one’s lifetime
20.0% Any mental disorders in the preceding 12 months for the population aged 16–85
years—more prevalent in females (22.3%) than males (17.6%)
6.2% Affective (mood) disorders—more prevalent in females (7.1%) than males (5.3%)
14.4% Anxiety disorders—more prevalent in females (17.9%) than males (10.8%)
5.1% Substance misuse disorders—more prevalent in males (7.0%) than females (3.3%)
Sources: ABS 2016, Mindframe 2014
proportion of the population who are experiencing mental health problems,

it is clear that mental health and illness are issues of major concern for
the community in general and, in particular, for governments, health care
services, non-government organisations, families, carers, friends and those
people who are living with mental illness.
Every 10 years the Australian Government surveys the mental health of
the nation (ABS 1998, ABS 2008, ABS 2016, Mindframe 2014). Table
1.1 summarises the key findings of the most recent survey.
Based on these prevalence rates, it is estimated that over a 12-month
period more than three million Australians will be diagnosed with a mental
disorder, nearly one million will be diagnosed with affective disorders,
more than 2.3 million will have anxiety disorders and more than 800,000
will have substance misuse disorders. These findings are similar to other
international statistics for developed nations (Mental Health Foundation of
New Zealand 2014). The survey also found that social determinants
(poverty, education level, marital status, etc.) were strongly associated
with experiencing a mental illness or problem in the preceding 12 months
(Slade et al 2009). Furthermore, the national survey found that only 35%
of people experiencing symptoms of mental illness accessed health
services (Mindframe 2014). Therefore, the actual number of people living
with mental illness in the community is greater than the statistics suggest.
VULNERABLE POPULATIONS AND INDIVIDUALS

Mental illness can affect anyone; however, some populations are at
increased risk. At-risk populations include people who are: poor;
indigenous; from culturally and linguistically diverse backgrounds; lesbian,
gay, bisexual, trans or intersex; homeless; socially isolated; young men; in
the justice system; child abuse and domestic violence victims; or living
with pain or a chronic illness. They also include people who have: an
intellectual disability; a family history of mental illness; experience of
trauma such as refugees; chronic physical illness or comorbid drug and
alcohol problems (National Mental Health Commission 2012, WHO 2012,
World Federation for Mental Health 2010).
Chapter 1 Mental Health: Every Health Professional’s Business 3
Despite having increased risk these populations often have less than
optimal engagement with health care services. Identifying vulnerable
individuals and populations who are at risk assists policymakers to plan
and deliver prevention and early intervention programs to help facilitate
recovery.
Risk for Co-occurring Mental Illness

People living with a chronic physical illness are at increased risk of
developing depression, anxiety and substance abuse. People with
diabetes experience anxiety and depression at three to four times the
wider population incidence; 20% of people living with asthma or chronic
obstructive pulmonary disease also experience depression and anxiety;
and up to 40% of cardiac patients exhibit clinically significant symptoms
of depression (World Federation for Mental Health 2010). Katon (2010)
found that up to two-thirds of people who had co-occurring diabetes and
depression did not receive treatment for the depression.
This is of concern because depression and anxiety are disabling
conditions that can diminish a person’s quality of life, can lead to poor
control of the co-occurring medical condition, and can add to the cost of
health care due to reduced engagement in managing the chronic health
condition. Depression and anxiety are also associated with poor self-care
and an increased incidence of complications among people with diabetes
(Katon 2010, World Federation of Mental Health 2010).
Risk for Co-occurring Physical Illness

People who experience mental illness die younger—10–32 years earlier
than the general population. They also have higher rates of physical
illness, have poorer dental health, are less likely to engage in exercise,
and smoke tobacco at twice the rate of the general population (National
Mental Health Commission 2012, Thoms 2013). Despite these
discrepancies, people with mental illness are less likely to receive hospital
treatment than the general population. For example, people who are
diagnosed with schizophrenia or major depression have a 40–60% greater
chance of premature death than the rest of the population, as a
consequence of physical health problems that are not addressed. Such
conditions include cancers, cardiovascular diseases, diabetes and HIV
infection (Gibson et al 2011, WHO 2013). This is further compounded by
a low level of engagement with health care services for this population
(Gibson et al 2011), which in turn hinders recovery.
Co-occurring physical illness can partly be attributed to the side effects
of psychotropic medications and lifestyle factors such as smoking,
inactivity and diet (Thoms 2013). Metabolic syndrome (the presence of
three or more of the following symptoms: central abdominal obesity,
hyperglycaemia, hypertension, elevated triglycerides or low levels of
high-density lipoprotein cholesterol) is prevalent among people taking
atypical antipsychotic medications and accounts for the increased risk for
BOX 1.1
PROVIDING GENERAL HEALTH CARE FOR PEOPLE WITH MENTAL ILLNESS IN
THE PRIMARY CARE SETTING
• Promote healthy lifestyle choices:
• physical activity and fitness
• healthy eating
• avoiding or reducing tobacco smoking
• drinking alcohol in moderation
• avoiding or minimising illicit drug use.
• Undertake psychosocial assessment and review regularly—the Kessler
Psychological Distress Scale (K10) is an easily administered assessment tool
(Australian Mental Health Outcomes and Classification Network 2016).
• Regularly review psychiatric medications and their metabolic risk.
• Establish and monitor the person’s body mass index, weight, waist
circumference, cholesterol levels, blood pressure and blood glucose, and
respond early to any changes.
• Refer for specialist assessment if indicated.
Adapted from Gibson et al 2011 and Mitchell et al 2013
cardiovascular disease (Mitchell et al 2013, Vancampfort et al 2013).

Social determinants—such as inequities in a person’s social, physical
and economic environments—also contribute to poorer health outcomes
(WHO 2014b). See also Chapter 11 on co-occurring medical problems.
Providing General Health Care for People With Mental Illness in

the Primary Care Setting
Most people living with mental illness live in the community, and their first
point of contact with the health care system is usually through primary
care services. Hence, general practitioners, pharmacists and general
practice nurses are particularly well positioned to screen and respond to
the physical health problems of people living with mental illness. Box 1.1
summarises the recommendations made by Gibson et al (2011) and
Mitchell et al (2013) to promote wellbeing and to monitor for early signs
of metabolic syndrome in people living with mental illness.
Providing Mental Health Care for People With a Chronic

Physical Illness in the Acute Care and Primary Care Settings
Health professionals in both acute general hospital settings and primary
care can play a role in supporting the mental health of people living with
ongoing physical conditions such as chronic pain, terminal illness or
progressive neurological disorders. Health professionals are ideally placed
to screen for symptoms of mental illness or mental health problems in
people living with chronic physical conditions and in their carers, and to
refer for specialist assessment if indicated (see Box 1.2). The Kessler
Psychological Distress Scale (K10) is an easily administered assessment
BOX 1.2
PROVIDING MENTAL HEALTH CARE FOR PEOPLE WITH A CHRONIC PHYSICAL
ILLNESS IN THE ACUTE CARE AND PRIMARY CARE SETTINGS
• Promote healthy lifestyle choices:
• physical activity and fitness
• healthy eating
• avoiding or reducing tobacco smoking
• drinking alcohol in moderation
• avoiding or minimising illicit drug use.
• Undertake and monitor psychosocial as well as physical assessment.
• Use tools to screen for mental distress, such as K10.
• Refer for specialist assessment if indicated.
Adapted from World Federation for Mental Health 2010
tool that can be used in the primary care setting to identify psychosocial
distress. It consists of 10 questions rated on a Likert scale, with a score
of more than 20 out of 50 indicating mental distress (Australian Mental
Health Outcomes and Classification Network 2016).
CONCLUSION
To rephrase and expand on the WHO slogans—not only is there no health
without mental health but there is also no mental health without physical
health. Furthermore, this makes mental health every health professional’s
business. People living with mental illness and chronic physical conditions
need regular monitoring of both physical and mental health indicators to
ensure they achieve optimal care to maintain their health and wellbeing
and achieve recovery. Both the acute hospital and the primary care
sectors are particularly well placed to undertake this role and thereby to
promote mental wellbeing, to prevent mental illness and to screen and
intervene early when mental illness symptoms are evident—and also to
respond early to physical health problems experienced by people living
with mental illness.
References
Australian Bureau of Statistics (ABS). (1998). Mental health and wellbeing: Profile of adults
Australia 1997. Cat no 4326.0. Online. Available: http://www.abs.gov.au/AUSSTATS/[email protected]/
allprimarymainfeatures/D5A0AC778746378FCA2574EA00122887?opendocument 14 July 2017.
Australian Bureau of Statistics (ABS). (2008). National survey of mental health and wellbeing:
Summary of results, 2007. Online. Available: http://www.abs.gov.au/ausstats/[email protected]/mf/4326.0
14 July 2017.
Australian Bureau of Statistics (ABS). (2016). Gender indicators, Australia: Health: mental health.
Cat no 4125.0. Online. Available: http://www.abs.gov.au/ausstats/[email protected]/Lookup/by%20
Subject/4125.0~August%202016~Main%20Features~Health~2321 14 July 2017.
Australian Mental Health Outcomes and Classification Network. (2016). Kessler–10+. Online.
Available: http://www.amhocn.org/publications/kessler-10 14 July 2017.
Department of Health. (2015). Australian Government response to ‘Contributing lives, thriving
communities—review of mental health programmes and services’. Online. Available: http://www
.health.gov.au/internet/main/publishing.nsf/Content/mental-review-response 14 July 2017.
Department of Health. (2016). Fifth national mental health plan: An agenda for collaborative
government action in mental health 2017–2022. Canberra: Commonwealth of Australia. Online.
Available: http://www.health.gov.au/internet/main/publishing.nsf/content/mental-fifth-national-
mental-health-plan 14 July 2017.
Gibson, M., Carek, P. J., & Sullivan, B. (2011). Treatment of co-morbid mental illness in primary
care: How to minimise weight gain, diabetes and metabolic syndrome. International Journal of
Psychiatry in Medicine, 41(2), 127–142.
Katon, W. (2010). Depression and diabetes: Unhealthy bedfellows. Depression and Anxiety, 27(4),
323–326.
Mental Health Foundation of New Zealand. (2014). Mental health quick statistics. Online.
Available: https://www.mentalhealth.org.nz/assets/Uploads/MHF-Quick-facts-and-stats-FINAL.pdf
14 July 2017.
Mental Health Taskforce UK. (2016). The five year forward view for mental health: A report from
the mental health taskforce to the NHS in England. Online. Available: https://www.england.nhs.
uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-FYFV-final.pdf 14 July, 2017.
Mindframe. (2014). Facts and stats about mental illness in Australia. Online. Available: http://www.
mindframe-media.info/for-mental-health-and-suicide-prevention/talking-to-media-about-mental-
illness/facts-and-stats 14 July 2017.
Mitchell, A., Vancampfort, D., Sweers, K., et al. (2013). Prevalence of metabolic syndrome and
metabolic abnormalities in schizophrenia and related disorders—a systematic review and
meta-analysis. Schizophrenia Bulletin, 39(2), 306–318.
National Mental Health Commission. (2012). A contributing life: The 2012 national report card on
mental health and suicide prevention. Sydney: NMHC.
New Zealand Ministry of Health. (2014). Rising to the challenge: The mental health and addiction
service development plan 2012–2017. Online. Available: http://www.health.govt.nz/our-work/
mental-health-and-addictions/rising-challenge 14 July 2017.
Slade, T., Johnston, A., Teesson, M., et al. (2009). The mental health of Australians 2. Report on
the 2007 National Survey of Mental Health and Wellbeing. Canberra: Department of Health and
Ageing.
Thoms, D. (2013). The physical burdens of mental illness. Nursing Review. Online. Available:
https://www.nursingreview.com.au 14 July 2017.
Vancampfort, D., Probst, M., Scheewe, T., et al. (2013). Relationships between physical fitness,
physical activity, smoking and metabolic and mental health parameters in people with
schizophrenia. Psychiatry Research, 207, 25–32.
World Federation for Mental Health. (2010). Mental health and chronic physical illness: The need
for continued and integrated care. Online. Available: http://www.encontrarse.pt/wp-content/
uploads/2016/12/docs_wmfh2010.pdf 14 July 2017.
World Health Organization (WHO). (2004). Mental health promotion. Geneva: WHO. Online.
Available: http://www.who.int/mental_health/evidence/en/promoting_mhh.pdf 14 July 2017.
World Health Organization (WHO). (2012). Risks to mental health: An overview of vulnerabilities
and risk factors. Online. Available: http://www.who.int/mental_health/mhgap/risks_to_mental_
health_EN_27_08_12.pdf 14 July 2017.
World Health Organization (WHO). (2013). Comprehensive mental health action plan 2013–2020.
Geneva: WHO. Online. Available: http://www.who.int/mental_health/action_plan_2013/en/ 14 July
2017.
World Health Organization (WHO). (2014a). Mental health: A state of well-being. Geneva: WHO.
Online. Available: http://www.who.int/features/factfiles/mental_health/en 14 July 2017.
World Health Organization (WHO). (2014b). Social determinants of mental health. Online.
Available: http://apps.who.int/iris/bitstream/10665/112828/1/9789241506809_eng.pdf 15 July
2017.
Web Resources
Australian College of Mental Health Nurses. Chronic disease and mental health. http://www.acmhn
.org/chronic-disease-elearning. This is a free interactive e-learning program for nurses working
with people who live with chronic disease. It uses video vignettes and a range of activities to
highlight the key issues related to mental health.
Australian Government, Department of Health and Ageing. http://www.health.gov.au/internet/main/

publishing.nsf/content/mental-fifth-national-mental-health-plan. This is the site for the Fifth
National Mental Health Plan: An agenda for collaborative government action in mental health
2017–2022.
Mental Illness Foundation New Zealand. https://www.mentalhealth.org.nz. The foundation works to
enhance and ensure the mental health of all New Zealanders. The site provides resources and
information about mental health and illness for the general public and health professionals,
including links to mental health care services.
National Mental Health Commission. http://www.mentalhealthcommission.gov.au/media/39270/
NMHC_ReportCard_Enhanced.pdf. This is the site for accessing A contributing life: the 2012
national report card on mental health and suicide prevention—the first report of the National
Mental Health Commission on the mental health of Australians and identifying the factors that
facilitate recovery and enable people living with mental illness to live a ‘contributing life’.
New Zealand Mental Health Commission. http://www.hdc.org.nz/media/207642/blueprint%20ii%20
how%20things%20need%20to%20be.pdf. Blueprint II: Improving mental health and well-being
for all New Zealanders is a 10-year plan that presents the vision of the Mental Health
Commission to improve the health and wellbeing of all New Zealanders. It encompasses all
levels of government and provides guidance on future needs and required changes.
World Health Organization. http://www.who.int/mental_health/action_plan_2013/en/. The
Comprehensive mental health action plan 2013–2020 has at its core the globally accepted
principle that there is ‘no health without mental health’. It proposes for member states clear
actions, key indicators and targets, with an emphasis on prevention, promotion, treatment,
rehabilitation, care and recovery. The plan is global in scope and aims to provide guidance for
national action plans.
Chapter 2
Working in a Recovery
Framework
INTRODUCTION
A recovery-oriented approach to mental health care aims to facilitate
mental health, minimise the impact of mental illness and manage the
symptoms of mental illness. The recovery model emerged in the latter
part of the 20th century amid worldwide reform of mental health services.
It is a person-centred approach underpinned by principles of social
justice and equity, which challenges an exclusive biomedical model of
focusing mainly on symptom identification and treatment. This chapter
examines the principles of recovery as a framework within which to deliver
mental health services from the perspective of people with mental illness
and their carers, health professionals and the health care system.
RECOVERY
Recovery is a practical approach to mental health care that incorporates
social justice principles with an emphasis on the person’s wellbeing,
autonomy and empowerment. Recovery is not just about reducing or
eliminating symptoms; it is about a person’s journey while living with
mental illness. Recovery in this context has many meanings. It is an
individual and a dynamic experience, not a static process. Anthony, an
early advocate of the recovery approach, described the journey as:
… a deeply personal, unique process of changing one’s attitudes,

values, feelings, goals, skills, and/or roles. It is a way of living a
satisfying, hopeful, and contributing life even within the limitations
caused by illness. Recovery involves the development of new meaning
and purpose in one’s life as one grows beyond the catastrophic effects
of mental illness.
(Anthony 1993)
For people with mental illness and for carers, therefore, recovery means
living well with an ongoing mental illness, having hope and setting goals
for the future—not just symptom management. It encompasses learning
about the illness and factors that trigger episodes, and making necessary
lifestyle changes. For health professionals, recovery means not only
working with the person to manage the symptoms of mental illness but
also working with the person to enable them to lead a full and meaningful
life, despite the illness.
In the past, the phenomenon (i.e. the lived experience of the person
with mental illness) was at the core of mental health care. However,
8
Chapter 2 Working in a Recovery Framework 9
TABLE 2.1
COMPARISON OF BIOMEDICAL AND RECOVERY-FOCUSED UNDERSTANDINGS
Biomedical Approach to Mental Illness Person-Centred Recovery Approach
A linear process of illness and wellness A cyclical process of trying and trying again
Focus on treatment and medication Focus on meaningful relationships and leading
management an ‘ordinary life’
Spirituality and meaning are not viewed as Spirituality is important in developing meaning
important and understanding
Relapse is viewed as a failure Relapse is viewed as an opportunity for growth
and learning
The experience of mental illness is a The experience of recovery from a mental illness
negative one has positive aspects
The nature of mental illness is predetermined Having a mental illness is an individual and
unique process
Relinquishing roles and responsibilities is Maintaining roles and responsibilities is
accepted promoted
throughout the 20th century the focus shifted from a person-centred

approach to a biomedically dominated one. The biomedical model
concentrates on symptom identification and reduction, primarily through
medication, with the subjective experience having less emphasis. Recent
decades, however, have seen a shift towards a recovery approach in
which ‘person-centred’ care is now central. Table 2.1 provides a
comparison of biomedical and recovery-focused understandings.
PROTECTIVE AND RISK FACTORS

A recovery approach acknowledges that some factors increase the risk of
relapse, while others are protective of mental health. Hence, a recovery
approach encompasses more than merely treating or managing the
symptoms of the illness. It includes recognition of and attention to the
social and economic aspects of people’s lives, as well as their mental
illness or disability. Health professionals who use a recovery framework
work in partnership with the person with mental illness (and carer) to
maximise the quality of life for the person (O’Kane 2013).
Rickwood (2006) distinguishes protective and risk factors for the
development of and recovery from mental illness. She states that
protective factors reduce the likelihood that a disorder will develop by
reducing the exposure to risk, and by reducing the effect of risk factors
for those exposed to risk. Protective factors also foster resilience in the
face of adversity and moderate against the effects of stress, whereas risk
factors increase the likelihood that a disorder will develop, exacerbate the
burden of an existing disorder and can indicate a person’s vulnerability.
Both protective and risk factors include genetic, biological, behavioural,
sociocultural and demographic conditions and characteristics (Rickwood
2006, World Health Organization 2014), with some factors being internal
10 Chapter 2 Working in a Recovery Framework
to the person, while others are external. Internal factors include genetics,
disposition and intelligence, while external drivers comprise the social
determinants of health related to social, economic, political and
environmental factors, including the availability of opportunities in life and
access to health services (World Health Organization 2008, 2014).
Risk factors increase vulnerability to mental illness and mitigate against
recovery from mental illness. Risk factors for mental illness in children, for
example, have been identified as: the child having special needs; poor
family functioning; living in a rural area or unsafe neighbourhood;
financial stress; and poor parental (particularly maternal) mental health
(Goldfeld & Hayes 2012).
Protective factors, such as supportive family and friends, assist the
person to maintain emotional and social wellbeing and to cope with life
experiences—including adversity. They can provide a buffer against
stress, as well as be a set of resources to draw upon to deal with stress.
Factors that are protective against mental illness in children, for example,
include having personal resilience, a supportive family, a supportive
school environment and access to social resources (Ottova et al 2012).
A recovery-based model is underpinned by an emphasis on a number
of protective factors that can be harnessed to reduce the severity and
impact of the experience of mental illness. Protective factors serve a
number of purposes. They can provide a buffer against negative effects
and may interrupt the processes through which risk factors operate. For
example, a literacy program for illiterate young people may interrupt a
potential path to unemployment. Protective factors are social determinants
of health outcomes and can be grouped into three areas: individual;
family and peers; and community (see Box 2.1).
RECOVERY-ORIENTED MENTAL HEALTH SERVICES

The National Mental Health Promotion and Prevention Working Party
proposed a framework for recovery-oriented mental health services in
Australia in 2006 following an extensive consultation process with people
with mental illness, carers and service providers (Rickwood 2006). In
2013 the Australian Government published a national framework that
identifies the responsibilities of recovery-oriented mental health service
delivery. These are to:
• provide evidence-informed treatment, therapy, rehabilitation and
psychosocial support that helps people to achieve the best outcomes
for their mental health, physical health and wellbeing
• work in partnership with consumer organisations and a broad
cross-section of services and community groups
• embrace and support the development of new models of peer-run
programs and services (Department of Health 2013 p 3).
In 2011 the Victorian Department of Health developed the Framework
for recovery-oriented practice, which outlines domains and core principles
BOX 2.1
PROTECTIVE FACTORS
INDIVIDUAL
• Resilient characteristics such as effective coping skills and being able to
manage stress
• A sense of one’s own spirituality
• Effective interpersonal skills
• Problem-solving skills
• A perception of social support from family and peers
• A healthy sense of self and a sense of belonging
• Positive expectations (optimism for the future)
• Meaningful activities in which to engage
FAMILY AND PEERS
• Good relationships and regular contact with family members
• A stable family environment with positive peer-group activities and norms
• Friends to socialise with
COMMUNITY
• An economically sustainable community
• A safe and health-promoting environment
• Active community centres
• Neighbourhood cohesion
for delivering recovery-oriented mental health care. They are summarised

in Table 2.2, overleaf.
PROVIDING RECOVERY-ORIENTED MENTAL HEALTH CARE

Hildegard Peplau first drew attention to the pivotal role of the therapeutic
relationship in mental health care in her book Interpersonal relationships
in nursing (Peplau 1952). In her model, Peplau identifies the foundation
for developing a therapeutic relationship with people with mental illness
as requiring unconditional positive regard, authenticity, genuineness and
respect. Her model led to a shift in psychiatric nursing practice from
doing to a client to being with a client—an approach to mental health
care that is evident in the contemporary recovery models of today.
Peplau’s model also empowers health professionals ‘to move away from a
disease orientation to one whereby the psychological meaning of events,
feelings and behaviours could be incorporated in [health care]
interventions’ (Peplau 1996).
In clinical practice, establishing rapport and a therapeutic relationship
between the health care worker and the person with mental illness and
their family is the cornerstone of effective mental health care. It requires
empathy, trust and effective communication. The purpose of the
relationship is to:
• engage with the person in order to complete a full assessment and care
plan
• encourage the person to define their problems and perceptions of their

distress
• facilitate the development of learning and coping skills by the person
• resolve or minimise existing problems or symptoms.
TABLE 2.2
FRAMEWORK FOR RECOVERY
Domain Core Principles to Facilitate Recovery
Promoting a culture of hope Promote values of hope, self-determination, personal agency,
social inclusion and choice
Enable a culture of hope and optimism, and encourage the
person’s recovery efforts
Promoting autonomy and Involve the person as a partner in their mental health care,
self-determination ensuring their lived experience and expertise is recognised
Encourage informed risk taking within a safe and supportive
environment, and organise the service environment to ensure
safety and optimal wellbeing
Collaborative partnerships and Provide personalised mental health care through collaborative
meaningful engagement partnerships with the person and their support networks
Promote mental health, wellbeing and recovery by establishing
and sustaining a collaborative partnership with the person
Focus on strengths Focus on the person’s strengths, resources, skills and assets
Support the person to build their confidence, strengths,
resourcefulness and resilience
Holistic and personalised care Provide personalised mental health care informed by the person’s
circumstances, preferences, goals and needs
Understand the range of factors that can impact on the person’s
wellbeing
Family, carers, support people Recognise the role of family and significant others in supporting
and significant others the person’s recovery
Support the person to utilise and enhance their existing support
networks
Community participation and Foster positive relationships, meaningful opportunities and
citizenship community participation
Recognise the impact of stigma on recovery
Responsiveness to diversity Provide mental health care that is personalised, respectful,
relevant and responsive to diversity including the person’s
culture and community background, gender and sexual identity
Reflection and learning Engage in ongoing critical reflection and continuous learning
Recognise that the person’s lived experience of mental illness
and recovery are valuable resources
Adapted from Department of Health 2011
The role of health professionals in mental health promotion is to:

• facilitate a healthy lifestyle through education about diet and nutrition,
rest, sleep and exercise
• support people to access employment services, housing, education and

health services
• provide mental health care early and provide continuing intervention
programs.
The Tidal Model

Developed by Dr Phil Barker in the United Kingdom in the late 1990s, the
Tidal Model is an example of a recovery-oriented model of mental health
care. Since 2001 the Tidal Model has been revised and further developed
by Poppy Buchanan-Barker and Phil Barker. It is a philosophical
approach underpinned by the following core values:
• People need to reclaim their personal story of mental distress in order
to reclaim their lives.
• The role of health professionals is to help people realise what they want
in relation to their lives.
The following 10 commitments guide the Tidal Model approach to
mental health care clinical practice (Barker 2008):
1. Value the voice of the person. Their voice of experience is central,
not the professional medicalised account.
2. Respect the language. Use the person’s words to describe their experience.
3. Develop genuine curiosity. Listen to the person, be interested in what
they have to say, not just ‘what is wrong with them’.
4. Become an apprentice. The person with mental illness is the
expert—learn from them.
5. Use the available toolkit. What resources does the person have? What
worked before?
6. Craft the step beyond. What needs to be done now? Plan.
7. Give the gift of time. Take time to listen and communicate.
8. Reveal personal wisdom. The person knows themselves best.
9. Know that change is constant. While change is inevitable, growth is
optional and requires choices and decisions.
10. Be transparent. Be honest and upfront and use the person’s
language in their care and assessment plans.
WORKING WITH INDIVIDUALS

When working with individuals to facilitate recovery, Rethink (the leading
United Kingdom mental health charity) challenges an exclusive
biomedical model approach of focusing on illness and symptom
management, advocating a model in which mental wellness is the goal.
Rethink recommends an approach that:
• focuses on goals, not problems
• values the strengths the person brings to their personal recovery
• respects the person’s self-direction
• creates an environment that supports personal recovery and values

small steps (Rethink 2017).
In summary, the Rethink model is person-centred and directed, and
proposes working with the person’s strengths and addressing issues of
everyday living—as well as managing the symptoms of mental illness and
respecting their dignity of risk (i.e. enabling choices through facilitating
autonomy and self-determination).
WORKING WITH FAMILIES

An example of a recovery-oriented approach to working with families is
the work of the Canadian Mental Health Alliance (2013). This organisation
supports and educates families and friends during the recovery process to
build on the strength and resilience of families to enhance their lives.
They provide recovery-related educational courses and support groups to
develop a stronger voice for families in the mental health and addiction
system, strengthen the supports provided to families and raise awareness
of issues from a family perspective.
The alliance has identified four needs of families and caregivers of
people with mental illness or addictions as:
• Services for families: educating, supporting and caring for the
caregivers. Provide psychoeducational programs for families, carers and
friends of people with mental illness that are aimed at increasing the
capacity for carers to care for themselves, other family members and
their relative living with mental illness.
• Peer support: families helping families. Provide support and funding for
peer-support initiatives and facilitate access for people with mental illness.
• Recognition as partners in care, rehabilitation and recovery. Develop
organisational policies and provide training that assists clinicians to
work with families. Include family members in policy development and
the delivery of education for clinicians.
• Families as system partners. Recognise and involve family members as
key stakeholders of mental health services (e.g. as members of advisory
committees and boards of mental health services) (Canadian Mental
Health Alliance 2013).
Addressing the needs of families and caregivers recognises the
significant role they play in caregiving and, importantly, that they too have
needs as a consequence of their caregiving role.
RECOVERY COMPETENCIES FOR MENTAL HEALTH WORKERS

The former New Zealand Mental Health Commissioner Mary O’Hagan
describes a competent mental health worker as one who:
Understands recovery principles and experiences, supports service

users’ personal resourcefulness, accommodates diverse views on mental
health issues, has self-awareness and respectful communication skills,

protects service users’ rights, understands discrimination and how to
reduce it, can work with diverse cultures, understands and supports the
user/survivor movement, and understands and supports family
perspectives
(O’Hagan 2004 p 2)
This is exemplified in the ‘Recovery competencies for New Zealand

mental health workers’, which were developed by the Mental Health
Commission of New Zealand (2001). The competencies outline the
knowledge, skills and disposition required by mental health workers to
enable them to work within a recovery framework.
According to the competencies, a competent mental health worker:
• understands recovery principles and experiences in the Aotearoa/New
Zealand and international contexts
• recognises and supports the personal resourcefulness of people with
mental illness
• understands and accommodates the diverse views on mental illness,
treatments, services and recovery
• has the self-awareness and skills to communicate respectfully and
develop good relationships with service users
• understands and actively protects service users’ rights
• understands discrimination and social exclusion, its impact on service
users and how to reduce it
• acknowledges the different cultures of Aotearoa/New Zealand and
knows how to provide a service in partnership with them
• has comprehensive knowledge of community services and resources
and actively supports service users to use them
• has knowledge of the service user movement and is able to support
their participation in services
• has knowledge of family/whānau perspectives and is able to support
their participation in services (Mental Health Commission of New
Zealand 2001 p 7).
Subsequently, the New Zealand Ministry of Health (2008) released
the Let’s get real framework, which outlines the knowledge, skills and
attitudes required to deliver recovery-focused mental health and addiction
services. The framework consists of seven skill sets focusing on three
levels of practice: essential (early career practitioner), practitioner and
leader. For example, when working with people with mental illness to
support recovery: an early career practitioner ‘establishes a connection
and rapport with service users as part of a thorough assessment process
and recovery planning’; a practitioner ‘develops effective therapeutic
relationships with service users and works flexibly with them’; and
a leader ‘develops and supports a service that is responsive to the
needs of service users, reflective of best practice, recovery focused,
culturally safe and trauma informed’ (New Zealand Ministry of Health

2008 p 8).
Recovery and Risk

When working within a recovery framework (which encourages individual
choice, empowerment and self-management), tensions can arise
regarding risk management. The Victorian Department of Health (2011)
acknowledges this and states that a level of risk tolerance is required, that
this needs to occur in an environment that is safe, and that staff need to
be aware of their duty of care. In delivering recovery-focused services the
Victorian Department of Health recommends ‘positive risk taking’, which
requires:
• assisting the person to decide what is an appropriate level of risk taking
for their recovery journey (within a safe environment and within the
limits of duty of care)
• balancing the risk by articulating the threshold of risk that is
appropriate for the setting and within the parameters of duty of care
• providing guidance, training and support to staff regarding flexible
responses to a person’s circumstances and preferences while
maintaining appropriate risk management (Department of Health 2013
p 3).
CONCLUSION
Recovery is the journey undertaken by the person living with mental
illness (often in collaboration with a health professional) as the person
rethinks their identity, goals and hopes (Slade 2013). For health
professionals, practising within a recovery framework involves working with
the person and their family to understand the person’s story/narrative,
identify strengths, set goals and address issues of everyday living—as well
as managing the symptoms of mental illness.
Finally, as a guiding framework for clinical practice, recovery is an
approach to achieving mental health, which involves more than the
absence of symptoms of mental illness. It includes notions of hope and
empowerment of people with mental illness and their carers, the delivery
of person-centred care and the establishment of a partnership between
people with mental illness, carers and health professionals in attaining the
goal of mental health. Importantly, there is a focus on the person’s
strengths rather than the deficits that may be a consequence of the
mental illness.
References
Anthony, W. (1993). Recovery from mental illness: The guiding vision of the mental health service
system in the 1990s. Psychosocial Rehabilitation Journal, 16(4), 11–23.
Buchanan-Barker, P., & Barker, P. (2008). The Tidal Commitments: extending the value base
of mental health recovery. Journal of Psychiatric and Mental Health Nursing, 15, 93–100.
http://www..tidal-model.com/10%20commitments.html, http://www.tidal-model.com/10%20
commitments.html.
Canadian Mental Health Alliance. (2013). Support for families and caregivers. Online. Available:
http://ontario.cmha.ca/mental-health/services-and-support/support-for-families-and-caregivers/
15 July 2017.
Department of Health. (2011). Framework for recovery-oriented practice. Melbourne: Mental
Health, Drug and Alcohol Division, State Government of Victoria.
Department of Health. (2013). A national framework for recovery-oriented mental health services:
guide for practitioners and providers. Canberra: Commonwealth of Australia. Online. Available:
http://www.health.gov.au/internet/main/publishing.nsf/content/mental-pubs-n-recovgde 15 July
2017.
Goldfeld, S., & Hayes, L. (2012). Factors influencing child mental health: A state-wide survey of
Victorian children. Journal of Paediatrics and Child Health, 48, 1065–1070.
Mental Health Commission of New Zealand. (2001). Recovery competencies for New Zealand
mental health workers. Wellington: MHC. Online. Available: http://www.hdc.org.nz/publications/
other-publications-from-hdc/mental-health-resources/recovery-competencies-for-new-zealand-
mental-health-workers 15 July 2017.
New Zealand Ministry of Health. (2008). Let’s get real: Real skills for people working in mental
health and addiction. Online. Available: https://www.health.govt.nz/system/files/documents/
publications/letsgetreal-sep08.pdf, 15 July 2017.
O’Hagan, M. (2004). Recovery in New Zealand: Lessons for Australia? Guest editorial. Australian
e-Journal for the Advancement of Mental Health, 3(1), 1–3.
O’Kane, D. (2013). Partnerships in health. In P. Barkway (Ed.), Psychology for health
professionals. Sydney: Elsevier.
Ottova, V., Hjern, A., Rasche, C., et al. (2012). Child mental health measurement: Reflections and
future directions. In J. Maddock (Ed.), Public health—methodology, environmental and systems
issues. Online. Available: http://cdn.intechopen.com/pdfs/37287/InTech-Child_mental_health
_measurement_reflections_and_future_directions.pdf 15 July 2017.
Peplau, H. (1952). Interpersonal relations in nursing. New York: GP Putnam.
Peplau, H. (1996). Fundamental and special—the dilemma of psychiatric and mental health
nursing. Commentary Archives of Psychiatric Nursing, 10(1), 14–15.
Rethink. (2017). Recovery. Online. Available: http://www.rethink.org/living-with-mental-illness/
recovery 15 July 2017.
Rickwood, D. (2006). Pathways of recovery: Preventing further episodes of mental illness
(monograph). Canberra: Commonwealth of Australia.
Slade, M. (2013). 100 ways to support recovery: a guide for mental health professionals, 2nd edn.
London: Rethink Recovery Series. Online. Available: https://www.rethink.org/media/704895/100_
ways_to_support_recovery_2nd_edition.pdf 14 July 2017.
World Health Organization. (2008). Closing the gap in a generation: health equity through action
on the social determinants of health. Online. Available: http://apps.who.int/iris/bitstream/1066
5/43943/1/9789241563703_eng.pdf 15 July 2017.
World Health Organization. (2014). Social determinants of mental health. Online. Available: http://
apps.who.int/iris/bitstream/10665/112828/1/9789241506809_eng.pdf 15 July 2017.
Web Resources
Department of Health. http://www.health.gov.au/internet/main/publishing.nsf/content/
mental-pubs-n-recovgde. A national framework for recovery-oriented mental health services:
guide for practitioners and providers is a guide for mental health professionals and services to
Australia’s national framework for recovery-oriented mental health services.
Emerge Aoteroa. https://emergeaotearoa.org.nz/about-us/our-history/. Emerge Aoteroa was formed
by the merging of Recovery Solutions (formerly Carnegie Trust) and the Richmond Fellowship. It
promotes mental health and recovery for people living with mental illness by providing culturally
appropriate, community-based rehabilitation within an accommodation support framework for
people living with mental illness or addiction and drug abuse.
Recovery Hub. http://recovery.awh.org.au. Recovery Hub contains many activities, articles and
practical resources to provide choice, encourage hope and inspire people with mental illness to
improve their health and wellness and to live a positive lifestyle.
Rethink (UK). www.rethink.org. Rethink is the largest charity in the UK supporting severe mental
illness. It is dedicated to improving the lives of everyone affected by severe mental illness,
whether they have a condition themselves, care for others who do or are professionals or
volunteers working in the mental health field.
Richmond Wellbeing Australia. https://www.rw.org.au. Richmond Wellbeing Australia supports the
recovery journey of people living with mental illness to grow the confidences and skills needed to
meet the challenges of daily life. Through its core values of hope, service excellence, inclusion
and compassion, Richmond Wellbeing aims to assist people living with mental illness to live a
life of recovery within their community.
Tidal Model. www.tidal-model.com. The Tidal Model is the first mental health recovery model
developed conjointly by mental health nurses and people who have used mental health services.
Chapter 3
Essentials for Mental
Health Practice
INTRODUCTION
People seeking assistance for mental health concerns require care that
meets their needs for support, treatment, information, advocacy or refuge.
All care delivered by health professionals needs to be generated from
values such as respect and concern for each person and their
experience. Values-based care guides the provision of appropriate health
care and promotes the connection between the health care provider and
the person seeking support.
For health professionals from all disciplines, their level of education and
unique discipline knowledge, personal values and established standards
and principles of practice guide them in their practice. This chapter
outlines some key components of practice when working with people
needing mental health care.
The chapter introduces the term ‘working alliance’ to establish that
health professionals work with people with mental illness in a committed
professional partnership, acknowledging their experience and supporting
the person’s recovery (see Chapter 2).
Mental health promotion and prevention of mental illness underpin
mental health care. Promotion and prevention aim to strengthen a
person’s resilience. They aim to increase protective factors and
lessen a person’s vulnerability to mental health problems. For
those who are unwell, promotion and prevention strategies aim to
increase relapse-prevention skills. A focus on individual strengths
and building resilience are a necessary component of recovery-oriented
practice.
PRACTICE ESSENTIALS
National Practice Standards
There are 13 national practice standards that relate to all health
professionals working with people with mental illness and their families in
Australia. The standards aim to provide a benchmark for practice,
education and skill development. Table 3.1 (overleaf) lists the 13 practice
standards.
19
20 Chapter 3 Essentials for Mental Health Practice
TABLE 3.1
NATIONAL PRACTICE STANDARDS FOR THE MENTAL HEALTH WORKFORCE 2013
National Standard Explanation (Adapted From the Practice
Standards Overview)
1. Rights, responsibilities, safety Mental health professionals uphold the rights of people
and privacy affected by mental health problems and mental
disorders, and those of their family members or
carers, maintaining their privacy, dignity and
confidentiality, and actively promoting their safety
2. Working with people, families and Mental health professionals support people to become
carers in recovery-focused ways decision-makers in their own care
3. Meeting diverse needs Mental health professionals respectfully respond to the
social, cultural, linguistic, spiritual and gender
diversity of people with mental illness and of carers,
incorporating those differences in their practice
4. Working with Aboriginal and Mental health professionals provide culturally safe
Torres Strait Islander people, systems of care, reduce barriers to access and
families and communities improve social and emotional wellbeing
5. Access Mental health professionals facilitate timely access to
quality evidence-based assessment
6. Individual planning Mental health professionals facilitate and support care
planning from a quality evidence base
7. Treatment and support Mental health professionals provide quality
evidence-informed interventions
8. Transitions in care Mental health professionals support the exit or transition
of a person’s care in a structured and timely way
9. Integration and partnership Mental health professionals recognise and support the
provision of coordinated care across the broad
network of carers, community, programs and services
10. Quality improvement Mental health professionals collaborate with people with
a lived experience, families and team members to
actively improve mental health practices
11. Communication and information Mental health professionals establish therapeutic
management relationships and maintain quality documentation,
information systems and evaluation to monitor and
evaluate needs
12. Health promotion and prevention Mental health clinicians seek to build resilience in
individuals and communities through mental health
promotion and primary prevention principles
13. Ethical practice and professional Mental health professionals are aware of their individual
development responsibilities scope of practice and the codes and regulations
supporting their practice; they take responsibility for
their own professional development and continuing
education and contribute to the development of others
Source: Adapted from Department of Health 2013
Chapter 3 Essentials for Mental Health Practice 21
Guiding Principles
The following principles form the basis for a holistic, preventative,
health-promoting and recovery-oriented system of specialised care
(Department of Health 2013). The guiding principles below are embedded
in the Standards (Table 3.1).
• Promote ideal quality of life for people with a mental illness.
• Supply services with the aim of facilitating sustained recovery for people
with a mental illness.
• Involve service users in all decisions regarding their treatment, support
and care, including, the option to choose their treatment and setting if
possible.
• Acknowledge the right of the person to have their nominated carer
involved in all aspects of their care and treatment.
• Recognise the role played by carers, including their needs and
requirements, which is separate from the person receiving treatment.
• Learn about the people and carers using the service, in order to value
their lived experiences.
• Recognise and advocate the rights of children and young people
affected by a family member with a mental illness to appropriate
protection, care and information.
• Support participation and contribution by people, their families and
carers as part the mental health service development, planning, delivery
and evaluation process.
• Modify mental health treatment, support and care to meet the specific
needs of the individual.
• When delivering mental health treatment aim to provide a plan that
takes into account the individuals living situation, needs of their family
or carer and level of support within the community to ensure the least
amount of personal restriction on the individuals rights and choices.
• Implement evidence-informed practices and quality improvement
processes.
• Participate in professional development activities.
The National practice standards for the mental health workforce 2013
provide further information and examples. The practice standards
complement the National standards for mental health services 2010, both
ensuring a supportive framework for high-quality mental health practice.
In New Zealand the Mental Health Commission’s (2001) document
Recovery competencies for New Zealand mental health workers (available
at www.hdc.org.nz) comprehensively addresses recovery and suggests
that practitioner competencies can inform standards. The document also
includes examples of using competencies in practice. The 10 recovery
competencies are listed in Section A of the document (see p 11; see also
Chapter 2, p 15 of this book, where the principles are listed), and the
subcategories and examples that are very specific and an aid for practice
are in Section B (see pp 13–31). More recently the ‘Like Minds, Like
Mine’ project (Ministry of Health and Health Promotion Agency 2014),
which began in 1997, focuses on social inclusion and aims to create a
nation that values and includes people with a lived experience of mental
illness. The broad primary health focus of this initiative further supports
integration of recovery-oriented care.
Settings and Models for Care

The environment across mental health care settings is sometimes referred
to as the therapeutic milieu. The environment is seen as being
‘therapeutic’ in itself if the underlying principles are supported:
• open communication
• democratisation
• orientation to the therapeutic milieu
• privacy and respect for one another
• group cohesion.
Mental health professionals can influence and increase the therapeutic
potential of the environment by creating and promoting the following
elements in the environment (Sharrock et al 2017):
• a place of safety
• a predictable, organised structure
• personal and social support
• involvement and collaboration in the care environment
• validation of each person’s individual experience through interpersonal
communication
• symptom management
• maintaining links with the person’s family and support structure
• developing links and resources in the community.
More and more care is being delivered to people in their local
community or their home through a range of non-government, primary
health and community organisations and partnerships (see Chapter 14).
Care delivered in diverse settings has seen the development of a range of
models of care—for example, integrated teams that provide triage, crisis
and case management and hence optimise and streamline care delivery
and recovery. Another example is the Mental Health Nurse Incentive
Program where credentialled mental health nurses work to their full scope
of practice providing primary and supportive ongoing care to people with
the full range of mental health issues.
Teamwork
The ‘multidisciplinary team’ is a team approach for care delivery. Because
the multidisciplinary team comprises nursing, medical and allied health
professionals, this model optimises options for the person, as each health
professional has unique and complementary skills that provide holistic
coordinated care to assist the person’s recovery. There can be overlap in
skill sets among mental health professionals, so frequent meetings are

required to ensure coordinated care.
‘Case management’ is a model of care in which treatment options and
care delivery is provided and coordinated by one health professional in a
consistent manner. Case management can be used in all mental health
settings; its strengths are that the case manager can refer the person to other
members of the team with expertise to meet the person’s specific needs.
Scope of Practice
Each health practitioner works within a ‘scope of practice’, which
describes the full spectrum of roles, functions, responsibilities, activities
and decision-making capacity that individuals within professions are
educated, competent and authorised to perform. The scope defines
boundaries of responsibility and accountability for each mental health
professional and therefore influences decision making in care and service
delivery. Scope of practice within the multidisciplinary team requires that
individual members negotiate care delivery and establish who is
responsible for particular care or services according to their individual
scope of practice, even if a particular discipline is accountable for care or
service delivery.
MENTAL HEALTH LITERACY AND PSYCHOEDUCATION

‘Mental health literacy’ refers to an individual’s or group’s awareness,
understanding and knowledge about mental health and illness. It can
influence their response to recognising signs or behaviours of mental
illness and identifying pathways for treatment and recovery. Mental health
practitioners and people with mental illness play an important role in
increasing public awareness and understanding of mental illness to
facilitate early recognition and intervention.
Awareness raising and increasing mental health literacy can be
achieved by identifying or providing resources such as:
• information sheets about mental health services, types of treatments
and types of mental health problems
• medication information sheets (in a style and format appropriate for the
general public)
• website addresses
• referrals to and engagement with community support groups, parenting
programs, employment programs, abuse-related programs, addiction
programs, health advisory groups and health and mental health
education programs
• peer support services.
‘Psychoeducation’ is the provision of information required by the person,
their family or a group to improve mental health literacy, self-determination
and quality of life. Mental health literacy and psychoeducation are vital to
enabling the person and family to determine their own needs and to make
their own decisions about treatment and recovery.
ASSESSMENT
Assessment is an ongoing process because a person’s functioning can
change depending on what is happening in their environment (internal
and external). The person’s internal environment consists of their
thoughts, feelings and physical health; their external environment can be
their family, their physical world and the social relationships within it. A
range of assessments can be performed by different mental health
professionals depending on a person’s presentation and needs.
Holistic mental health assessment measures the person’s functioning in
the following domains:
• physical
• cultural
• spiritual
• mental and emotional (mental state assessment; see Chapter 5)
• developmental and functional
• family
• social/environmental.
PRACTITIONER ESSENTIALS
Personal and Professional Values
Humanistic and holistic values underpin the mental health practice for
many health professionals. ‘Humanism’ can be defined as a perspective
on life that is centred on a concern for human interests, values and
upholding a person’s dignity. It is particularly relevant in health care when
people may be vulnerable and seeking assistance. ‘Holism’ in health
relates to the idea that the person is more than the sum of their parts and
that if we recognise the importance of the interrelationships between the
biological, psychological, social and spiritual aspects of the person,
healing and wellbeing are enhanced.
Important values include:
• A person-centred approach. A person-centred approach is essential for
mental health care. You are there for the person and to liaise with
carers/family/friends as appropriate.
• A working alliance. Developing a working alliance enables you to
understand the person’s (and family’s) recovery plan. Work with the
person to achieve recovery defined by them using their strengths. You
remain positive and hopeful and support their recovery plan.
• Compassionate care. Compassionate care supports recovery and
emotional wellbeing. It matters how you care because it affects the
person and their family’s feelings (e.g. maintain compassion and best
practice in situations of distress, anxiety and ‘busyness’).
• Respect. Respect underpins person-centred care and includes respect
for both the person and their experience.
• A ‘safe’ environment. Mental health care is best delivered in

environments that support cultural, physical and emotional safety.
Encourage feedback about the environment and appropriateness of
care delivery.
• A multidisciplinary team. A multidisciplinary team approach presents
the person with a wide range of therapies and treatment options
suitable to promote recovery.
Self-Awareness and Self-Care

‘Self-awareness’ involves consciousness of our own values, beliefs,
attitudes and motivations and understanding how they may affect others.
It also includes the ability to reflect on and accommodate the values and
beliefs of others. It requires being grounded in the here and now and
knowing our thoughts, feelings and reactions. Having this awareness will
help you to focus on people with mental illness, families and their needs.
Self-awareness is developed over time through experience and focused
activities. Strategies that can develop self-awareness and constitute
professional self-care include:
• clinical supervision
• mentorship
• professional development and education
• requesting feedback on your practice
• asking questions of mentors
• keeping a journal of your practice for reflection or discussion with a
mentor.
Appendix 1 provides some guidance on surviving clinical placement
and engaging in professional self-care.
As well as professional self-care, personal self-care is essential for
anyone working in the human services. Engaging on a therapeutic and
interpersonal level with people who are in crisis, are experiencing loss or
have difficulty managing their own thoughts, feelings, emotions and
behaviour can be challenging. Strategies to develop self-awareness can
provide the information we need to maintain our own wellbeing. Personal
self-care requires an active awareness of our health and wellbeing needs.
Self-care is any preventative and balancing activity that is activated to
optimise our personal coping when we are stressed and challenged
emotionally, cognitively and physically.
Strategies to promote personal self-care may include:
• physical self-care and activity—exercise such as running, yoga, sport,
good nutrition, sleep hygiene
• psychological self-care—reflection, meditation and mindfulness;
journaling and reading
• emotional and spiritual self-care—relaxation and social connectedness;
dancing, artistic activity, music.
BOX 3.1
TIPS FOR INITIATING THE ALLIANCE: DEVELOPING RAPPORT
• Put aside everything else that is happening to you and around you and focus
on the person.
• Choose a time and place to invite the person to tell you their story or to
discuss their issue when it is convenient for them.
• Be gentle and confident in your approach. You may lead the interaction
initially by inviting the person to set timelines. However, the person will take
the lead and define their therapeutic needs.
• Collaborate with the person in setting expectations and timelines for the
working alliance.
The Working Alliance

The aim of the working alliance is to develop a relationship where the
therapeutic goals for the person and/or family can be realised. In this
context mental health professionals use their knowledge and their own
strengths and insights (developed from professional and personal
self-care) to use the ‘self’ as a therapeutic tool. Empathy, understanding
the person’s experience and working with them to achieve their goals is
the process essential to the alliance. The following is a framework for the
working alliance:
• Professional boundaries are in place and are the responsibility of the
practitioner.
• The person with mental illness and their recovery pathway are the focus
of the alliance.
• The person with mental illness determines or defines their desired
outcomes of the working alliance.
• Respect for the experience of the person and a non-judgmental attitude
are essential for care provision.
• Communication skills are the foundation of the working alliance. The
practitioner often needs to role model health communication
techniques.
Box 3.1 provides some tips for initiating the alliance, Box 3.2 provides
tips for developing and maintaining the alliance and Box 3.3 provides tips
for building strengths in the alliance.
Professional Boundaries
Boundaries refer to verbal and non-verbal actions and interactions
between individuals or groups of people. Safe and appropriate boundaries
are in place when interactions are mutually respectful of the person or
group, their culture and experience. Health practitioners are responsible
for setting and/or negotiating boundaries in the working alliance to focus
on and facilitate the achievement of the person’s goals. Most professions
have codes of conduct or codes of ethics that identify boundary setting as
BOX 3.2
TIPS FOR DEVELOPING AND MAINTAINING THE ALLIANCE: RESPONDING
How can you respond usefully? Everything you need to know about the person is
in what they tell you and what you observe in their appearance and behaviour.
Listed below are steps to a useful response.
LISTEN
• Listen to the person’s story for content (the ‘what’ of their story), their feelings
(the tone of their story) and themes (the priorities of their story).
• Identify a keyword, feeling or theme, and reflect it back—for example, ‘You
mentioned you had a car accident (content). Can you tell me more about it?’
‘You sounded angry (feeling) when you told me about your car accident.’ ‘You
mentioned your car accident several times (theme). It sounds like it was a
significant event in your life.’ Any of these responses, plus single-word prompts
or non-verbal nods also work to indicate to the person that you are listening
and interested to hear more.
PAY ATTENTION
• Show in your body language that you are making an effort to attend to the
story.
• Summarise and clarify content, feelings and themes in the person’s story—for
example, ‘You continue to be angry and blame yourself for the car accident
and it sounds like you find it difficult to cope with your anger in general since
the accident. Is this how it is for you?’
• Explore previous coping and available or needed skills and options for the
future. This exploration might need to occur at a later time when the person is
less distressed or you may need to refer them to a more experienced
practitioner. Negotiate a time for further alliance work.
BOX 3.3
TIPS FOR BUILDING STRENGTHS IN THE ALLIANCE: DEVELOPING RESILIENCE
Resilience can be developed by:
• encouraging mutual and shared learning (psychoeducation)
• providing and exploring options
• being clear and assertive
• challenging and responding openly to challenge
• identifying and providing resources
• maintaining a positive attitude
• role modelling a wellness attitude
• persevering and maintaining hope.
part of the professional responsibility. Box 3.4 (overleaf) provides tips for
setting boundaries.
Pathways to developing expertise and the capacity to provide holistic
assessment and care in mental health work exist in the professional
health disciplines and human services. Acquiring additional
communication, engagement and therapeutic alliance skills, as well as
self-awareness, promotes the potential for the wellbeing and recovery of
people with mental illness.
BOX 3.4
TIPS FOR SETTING BOUNDARIES
• Introduce yourself and say what you prefer to be called and the purpose of
your role. Consistently refer to the person using their preferred title.
• Keep a focus on the person’s story during communication with the person.
Keeping the storyline in focus helps them tell a rich and detailed story, free of
distractions.
• Provide summaries and updates on therapeutic goals. Summaries will help the
person self-monitor and keep a focus on their recovery.
• Remain open and non-judgmental. Humanistic values promote the concept of
unconditional positive regard (i.e. unconditional acceptance of the person—not
necessarily to any behaviours or feelings).
• Criticism or disapproval is a warning of boundary vulnerability. Attempt to
clarify instead.
• Discuss any uncomfortable or unexpected feelings or feelings of confusion
with your line or clinical supervisor. Feelings of guilt, anger and attraction can
disrupt the alliance.
• Remember that the alliance is not the same as a social relationship. Stop and
reflect if it starts to feel like friendship. This includes things friends typically do
such as giving each other small gifts, making contact out of work time or
chatting socially. All of these behaviours impair the alliance and are warnings
of a boundary threat.
• Respond respectfully and thoughtfully to the person with mental illness at all
times. Keeping your communication at a professional level will keep the
alliance on track.
• Engage in clinical supervision. Clinical supervision develops your practice
expertise and professional awareness.
CONCLUSION
Working from a humanistic and holistic values base is the foundation for
mental health work; it also requires an awareness of and adherence to
national standards/principles and any jurisdictional standards as a baseline
for practice. Skill in developing the working alliance increases with
experience, feedback from people with mental illness and peers, clinical
supervision and greater self-awareness from critical reflection on practice.
Most importantly it is essential for the helpers to care for themselves
because self-care can have a positive impact on professional quality of life.
References
Department of Health. (2013). National practice standards for the mental health workforce 2013.
Melbourne: State Government of Victoria.
Mental Health Commission. (2001). Recovery competencies for New Zealand mental health
workers. Online. Available: hdc.org.nz 14 July 2017.
Ministry of Health and Health Promotion Agency. (2014). Like Minds, Like Mine: national plan
2014–2019: program to increase social inclusion and reduce stigma and discrimination for
people with experience of mental illness. Wellington: Ministry of Health. Online. Available,
www.health.govt.nz. 14 July 2017.
Sharrock, J., Maude, P., Wilson, L., et al. (2017). Settings for mental health. In K. Evans, D.
Nizette, & A. O’Brien (Eds.), Psychiatric and mental health nursing (4th ed.). Sydney: Elsevier.
Chapter 4
An Overview of Mental
Health Problems
INTRODUCTION
This chapter provides a quick reference to the common mental illnesses
that health professionals may come across in their daily practice.
Incidence, causative factors and descriptions of the major mental illnesses
are covered, with reference to useful websites. The major mental illnesses
include disorders of anxiety, mood, thinking and perception and
personality disorders. It is increasingly recognised that the diagnostic
classifications of mental illness as well as the concept of schizophrenia
are inaccurate and provide an incomplete perspective of the experiences
of mental illness. With this in mind, disorders specific to particular
populations—the young, the elderly, those with intellectual disabilities and
substance misuse disorders—are described here, acknowledging that
intellectual disabilities, delirium and substance misuse disorders are not
mental illnesses per se but are generally discussed in association with
mental illnesses. This chapter will be of use to health professionals in the
general setting where they will encounter people with physical health
conditions as well as a mental health disorder, bearing in mind that
diagnostic groupings can be of limited use to people with mental illness
and carers.
In 2014–15, 17.5% of Australians reported having a mental or
behavioural condition. Anxiety-related disorders ranked at 11.2% of the
population followed by mood disorders, including depression at 9.3%
(Australian Bureau of Statistics 2015a).
In the 2012–13 New Zealand Health Survey (Ministry of Health 2013),
one in six, or 16% of adults, had been diagnosed with a common mental
disorder (depression, bipolar or anxiety disorder) at some time in their
lives. As a group, mental illness is the third leading cause of loss of health
for New Zealanders (11.1%) behind only cancers (17.5%) and vascular
and blood disorders (17.5%).
DIAGNOSTIC CLASSIFICATIONS
There are two main classifications for diagnosing mental illness used
around the world. The 5th edition of the Diagnostic and Statistical Manual
of Mental Disorders (known as DSM-5), which is published by the
American Psychiatric Association (2013), is commonly used in most
states and territories in Australia. This classification system assesses the
person across five domains, which helps with treatment planning and
outcomes. The International Statistical Classification of Diseases and
Related Health Problems (ICD-11), published by the World Health
29
30 Chapter 4 An Overview of Mental Health Problems
Organization, provides a listing of clinical diagnoses that are coded and is

commonly used in Europe and the northern hemisphere, as well as in
some states of Australia (e.g. Queensland).
While there is discussion about future classification systems referring
more to the experience of mental illness and specific symptoms rather
than definite categories of illness such as depression and schizophrenia,
these categories remain the basis of diagnosis around the world at the
moment. With that in mind, it is important to note that there is significant
overlap between symptoms in mood disorders and other diagnoses such
as personality disorders. Further, symptoms of anxiety can occur in a
range of anxiety and depressive disorders. Finally, psychotic symptoms
can occur in schizophrenia, depressive and bipolar conditions. This
chapter is a guide to the common mental illnesses and their symptoms
but is not an exhaustive account.
AETIOLOGY OF MENTAL ILLNESS

In short, there is not enough evidence about specific theories to be
certain of the causes of mental illness. There are several theories,
including genetic, family history, neurochemical (imbalance of the
neurotransmitter serotonin), social/cultural factors, psychological factors
and upbringing. It is thought that some mental illness such as depression
and schizophrenia are linked to abnormalities in many genes, not just
one. In schizophrenia, for example, identical and non-identical twins are
more likely to develop the disease if their twin has it (i.e. more than the
general population). A person may inherit a susceptibility to a mental
illness such as anxiety from one of their parents but may not necessarily
develop the illness. Psychological factors include severe trauma (e.g.
physical, sexual or emotional abuse), neglect and early loss of a parent.
ANXIETY DISORDERS
How Common?
Approximately 10% of the population experience anxiety at a level that
affects their daily life, with 2–4% having an anxiety disorder (Royal College
of Psychiatrists 2013). Anxiety disorders are more common in females than
males. Generalised anxiety disorder affects about 3% and phobias affect
about 10% of people. Between 2% and 3% of the population are affected
by obsessive-compulsive disorders (Albucher 2008).
Generalised Anxiety Disorder

Generalised anxiety disorder is characterised by persistent and
troublesome worrying for a period of more than six months independent
of other mental health conditions (Bermak 2008). There is controversy
concerning the validity of this diagnosis, with claims that such people are
in fact ‘the worried well’, but it is seriously disabling, and these people
present frequently for assistance to health services (Barton et al 2012).
Chapter 4 An Overview of Mental Health Problems 31
Symptoms
Symptoms are:
• a feeling of being consistently on edge
• excessive worry or ruminations
• fatigue
• irritability
• physical tension
• poor concentration
• restlessness.
PHOBIAS
A phobia is defined as a marked and persistent fear that typically lasts
more than six months. Fear is cued by the presence or anticipation of a
specific object or situation (e.g. flying, heights, animals, receiving an
injection, seeing blood). Exposure to the phobic stimulus results in
extreme anxiety. A useful mnemonic to remember the key elements
necessary for a diagnosis of phobia is ‘PHOBIA’:
P persistent
H handicapping (restricted lifestyle)
O object/situation
B behaviour (avoidance)
I irrational fears (recognised as such by the person)
A anxiety response.
For a diagnosis of a specific phobia, the person’s fear must result in
significant interference with their functioning, not just distress.
There are five subtypes of specific phobia, depending on the type of
trigger:
• animal: animals or insects
• natural environment: for example, storms, heights and water (generally
childhood onset)
• blood/injections/injury: seeing blood or injury, or receiving an injection
or other procedure (vasovagal fainting response)
• situational: for example, bridges, elevators and flying
• other: for example, choking, vomiting and contracting an illness.
Often more than one type will be present. Features associated with
specific phobias include a restricted lifestyle. Comorbid conditions include
other anxiety disorders, mood disorders and substance-related disorders.
Agoraphobia
Agoraphobia is a specific fear of being in places or situations from which
escape may be difficult. The term comes from the Greek agora, meaning
marketplace, but typical agoraphobic situations include being home alone,
queuing, being in a crowd or travelling on public transport.
TABLE 4.1
COMMON THEMES OF OBSESSIVE-COMPULSIVE BEHAVIOUR
Obsession Compulsion
Contamination Excessive handwashing
Pathological doubt Checking the gas is off or the door is locked
Physical illness Excessive visits to a general practitioner
Need for symmetry Lining things up, straightening things, counting or checking excessively
Religious Excessive recitation of the rosary
OBSESSIVE-COMPULSIVE AND RELATED DISORDERS

Obsessive-compulsive disorder (OCD) is characterised by obsessions
(persistent and recurrent intrusive thoughts or feelings perceived to be
inappropriate by the person) and compulsions (thoughts, actions and
behaviours that the person feels compelled to undertake in order to
reduce the anxiety experienced). This disorder is no longer listed in the
chapter about anxiety in the DSM-5. Any reduction in anxiety is
short-lived, and the obsessive thought and associated ritual compulsive
behaviours recur, causing havoc in a person’s daily life.
Table 4.1 lists examples of common themes of OCD.
Newly listed disorders in the DSM-5 include hoarding disorder and
excoriation (skin picking) disorder.
POST-TRAUMATIC STRESS DISORDER

PTSD used to be called ‘shell shock’ after soldiers from World War I
returned emotionally scarred from their experiences. PTSD is no longer
categorised in the DSM-5 with anxiety disorders; it is now described
under trauma and stressor-related disorders. For a diagnosis of PTSD the
person must have been exposed to actual or threatened death, serious
injury or sexual violence.
The exposure can be:
• direct
• witnessed
• indirect, by hearing of a relative or close friend who has experienced
the event—indirectly experienced death must be accidental or violent.
How Common?
Incidence depends on the nature of the trauma. The prevalence of PTSD
needs to be understood in the context of the prevalence of exposure to
post-traumatic events (PTEs). Across their lifetime, most people (50–70%)
will be exposed to a PTE and, of this group, 15–25% will develop PTSD.
The 12-month prevalence of PTSD in Australia is 4.4% or approximately
one million people (McEvoy et al 2011).
Symptoms
Symptoms are in four groupings focusing on the behavioural effects of
symptoms, which are: intrusion; avoidance; negative alterations in
cognitions and mood; and alterations in arousal and reactivity. Two new
symptoms have now been added:
• persistent and distorted blame of self or others
• reckless or destructive behaviour (American Psychiatric Association
2013).
Treatment for Anxiety Disorders

Treatment involves cognitive behaviour therapy, exposure and
response prevention and eye movement desensitisation therapy.
Antidepressants also have a role in maintaining a stable mood and
reducing anxiety.
SCHIZOPHRENIA
How Common?
Schizophrenia is a mental disorder affecting approximately 1% of the
population worldwide, beginning in the 16–35 age group. It occurs
equally in males and females. Schizophrenia means different things for
people with the condition due to the nature of the experience of illness.
The diagnostic label refers only to the presence of a specific set of
symptoms.
Symptoms include:
• delusions, hallucinations, disorganised speech (also referred to as
positive symptoms)
• grossly disorganised behaviour
• flat affect, lack of volition, lack of pleasure in everyday life,
diminished ability to initiate and sustain planned activity, speaking
infrequently even when forced to interact (also referred to as negative
symptoms).
People with schizophrenia may neglect basic hygiene and need help
with everyday activities when acutely unwell. People with schizophrenia
are sometimes perceived as lazy because others don’t recognise these
behaviours as symptoms of schizophrenia.
Schizoaffective Disorder
Schizoaffective disorder is characterised by the presence of symptoms of
schizophrenia with an abnormal (elevated or lowered) mood.
Schizophreniform
Schizophreniform disorder differs only from the diagnosis of schizophrenia
in that the duration of the symptoms is less than six months and
functioning has not been negatively affected in the person.
Brief Psychotic Disorder

Brief psychotic disorder refers to a person experiencing a psychotic
episode that endures for more than one day but less than one month.
Psychosis is defined as a mental state characterised by the experience of
hallucinations or delusions where the person is out of touch with reality.
Drug-induced Psychosis
Drug-induced psychosis refers to a person presenting with symptoms of
schizophrenia as a direct result of ingesting prescribed or non-prescribed
medication.
Treatment
Treatment for schizophrenia and psychosis involve psychotropic
medications, psychotherapy and psychosocial care and may be necessary
for long periods. For some people treatment lasts their whole life.
DISORDERS OF MOOD
How Common?
Between 3% and 5% of the population experience depression (Sadock &
Sadock 2007). Among young people aged 12–25 years, depression is the
most common mental health problem. Depression is a leading cause of
disability in the Western world. In the 2015–16 New Zealand Health
Survey (Ministry of Health 2016) 15% of adults had been diagnosed with
depression at some time in their lives. In Australia it is estimated that
approximately 1.8% of males and 1.7% of females have had bipolar
disorder in the previous 12 months (Slade et al 2009). About 13% of
women may develop depression during their pregnancy, and it can be
life-threatening (Sadock & Sadock 2007).
Major Depressive Disorder

Symptoms of major depressive disorder include:
• depressed mood (has to be present for diagnosis)
• loss of pleasure in activities that were previously pleasurable (has to be
present for diagnosis)
• significant change in weight (up or down)
• sleep disturbances
• psychomotor agitation or retardation
• loss of energy, or fatigue
• feelings of worthlessness
• impaired concentration
• suicidal ideation.
Bipolar Disorder
Previously known as manic depression, bipolar disorder is characterised
by episodes of depression and mania. These episodes must last at least
one week. Manic episodes are characterised by insomnia, boundless

energy, inability to concentrate, persistently elevated mood, irritability and
fluctuating mood. Depressive episodes have the same criteria as for major
depressive disorder.
Types of Bipolar Disorder
Bipolar illness is usually grouped into two types: bipolar I and bipolar II.
Although bipolar I is the most studied of the two types, guidance on
managing bipolar II is based on data from those studies.
People with bipolar I experience at least one lifetime episode of mania
and usually episodes of depression. People with bipolar II experience
episodes of depression plus episodes of a mild form of mania called
hypomania (persistent elevation of mood, energy and activity). It
can take up to 10 years for a diagnosis of this disorder to be made
(DSM-5).
Childbirth and Mood Disorders

Although childbirth is usually seen as a happy event, some women (up to
50%) and a few men experience postpartum (after birth) ‘blues’.
Symptoms include anxiety and tearfulness and may be episodic, with the
person feeling happy one minute and very upset the next. The cause is
unclear, but exhaustion, hormonal changes and stress appear to play a
part. If symptoms persist beyond two weeks, medical assessment for
postnatal depression is required.
Pre- and Postnatal Depression

The signs of pre- and postnatal depression are similar to general
depression. Postnatal depression can develop several months after giving
birth. The main symptoms that are common to postnatal depression are
low mood, poor appetite, altered sleep pattern and low self-esteem.
Treatment may involve medications that are not thought to cause damage
to the baby.
Postpartum psychosis is rare, affecting one in 1,000 mothers. This
condition is characterised by depressed mood and delusions, often with
thoughts of self-harm or harming the baby.
In Australia the National Perinatal Depression Initiative (Department of
Health and Ageing 2013) aims to improve prevention and early detection
of antenatal and postnatal depression and provide better support and
treatment for expectant and new mothers experiencing depression. This
initiative benefits women who are at risk of or experiencing depression
during pregnancy or in the first year following childbirth. The National
Perinatal Depression Initiative involves routine and universal screening for
depression for women during the perinatal period (once during pregnancy
and again about four to six weeks after the birth) by a range of health
professionals including midwives, child and maternal health nurses,
physiotherapists, general practitioners and Aboriginal health workers using
the Edinburgh Postnatal Depression Scale. Follow-up treatment and care

is also provided (Department of Health and Ageing 2013).
Treatment
Treatment of depressive disorders includes medication to stabilise, raise
or lower mood (in mania) and a range of psychotherapies including
behaviour therapy and cognitive behaviour therapy.
DISORDERS IN YOUNG PEOPLE

Young people may experience mental illness in the same way as adults.
Depression and anxiety are the most common illnesses.
Autism spectrum disorder is the DSM-5 diagnosis that includes all other
subtypes of autism in previous diagnostic categorisations. Thus,
Asperger’s syndrome, which was generally considered to be on the
high-functioning end of the spectrum, falls under this term.
How Common?
Autism was once considered rare but now makes up 31% of the National
Disability Insurance Scheme participants in Australia. It is not known
why but an increase in diagnosis appears to have an influence. Annual
prevalence rates in 2015 were 1.1% for males and 0.3% for females
(Australian Bureau of Statistics 2015b). There is uncertainty about the
incidence of attention deficit with hyperactivity disorder (ADHD), being
perhaps 5–10%, and as to whether this disorder exists in adults also.
Autism is a condition that affects how a person communicates with,
and relates to, other people. It also affects how they make sense of the
world around them.
Core features include:
• persistent difficulties with social communication and social interaction—
for example, they may find it hard to begin or carry on a conversation
and do not understand social rules such as how far to stand from
somebody else
• repetitive patterns of behaviour and interests—for example, they may
be very inflexible in their routines or rituals, make repetitive body
movements or be very sensitive to certain sounds.
Attention Deficit With Hyperactivity Disorder

ADHD is a controversial disorder that is thought to be a syndrome of
behaviours where children have more difficulty with concentrating on what
they are doing (problems with attention) than other children of their age.
Boys are more likely to be diagnosed with this disorder than girls.
Behaviours include:
• lack of attention to detail with schoolwork or other activities
• trouble organising and sticking to tasks and activities
• not following through on instructions (that they are able to understand)
and not finishing tasks (e.g. at school or chores at home)
• being easily distracted and forgetful generally

• hyperactivity/impulsivity.
Treatment
Treatment for autism spectrum disorder includes early intensive
behavioural interventions with specialised health professionals. Treatment
is intensive, time-consuming and very expensive. Treatment for ADHD is
complex and can include medication, behaviour management and
psychological counselling.
EATING DISORDERS
How Common?
Anorexia nervosa is an eating disorder that affects 0.3–0.5% of the
population. It affects more females than males (ratio 10 : 1). Bulimia
affects 1–3% of young adult females and is less common in males. Onset
usually occurs in late adolescence, and it is more common in Westernised
countries.
Anorexia Nervosa
There are two main types of anorexia:
• the restricting type, where the person inhibits food overall, is less impulsive
and there are fewer self-harming behaviours and suicide attempts
• the bingeing/purging type, which is characterised by:
• a family history of obesity or being overweight prior to the condition
developing
• use of vomiting and medications to decrease weight
• self-harm and suicidal behaviours (Makhdoom 2008).
Symptoms include:
• persistent restriction of energy intake leading to significantly low
bodyweight (in the context of what is minimally expected for the
person’s age, sex, developmental trajectory and physical health)
• either an intense fear of gaining weight or of becoming fat or persistent
behaviour that interferes with weight gain (even though the person has
significantly low weight)
• disturbance in the way the person’s bodyweight or shape is
experienced, undue influence of body shape and weight on
self-evaluation, or persistent lack of recognition of the seriousness of
the current low bodyweight (Eating Disorders Victoria 2013).
Physical Symptoms
Physical symptoms of anorexia nervosa include:
• anaemia (low iron blood count)
• bradycardia (low pulse rate)
• eroded teeth enamel
• fine, downy body hair

• hypotension (low blood pressure)
• loss of muscle mass.
Mental Health Symptoms

Mental health symptoms include:
• depression
• insomnia
• lack of energy
• loss of appetite
• low self-esteem
• obsessive behaviour around food
• poor concentration
• poor memory
• social withdrawal.
Bulimia Nervosa
Bulimia nervosa is an eating disorder where the person has patterns of
bingeing and purging, causing emotional distress, preoccupation with
body shape and weight. The person’s bodyweight is often normal.
Behaviours
Behaviours include:
• craving for food
• preoccupation with eating
• a pattern of overeating followed by compensatory behaviour to reverse
food intake (exercise or self-induced vomiting).
Physical and Psychological Symptoms

Symptoms are similar to that for anorexia nervosa, but bodyweight may be
within the normal range. Purging-related symptoms include:
• constipation
• electrolyte (salt) imbalance
• irregular heart beat
• oesophageal/gastric perforation
• stomach ulcers
• tooth decay.
Treatment
Treatment for an eating disorder is dependent on the severity of the
condition and can include intensive medical treatment, psychotherapies
including cognitive behaviour therapy and family therapy, antidepressant
medication and nutritional educational and support.
INTELLECTUAL DISABILITY
How Common?
About 1% of the population have an intellectual disability. Intellectual
disability is not a mental illness per se; rather it is a neurodevelopment
disorder. Reasons for disability vary but include infections, trauma, toxins,
problems during childbirth and genetic problems (e.g. Down syndrome,
Angelman’s syndrome).
Criteria for Diagnosis

In the new DSM-5 less emphasis is placed on an IQ (measure of
intelligence) of less than 70 for diagnosis. Instead, it focuses on problems
with communication with others and activities of daily living, and lack of
independence.
Treatment
Recovery-based models of care focus on personal strengths and
maximum level of functioning in the community.
PERSONALITY DISORDERS
Personality can be defined as a person’s lifelong, persistent and enduring
characteristics and attitudes, including their ways of thinking, feeling and
behaving. These characteristics affect all aspects of a person’s life
including their work, social and personal relationships. Personality
disorders can be defined as abnormal, extreme, inflexible and pervasive
variations from the normal range of one or more personality attributes,
causing suffering to the person as well as to those around them.
Personality has generally formed by about 16 years of age, and so after
this age a disorder can be diagnosed. Personality traits are continuous
and need to be distinguished from episodic symptoms and behaviours
that occur with mental illness.
How Common?
About 3% of the general population has a borderline personality
disorder—the most common disorder of personality. Rates for other
personality disorders are much smaller and hard to establish. Within
inpatient mental health settings, as many as 50% of patients may have a
diagnosis of a personality disorder, many of whom have another mental
illness (Sadock & Sadock 2007).
Diagnosing and treating personality disorders remains controversial and
problematic because critics of these diagnoses believe that personality, by
definition, cannot be changed and is therefore untreatable by the mental
health system. Health professionals have a responsibility to work with
people with mental illness to reduce the distress and suffering they
endure on a daily basis due to living with a personality disorder (MacLean
2008).
Personality Disorder Groups

There are three groups of personality disorders (see Table 4.2):
• Cluster A—the odd or eccentric. As a group, these people tend to be
perceived as odd, eccentric and withdrawn. This group of personality
disorders includes paranoid personality disorder, schizoid personality
disorder and schizotypal personality disorder.
• Cluster B—the dramatic and emotional. People with these disorders
appear dramatic, emotional and erratic. This group of personality
disorders includes histrionic personality disorder, antisocial personality
disorder, narcissistic personality disorder and borderline personality
disorder. People with a severe borderline personality disorder or those
who have another mental illness such as depression may come into
frequent contact with mental health and emergency services when they
are in crisis. Careful and consistent management and support is
required (see Chapter 8).
• Cluster C—the anxious or fearful. People with these disorders appear
highly anxious and fearful of events and people. This group of
personality disorders includes avoidant personality disorder,
obsessive-compulsive personality disorder and dependent personality
disorder.
Treatment
Treatment for personality disorders focuses on psychotherapeutic
approaches—in particular, dialectical behaviour therapy.
DISORDERS IN OLDER PEOPLE

How Common?
Delirium is a relatively common health problem in old age, with about
30% of older people admitted to hospital experiencing it. It is marked by
an acute disturbance in attention and thinking. Any changes in old age
associated with a decline in function or thinking are not normal and need
to be investigated and treated.
Delirium is an acute medical condition that can lead to death. It should
be treated as a medical emergency. It is not a mental illness or disorder.
Rather, it is a reversible clinical syndrome, which is often commonly
confused with other disorders such as dementia or depression. Dementia
affects about 10% of people aged older than 60 and about 40% of people
aged older than 85.
Delirium
Delirium can be precipitated by:
• dehydration or constipation
• drug or alcohol withdrawal
• immobility
TABLE 4.2
PERSONALITY DISORDER GROUPS
Personality
Disorders by Type Characteristics
Cluster A
Paranoid Distrusting and suspicious
Highly sensitive
Schizoid Cold and unemotional
Lack of interest in other people
Very introspective
Schizotypal Socially isolative
Has unusual ideas
Often has odd behaviours and appearance
Cluster B
Borderline Unstable relationships with other people
Poor self-image
Unpredictable and erratic moods
Impulsive substance misuse
Impulsive self-harming behaviours
Narcissistic Strong sense of entitlement
Grandiosity
Seeks admiration
Lack of empathy for others
Antisocial Tendency to violate the boundaries of others
Superficial charm
Poor behaviour control: expressions of irritability, threats, aggression
and verbal abuse
Histrionic Excessive attention-seeking behaviours
Egocentric
Highly emotional
Cluster C
Avoidant Insecure
Social isolation due to fears of rejection or humiliation by others
Obsessive- Preoccupation with orderliness and control over situations
compulsive Rigid behaviour
Perfectionism
Dependent Excessive need to be taken care of
Clinging, submissive
Feels helpless when not in a relationship
Source: Sadock & Sadock 2007
TABLE 4.3
DIFFERENCES BETWEEN DELIRIUM, DEMENTIA AND DEPRESSION
Mental State
Examination Delirium Dementia Depression
Onset Hours to days Over months One or more weeks
Behaviour Restless and Wandering and Slowed, with changes to
uneasy searching activities of daily living,
eating and sleeping
Cognition Impaired Impaired Slowed, may seem impaired
Attention Poor/fluctuates Impaired May appear impaired
Affect Changeable; may Normal/flat/confused Sad/irritable/worried/
be irritable or depressed/guilty
flat, withdrawn
Thought May be incoherent Shallow; content may Slowed up, guilty thoughts,
be paranoid due to hypochondria
memory problems
Judgment Often impaired Declining May seem impaired
Insight Poor Reduced Changeable
• infections
• kidney or liver problems
• lack of sleep
• other disorders (e.g. cancer, neurological disorders)
• pain
• polypharmacy.
The three main criteria for a diagnosis of delirium are:
• attention span impairment
• change in cognitive function or altered perception (e.g. hallucinations,
thought disorder)
• rapid onset of symptoms (hours) or fluctuating mental state.
It is extremely important to differentiate between delirium and other
disorders such as dementia and depression in order to provide the most
appropriate care. Essential differences are listed in Table 4.3.
Memory aid: Depression develops over days and weeks, dementia
develops over months and delirium develops over hours.
Dementia
There are two main types: Alzheimer’s disease (more common) and
vascular dementia (Australian Institute of Health and Welfare 2017).
Dementia is characterised by one or more of the following cognitive
disturbances:
• difficulties with speech
• disturbance of memory
• loss of motor control

• decline from previous level of functioning
• impaired social or occupational abilities and performance.
Other Mental Disorders in Older People

Older people are particularly prone to depression because of a range of
life events including physical illness, isolation, chronic pain and
bereavement. The presence of depression is not a sign that the person
will necessarily develop dementia or Alzheimer’s disease. Schizophrenia
and bipolar disorder are less likely to occur in the older population, but
given the chronic nature of these illnesses, older adults may be living with
this condition.
Treatment
Treatment for delirium is managed by treating the cause; for example, if
the person has a urinary tract infection, antibiotics will be given, or if
dehydration is a cause, fluids will be administered. Medication may be
required if the person is very distressed or agitated.
Treatment for dementia includes cognitive-enhancing medications (see
Chapter 9), occupational therapy and rehabilitative therapy.
SUBSTANCE MISUSE DISORDERS

How Common?
Substance misuse disorders are the second most prevalent of the mental
health disorders and affect approximately 5% of Australian adults
(Australian Bureau of Statistics 2007). Substance misuse can involve
alcohol, cannabis, stimulants (amphetamines, cocaine), sedatives
(temazepam, oxazepam, diazepam) and opioids (morphine and codeine).
It is considered that 25% of men and 50% of women with substance
misuse disorders have an underlying anxiety disorder or depression
(Rothbard et al 2009). This disorder commonly occurs in people with
mental illness.
The DSM-5 defines substance misuse as a maladaptive pattern of
substance misuse leading to clinically significant impairment or distress,
as manifested by one (or more) of the following, occurring within a
12-month period:
• recurrent substance misuse resulting in a failure to fulfill major role
obligations at work, school or home (e.g. repeated absences or poor
work performance related to substance misuse; substance-related
absences, suspensions or expulsions from school; neglect of children or
household)
• recurrent substance misuse in situations in which it is physically
hazardous (e.g. driving a car or operating a machine when impaired by
substance misuse)
• recurrent substance-related legal problems (e.g. arrests for

substance-related disorderly conduct)
• continued substance misuse despite having persistent or recurrent
social or interpersonal problems caused or exacerbated by the effects
of the substance (e.g. arguments with spouse about consequences of
intoxication, physical fights).
In substance dependence, according to the DSM-5, there is a
maladaptive pattern of use leading to clinically significant impairment
involving three or more of the following occurring in a 12-month period:
• tolerance
• withdrawal
• desire to reduce and unsuccessful attempts to reduce use
• increase in amounts taken over time
• increasing time spent on activities associated with gaining substances
• reduction of activities because of use
• use continues despite knowledge of having a physical or psychological
problem caused or exacerbated by the substance.
Treatment
Treatment for substance misuse involves the following steps:
1. detoxification (the process by which the body rids itself of a drug)
2. behavioural counselling
3. medication (for opioid, tobacco or alcohol addiction)
4. evaluation and treatment for co-occurring mental health issues such as
depression and anxiety.
CONCLUSION
The most common mental illnesses have been included in this chapter as
an introduction to the types of symptoms, thoughts, feelings, behaviours
and beliefs that people with mental illness may have and suffer from.
Groupings of disorders are helpful only in as much as they group
symptoms together to gain a clear understanding of what is happening for
the person. Some symptoms, such as altered mood, altered perceptions
and suicidal feelings, can occur across a range of mental illnesses.
Finally, each person with mental illness has a unique experience and, for
that reason, carefully designed individualised care by trained health
professionals is required.
References
Albucher, R. C. (Ed.). (2008). Psychiatry: just the facts. New York: McGraw-Hill.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(DSM-5). Washington DC: American Psychiatric Publishing.
Australian Bureau of Statistics. (2007). National Survey of Mental Health and Well-being: Summary
of results. Catalogue No. 4326.0. Canberra, ACT: Australian Bureau of Statistics.
Australian Bureau of Statistics. (2015a). National Health Survey 2014–2015. Online. Available:
http://www.abs.gov.au/ausstats/[email protected]/mf/4364.0.55.001 22 April 2017.
Australian Bureau of Statistics. (2015b). The 2015 Survey of Disability, Ageing and Carers (SDAC)
Summary of findings. Online. Available: http://www.abs.gov.au/ausstats/[email protected]/Latestproducts/
4430.0Main%20Features152015?opendocument&tabname=Summary&prodno=4430.0&issue
=2015&num=&view= 22 April 2017.
Australian Institute of Health and Welfare. (2017). National health priority areas. Online. Available:
http://aihw.gov.au/national-health-priority-areas/ 22 April 2017.
Barton, D., Joubert, L., Alvarenga, M., et al. (2012). Anxiety disorders. In G. Meadows, M. Grigg,
& J. Farhall (Eds.), Mental health in Australia: collaborative community practice (3rd ed.).
Melbourne: Oxford University Press.
Bermak, J. C. (2008). Generalized anxiety disorder. In R. C. Albucher (Ed.), Psychiatry: just the
facts. New York: McGraw-Hill.
Department of Health and Ageing. (2013). National Perinatal Depression Initiative. Online. Available:
http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-perinat 28 April 2017.
Eating Disorders Victoria. (2013). Diagnostic and Statistical Manual of Mental Disorders. Anorexia
nervosa. Online. Available: http://www.eatingdisorders.org.au/eating-disorders/classifying-eating
-disorders/dsm-5#anorexia 28 April 2017.
MacLean, L. M. (2008). Personality disorders. In R. C. Albucher (Ed.), Psychiatry: just the facts.
New York: McGraw-Hill.
Makhdoom, S. (2008). Eating disorders. In R. C. Albucher (Ed.), Psychiatry: just the facts.
New York: McGraw-Hill.
McEvoy, P. M., Grove, R., & Slade, T. (2011). Epidemiology of anxiety disorders in the Australian
general population: findings of the 2007 Australian National Survey of Mental Health and
Wellbeing. Australian & New Zealand Journal of Psychiatry, 45, 957–967.
Ministry of Health (2016). New Zealand Health Survey: Annual update of key results 2015–16.
Online. Available: http://www.health.govt.nz/publication/annual-update-key-results-2015-1
6-new-zealand-health-survey 22 April 2017.
Ministry of Health (2013). New Zealand Health Survey: Annual update of key findings 2012–13.
Online. Available: http://www.health.govt.nz/publication/new-zealand-health-survey-annual-update
-key-findings-2012-13 21 April 2017.
Rothbard, A. B., Blank, M. B., Staab, J. P., et al. (2009). Previously undetected metabolic
syndromes and infectious diseases among psychiatric inpatients. Psychiatric Services, 60,
534–537.
Royal College of Psychiatrists. (2013). Anxiety panic and phobias (leaflet). Online. Available:
http://www.rcpsych.ac.uk/expertadvice/problemsdisorders/anxietyphobiaskeyfacts.aspx
1 November 2016.
Sadock, B. J., & Sadock, V. A. (2007). Synopsis of psychiatry: behavioral sciences/clinical
psychiatry (10th ed.). Philadelphia: Lippincott Williams.
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2017). Synopsis of psychiatry: behavioral sciences/
clinical psychiatry (11th ed.). Philadelphia: Lippincott Williams & Wilkins.
Slade, T., Johnston, A., Oakley Browne, M. A., et al. (2009). 2007 National Survey of Mental
Health and Wellbeing: methods and key findings. Australasian Psychiatry, 43(7), 594–605.
World Health Organization. (2017). International statistical classification of diseases and related
health problems, 11th revision (ICD-11). Online. Available: http://www.who.int/classifications/icd/
en/ 28 April 2017.
Assessment Scales
AUDIT (Alcohol Users Disorders Identification Test) alcohol assessment scale. www.therightmix
.gov.au. AUDIT detects excessive and harmful patterns of alcohol and is quick to complete and
simple to score.
CAGE (Cut down, Annoyed, Guilty, Eye opener) alcohol screening test. www.healthyplace.com.
This one of the oldest and most popular screening tools for alcohol misuse. It is a short,
four-question test that diagnoses alcohol problems over a lifetime.
Impact of Events Scale. http://academic.regis.edu/clinicaleducation/pdf’s/IES_scring.pdf. This a
scale of current subjective distress related to a specific event and is based on a list of items
composed of commonly reported experiences of intrusion and avoidance.
Kessler Psychological Distress Scale (K10) Anxiety and depression checklist. https://www
.beyondblue.org.au/the-facts/anxiety-and-depression-checklist-k10. This 10-item questionnaire
provides an overall measure of distress based on questions about anxiety and depressive
symptoms that a person has experienced in the preceding four weeks.
Mini Psychiatric Assessment Schedule for Adults with Developmental Disabilities (Mini PAS-ADD).
www.pasadd.co.uk. This is an accessible assessment tool based on a life-events checklist and
the person’s symptoms.
Mini-Mental State Examination (MMSE). www.minimental.com. This is an abbreviated form of the
mental state examination (MSE) based on observable behaviour in an assessment interview.
Minnesota Multiphasic Personality Inventory. http://psychcentral.com/lib/minnesota-multiphasi
c-personality-inventory-mmpi/0005959. This is a common personality test used by mental health
professionals to examine personality structure and psychopathology.
Positive and Negative Symptoms Scale (PANSS). http://egret.psychol.cam.ac.uk/medicine/scales/
PANSS. PANSS is a medical scale used for measuring symptom severity in patients with
schizophrenia.
Rowland Universal Dementia Assessment Scale (RUDAS). https://www.fightdementia.org.au/
resources/rudas. This is a short multicultural cognitive assessment scale.
Web Resources
Alzheimer’s Australia. www.fightdementia.org.au. This is the peak body providing support and
advocacy for the 500,000 Australians living with dementia.
beyondblue. www.beyondblue.org.au. beyondblue provides information about depression to
consumers, carers and health professionals.
Intellectual disability. www.intellectualdisability.info. This is a UK-based information website about
the nature of intellectual disability and resources. See also www.divine.vic.gov.au, which is a
website for people with a disability, their family and carers.
National Drug Strategy. http://www.nationaldrugstrategy.gov.au. This website provides information
about the National Drug Strategy and the advisory structures that support the strategy, links to
the current drug campaign sites, key research and data components and links to relevant
governments, professional organisations and drug-related portal sites.
National Institute of Mental Health. www.nimh.nih.gov/health/statistics. This website provides data
and statistics about mental illnesses in the United States.
National Perinatal Depression Initiative. http://www.health.gov.au/internet/main/publishing.nsf/
Content/mental-perinat. The Australian Government Department of Health website provides
information about this pre- and postnatal depression initiative.
Personality disorders. http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-pubs
-w-whatper. The Australian Government Department of Health website outlines the main types of
personality disorder, possible causes, treatment options and where to go for help.
Royal College of Psychiatrists UK. www.rcpsych.ac.uk/publications. This website provides
information about major mental illnesses for health professionals and the general public.
World Health Organization (WHO). http://www.who.int/topics/mental_disorders/en/. WHO is the
health arm of the United Nations and provides up-to-date information on a wide range of
health-related data. WHO’s classification of diseases (ICD-10) is available at www.who.int/
classifications/icd/en/.
Chapter 5
Mental Health Assessment
INTRODUCTION
This chapter focuses on the essentials of mental health assessment. The
purpose, aims and reasons for assessment are described in detail. The
mental state examination (MSE), a semi-structured interview that assesses
mental functioning, is a crucial component of mental health assessment
and is a really useful tool for working with people with a mental health
problem. The assessment process is not a tick box checklist but involves
developing rapport and engaging with the person you are with.
Contemporary mental health assessment also involves identifying the
resources that people have, and their coping skills and abilities, so
remember to ask about these also.
WHAT IS A MENTAL HEALTH ASSESSMENT?

Assessment is a method of gathering information in a structured and
comprehensive manner. Mental health assessment is a comprehensive,
holistic assessment based on the person’s developmental, family, social,
medical, recreational and employment history. Gently ask about any legal
issues such as criminal history as well as recreational drug use. If there is
any indication of current suicidal or homicidal ideation, the person must
be immediately referred for risk assessment by a qualified mental health
clinician.
Mental state assessment includes an MSE and history of current functioning
and presenting problems (see Fig. 5.1, overleaf). The person and family
members or carers may contribute perspectives to this assessment. Other
standardised assessments (such as specific cognitive or family assessments)
may form a part of a comprehensive mental health assessment.
An MSE (also referred to as a ‘mental state assessment’ (MSA)) is a
semi-structured interview to assess another person’s current neurological
and psychological functioning across several dimensions such as
perception, affect, thought content, form of thought and speech. An MSE
forms only part of an overall mental health assessment. For specialised
health professionals, including mental health nurses and psychiatrists, the
gathering of data for a complete mental health assessment is part of their
daily practice and will also identify a person’s coping skills, strategies for
dealing with stress and supports they can use. For other health workers,
such a comprehensive assessment may not be within their scope of
practice, and a careful MSE can aid them in providing information to the
mental health treating team in order to follow up concerns about a
person’s mental state.
An MSE can occur at a first meeting as part of a first presentation
assessment, during an admission interview, or at any time while
47
48 Chapter 5 Mental Health Assessment
Mental health assessment
Mental state
Strengths/ Challenges/
examination Background
resources threats
(MSE)
- Appearance, - Recent and - Social - Risk

activity and relevant past connectedness - to self
behaviour life events - to others
- Access to
- Speech, - Personal resources - Social
affect and mood isolation
- Family
- Thought form, - Few resources
content and
process
- Perceptions
- Conscious
awareness
- Insight
- Judgment
- Memory
FIGURE 5.1
Mental health assessment
communicating with a person. It gathers information about the person’s

experience and history, with the aim of making informed judgments about
the person’s need for care and options for care delivery.
An MSE is a ‘point in time’ assessment and needs to be conducted at
regular intervals because a person’s mental state may alter or deteriorate
rapidly. An initial MSE forms the benchmark for future assessments.
Though you may never need to undertake an MSE in its entirety, having a
basic understanding enables you to provide accurate information if a
referral to mental health services is required. For health professionals
such as paramedics, occupational therapists and physiotherapists, the
MSE provides a useful snapshot of the person’s psychological functioning
at the time of the assessment. For people with comorbidities, the MSE
allows additional information to be gathered that can inform the necessity
for referral to mental health services.
Chapter 5 Mental Health Assessment 49
WHY ASSESS?
Reasons for assessment include to:
• engage with the person in a helpful way
• collect information about the person
• allow the person to ‘tell their story’ (i.e. their understanding of what is
happening for them)
• decrease anxiety in the person
• validate that the information they have provided is accurate
• gain a full health picture and make a formulation
• develop an action or treatment plan with the person.
SETTINGS FOR A MENTAL STATE EXAMINATION

The context for assessment will vary according to the setting (e.g.
emergency department, community health centre, acute inpatient unit,
ambulance call to home, police attendance).
Try to find a quiet and safe place to provide privacy, and encourage the
person to engage with you. Establishing a relationship with the person is
essential in gaining trust and rapport. This may not be possible if you are
in a public place. Remember to assess and maintain your own safety
before approaching people in distress. Approach slowly but confidently,
and be careful not to invade their personal space.
CULTURAL ISSUES
It is important to ensure enquiries are made regarding the person’s main
language spoken and if an interpreter may be required. Religious beliefs
may also need to be considered. Factors such as the person’s gender and
culture and the context in which the assessment is being undertaken
need special consideration in order to provide culturally appropriate care.
(See Chapter 10 for further detail about cultural issues.)
HOW TO TALK TO FAMILY AND FRIENDS

While your focus is on the person in care, be aware of the need for family
and friends to be informed about what is going on. When talking to family
and friends:
• offer reassurance and understanding
• listen to their perspective and acknowledge their concerns.
ESSENTIAL MENTAL STATE EXAMINATION SKILLS

Essential skills include the following:
• Ensure your personal safety. Make sure you have a clear exit if in an
office space, and don’t place yourself in a corner.
• Consider the privacy needs of the person. Some people may prefer to
be outside or in an open space, others in a private office.
BOX 5.1
HISTORY-TAKING TIPS
• Begin with questions such as ‘What has brought you here today?’, ‘What can I
help you with today?’ or ‘Can you tell me what has been happening for you?’
• Look like you are listening!
• Be empathetic and acknowledge how the person is feeling.
• Repeat the person’s statements to seek agreement about what you have
heard.
• Use open and closed questions to gain information.
• Clarify if needed.
• Take notes and tell the person why you are writing things down.
• Show you care by displaying your concern.
• Make sure you understand the core complaint.
• If there are multiple concerns ask the person to rank them in order of
importance.
• Always introduce yourself. For example, ‘My name is … and I am a

nurse / police officer / ambulance officer / youth worker …’
• Allow a greater than normal personal space.
• Listen carefully.
• Be polite and gentle in your demeanour, but also be clear and direct.
• Observe non-verbal behaviour.
• Be honest in your responses.
• Keep communication open, and allow the person to explain what they
think is the current problem.
• Focus your attention on the person (be ‘in the moment’ with the
person).
• Bear in mind that the person may be anxious or fearful.
• Focus on the content of the person’s speech, as well as the associated
feelings (e.g. sadness, anger) and thoughts (unusual ideas).
• Ask open questions first. Focus on specific, closed questions later on.
• Use paraphrasing to convey to the person that you understand how
they are feeling—for example, ‘So you say this is the worst you have
ever felt? Have I got this right?’
• Don’t make promises you cannot keep. For example, don’t agree you
won’t tell anyone else what the person has told you.
Box 5.1 provides tips about taking a good history.
THE BASICS AND PURPOSE OF THE MENTAL

STATE EXAMINATION
The basics of an MSE are to:
• closely observe and evaluate the person’s appearance and behaviour
• listen attentively to the content of speech, which usually reflects
thoughts and thinking ability
• ask specific questions about the person’s thoughts, feelings and

perceptual experiences
• document your assessment and determine a plan of action. Remember
that undertaking an MSE is not an end in itself.
Conducting an MSE provides the framework for your plan of care. Its
purpose is to:
• clarify the nature of a person’s mental health problems
• evaluate a person’s present mental state
• identify areas for immediate intervention (e.g. relapse)
• provide a baseline so that a future MSE can evaluate changes in the
person’s condition and responses to treatment.
THE COMPONENTS OF A MENTAL STATE EXAMINATION

Fig. 5.2 illustrates the eight components of an MSE, beginning with
appearance, physical activity and behaviour, then moving to observations
Components of the mental state examination (MSE)
Appearance,
physical
activity and
behaviour
Memory Speech,
affect
and mood
Thought:
MENTAL STATE form,
Judgment EXAMINATION content and
process
Insight Perceptions
Conscious
awareness
FIGURE 5.2
Components of a mental state examination
that can be made before and during conversing with the person and
continuing through to insight and judgment assessments.
1. Appearance, Physical Activity and Behaviour

Appearance
The purpose of this section of the MSE is to describe the general
appearance of the person to get a sense of their ability to conduct their
personal activities of daily living and the appropriateness of their attire.
Noting physical characteristics can be useful (e.g. for future
identification). The following can be noted:
• gender and ethnicity
• general appearance, chronological age and apparent age
• physical characteristics such as body build, posture and any
distinguishing marks
• clothing, including condition of clothes, cleanliness and appropriateness
to weather conditions
• grooming, including peculiarities of dress, use of cosmetics, jewellery
and hairstyle
• gait (how a person walks).
Physical Activity and Behaviour
The aim of this section is to describe what the person does in terms of
observable behaviour, manner and attitude. Record your observations of:
• posture, gait, gestures, tics, grimaces, tremors and mannerisms
• activity (e.g. overactive or underactive, purposeful or disorganised,
pacing, restless, sedentary)1
• any signs of physical slowing down
• facial expression (e.g. alert, tense, worried, happy, sad, frightened,
angry, laughing, smiling, suspicious)
• rapport with the interviewer (friendly, aloof)
• attitude during the interview (e.g. indifferent, friendly, dramatic, evasive,
sullen, irritable, afraid, impulsive, embarrassed, sexually provocative).
2. Speech, Affect and Mood

This section includes how the person talks (e.g. quantity, rate, volume).
Use the following prompts as a guide:
• Is the person’s speech soft, loud, stuttering or hesitant?
• Is the flow of speech even or uneven, slow or rapid?
• Does the person’s speech contain references to disordered, negative,
unrealistic or unusual thoughts?
1
‘Avolition’ refers to having a distinct lack of motivation and energy to undertake
activities.
TABLE 5.1
DESCRIPTORS FOR AFFECT
Affect Descriptor
Full range What would normally be expected in variations of facial expression and gestures
Blunted Reduction in the emotions expressed or low intensity
Flat Absence of expressed emotion. Voice might be monotonous and face immobile
Inappropriate or Outward expression of the emotional state is not congruent with what the
incongruent person is expressing
Labile Expressed emotion fluctuates or is variable beyond normal expression. A person
is tearful one minute then angry the next
Restricted Limited variability of expressed emotion
Affect
Affect refers to the feeling or emotional state inferred by the assessor on
the basis of the person’s statements, appearance and behaviour at the
time of the assessment. Affect involves observable behaviours such as
hand and body movements, facial movements and the tone and pitch of
a person’s voice. Table 5.1 lists a range of descriptors for affect. Other
descriptors include aloof, apathetic, complacent, composed, dull, elated,
grandiose, tense, worried and euthymic (normal mood).
Mood
Mood refers to the person’s subjective statement about their emotional
state—their own description of their internal feeling or emotion—over the
past few days and is pervasive and sustained over that time. Mood might
be either:
• depressed, happy or sad
• neutral or apathetic2
• irritable, anxious or angry
• fearful or euphoric.
3. Thought: Form, Content and Process

Thought Form
Form refers to the amount of thought and its rate of production, such as:
• lack of ideas (cannot identify any thoughts)
• flight of ideas (cannot remain on one topic)
• loose associations (thinking jumps around without apparent connection)
• slow or hesitant.
The assessor makes an assessment of the person’s thoughts. Are they
able to communicate normally? Do their thoughts appear to be logical and
organised? Provide examples to illustrate your assessment.
2
The term anhedonia refers to the person not being able to experience any pleasure
in aspects of daily life.
Thought Content
Content refers to the topics or areas that one thinks about. Assessment
involves making a judgment about what the person is saying. Does it
make sense? Are the ideas related and do they flow logically from one to
the next? For example, is the person experiencing any delusional thinking?
Is the person ruminating about particular ideas? It is important to ask the
person if they have suicidal, self-harm or homicidal thoughts. Sensitivity is
required, and follow-up questions are important. Be aware that some
people have fleeting or occasional thoughts of suicide for many years but
do not act on them.
DELUSIONS. Delusions are known as fixed false beliefs or uncompromising

beliefs held in the face of incontrovertible evidence to the contrary and
that are not consistent with one’s cultural or religious beliefs. Examples of
delusions are:
• Persecutory delusions. The person has thoughts that life events are in
the form of punishment for past wrongdoings.
• Grandiose delusions. The person believes they possess unusual talents,
virtue, insight or identity.
• Delusions of reference. The person believes ordinary events have
special meaning or significance only intended for themselves.
• Delusions of influence. The person believes others are controlling or
manipulating them.
• Religious delusions. The person believes they have a special link with a
deity.
Delusions can also involve the following:
• Thought insertion. The person believes others are putting thoughts into
their head.
• Thought broadcasting. The person believes others can hear or know
what they are thinking.
• Thought withdrawal. The person believes someone is taking away their
thoughts.
OBSESSIONS. Obsessions are involuntary and unwelcome ideas that intrude

on the person’s other thoughts that then demand their attention, even
though the person may recognise them as irrational (e.g. a fear of being
contaminated when touching door handles or other surfaces).
COMPULSIONS. Compulsions are insistent, repetitive and unwanted urges to

perform a certain act (e.g. wash their hands 10 or more times after going
to the toilet).
Thought Process
Thought process refers to the movement and dynamics of how one
thought connects to the next. Thought process may be:
• Logical thought. Analyses are well-founded and make sense.

• Loose associations. Thinking is disorganised and jumps from one idea
to another with little apparent connection. Flight of ideas is also relevant
here where the person cannot remain on one topic.
• Word salad. Real words and sometimes neologisms are used, but there
is no connection between the words that convey any sense of meaning
to the listener.
• Echolalia. The person repeats what is said to them.
• Clang association. One word follows the next based on similarity of
sound or rhyming.
• Perseveration. The person continues to repeat an idea, phrase or word,
and has trouble shifting to a new thought or idea.
4. Perceptions
Perceptions refer to the person’s experience of their world through their
senses (their interpretation). The following experiences are false or
misperceptions usually associated with mental illness.
Hallucinations
A hallucination is a false sensory perception that occurs without an actual
external stimulus. Hallucinations can involve all five senses:
• Auditory. These are the most common type of hallucination and often
involve voices but can also be humming, tapping, music or laughing.
• Visual. These are common in mental disorders with a physical cause
(e.g. substance abuse) and involve seeing objects, people or images
that others are not able to see.
• Olfactory. These are common in mental disorders with a physical cause
and involve smelling things that do not exist (e.g. gas from the gas fire
or oven, but it is important to check that the gas has not in fact been
left on).
• Gustatory. These are most common in organic mental disorders and
involve a sense of an unexplained taste in the mouth.
• Tactile. These are commonly experienced during a delirium and involve
a false perception of touch or sensation (e.g. insects crawling on or
under the skin).
Illusions
An illusion is a misinterpretation of an actual external stimulus (e.g.
seeing a coat hanging on the wall and thinking that it is a person standing
in the room).
Depersonalisation
Depersonalisation refers to a feeling of unreality where the perception of
self seems different or unfamiliar (e.g. a person may describe a sense of
not being a part of their body or having an out-of-body experience). This
sensation is often associated with stress, fatigue and extreme anxiety.
Derealisation
Derealisation refers to the sense that the external world feels unreal,
different or altered. People report feeling distanced or cut off from the
world. This experience is also associated with stress, fatigue and extreme
anxiety.
5. Conscious Awareness
Level of Consciousness
Level of consciousness refers to the overall state of alertness and may be:
• Alert. The person is awake, fully aware and responsive.
• Lethargic. The person is drowsy but responds when spoken to. They
may fall asleep.
• Stuperous. The person is difficult to rouse, may groan or may become
restless when attempts are made to rouse them.
• Coma. The person is unresponsive to voice or painful stimuli.
Orientation
This includes orientation to:
• Time. Orientation to hour, day, month and year.
• Place. This relates to whether the person can identify which hospital,
city and country they are in.
• Person. This relates to orientation to self or others.
Concentration
Concentration is usually assessed by asking the person to count
back from 100 in serial sevens (ask the person to take seven from
100, seven from 93, etc.), spell ‘world’ backwards or repeat a three-part
task.
Abstract Thinking
Abstract thinking refers to the ability to deal with concepts and to extract
meaning, to understand the meaning of phrases beyond their literal
interpretation or to juggle more than one idea at a time. Asking the person
to explain the meaning of a common proverb is a good way for some
people to assess abstract thinking ability. Examples are:
• All that glitters is not gold.
• When the cat’s away the mice will play.
• Don’t count your chickens before they hatch.
• Rome wasn’t built in a day.
However, understanding of the above proverbs presumes a level of
educational attainment (about eight years) and assumes an understanding
of Western culture, so proverbs will not be a useful tool with all people.
The assessor needs to explain what a proverb is (a saying that has a
broader meaning) and provide an example before assessing the person.

You can assess higher intellectual functions like abstraction in other ways
such as asking, ‘How are an apple and an orange both alike?’ The
expected abstract answer would be ‘fruit’ and a concrete answer (showing
less intellectual function) would be ‘that they are both round’. Concrete
answers often signal a deficit in intellectual functioning and require further
investigation.
6. Insight
Insight is the degree to which the person realises the significance of their
symptoms or illness and their current situation, or the degree of
self-understanding. Consider the following:
• Is there an appreciation of how their illness may affect their life?
• Do they think they have an illness?
• Do they have full or partial understanding of their situation?
• Are they able to explain why an ambulance has been called?
7. Judgment
Judgment is the ability to make sensible decisions based on expected
consequences in everyday activities and social situations. Consider the
following:
• Are judgments socially appropriate?
• Are judgments about personal relationships appropriate?
• Is the person able to manage his or her own finances?
Be aware that the concepts of insight and judgment are increasingly
being challenged regarding their usefulness in assessing a person’s
mental health because they are recognised as subjective, contested and
loaded concepts.
8. Memory
Memory includes:
• Remote past recall. This is the ability of the person to present a
coherent life story with dates and places (e.g. birth, employment,
relationships).
• Recent past recall. This is the ability of the person to recall the history
and events leading to their hospitalisation.
• Immediate past recall. This is the ability of the person to recall a
person’s name and three unrelated facts five minutes after being given
them.
Summary
An MSE should include a summary statement containing a formulation of
what the central issues are and the reasons for admission, and a brief
problem list. For further detail, see Evans et al (2017).
CASE STUDY: A MENTAL STATE EXAMINATION

Phillipa is a single 31-year-old female with previous admissions to psychiatric
hospitals for relapse of schizophrenia. Phillipa has called an ambulance at 7.30 pm
because she is convinced there is a man outside her house who is spying on her.
She asks the ambulance staff to find the man and call the police to take him away.
APPEARANCE, PHYSICAL ACTIVITY AND BEHAVIOUR
Phillipa answers the door in her pyjamas and a dressing gown. Her hair is not
brushed, but she appears clean and appropriately dressed for a cool autumn
evening. Her height is about 162 cm, and she has a slim build.
She exhibits a closed posture, sitting hunched up on her lounge, rocking slightly
and chewing skin around her fingernails. There is occasional appropriate but brief
eye contact. She appears tense and anxious. The living room is clean but untidy.
There are few furnishings and the curtains are drawn (but it is dark outside). She
admits to keeping the curtains drawn during the day.
SPEECH, AFFECT AND MOOD
Phillipa is softly spoken, and her speech exhibits normal rate and flow. Her main
concern is that a man is waiting outside, and she thinks he is going to break in and
hurt her. Because of this, she is sleeping poorly and refuses to leave the house.
She exhibits labile affect and pervasive anxiety. She is suspicious of ambulance
staff and tearful at times. She is responding minimally to verbal reassurance.
THOUGHT: FORM, CONTENT AND PROCESS
Thought form appears normal. For thought content, there is a preoccupation with
the man who she thinks is outside her house. She has been outside to check but
thinks he hides when she ventures out.
PERCEPTIONS
Phillipa describes feeling outside her body (depersonalisation) and being cut off from
the world (derealisation).
CONSCIOUS AWARENESS
Phillipa is alert and oriented to time, place and person. Her memory is fully intact.
Her concentration is poor and she is easily distracted (e.g. by street noise).
INSIGHT
Phillipa does not relate her belief of being watched by a stranger to her mental
illness.
JUDGMENT
Phillipa’s judgment is impaired due to her mental state. She is unwilling to leave her
house and is unable to plan her day because she is persistently worried about being
harmed.
ADDITIONAL INFORMATION REQUIRED FOR A MENTAL

HEALTH ASSESSMENT
Presenting Information
For the overall mental health assessment, a statement is required of the
actual reason for the presentation, the nature of the presenting problem
and the history of the presenting problem, including precipitating factors

and recent stressors. In particular:
• Note the history of concordance with the current treatment regimen
if any.
• Identify if there are any urgent social issues that may need to be
addressed.
• Provide a brief outline of the support structures available to the
person.
• Identify the person’s strengths and any predisposing, precipitating and
perpetuating factors.
Medical History
Medical history includes:
• previous operations, illnesses and admissions to hospital
• family history of illness, medications and allergies
• drug and alcohol use
• nutritional state (weight gain/loss), energy levels, sleep/rest patterns and
exercise levels.
Psychiatric History
This section includes a brief summary of:
• any episodes of illness, including admissions to inpatient units, and
types of treatments/interventions that were helpful or unhelpful
• attitude to mental health services and treatment
• premorbid personality and level of functioning
• family history
• current mental health services involved in care.
Risk Assessment
The mental health assessment should contain a risk assessment,
including risk of harm to self or others, risk of abuse by family members
(elder abuse and domestic violence), risk of falls and risk of poor
nutrition.
Social History
Social history includes:
• developmental history (childhood illnesses, life events, education)
• current family structure (marital status, dependants, significant
relationships)
• housing situation
• social supports, employment and occupational history
• financial situation
• forensic history / legal issues
• spiritual and cultural considerations.
It is important to identify a person’s personal strengths and resources

as well as challenges in order to gain a holistic person-centred
assessment.
CONCLUSION
This chapter has provided the essential elements of a mental health
assessment. Careful gathering of information and engagement with the
person will allow useful care to be planned in partnership. It is important
to practise assessment skills to become proficient in this activity.
Reference
Evans, K., Nizette, D., & O’Brien, A. (2017). Psychiatric and mental health nursing (4th ed.).
Sydney: Elsevier.
Resources
The SAD PERSONS mnemonic (Sex, Age, Depression, Prior suicidality/self-harm, Ethanol: alcohol
misuse, Rational thinking, Support systems, Organised support system, No significant other,
Sickness is a quick easy assessment of suicidality and risk. It is not a rating instrument, just a
jog for the memory and has no validity in predicting future self-harm.
The Annual Population Survey (UK) includes four questions used to monitor wellbeing. These are:
1. Overall, how satisfied are you with your life nowadays?

2. Overall, to what extent do you feel the things you do in your life are worthwhile?
3. Overall, how happy did you feel yesterday?
4. Overall, how anxious did you feel yesterday?
These are not diagnostic but can be used by health professionals to start a meaningful
conversation about how people are feeling generally.
Web Resources
Kessler Psychological Distress Scale. https://www.tac.vic.gov.au/files-to-move/media/upload/
k10_english.pdf. The Kessler (K10) measure is a 10-item self-report questionnaire intended to
yield a global measure of ‘psychological distress’ based on questions about the level of anxiety
and depressive symptoms in the most recent four-week period.
Mini Mental State Examination. https://www.alzheimers.org.uk/info/20071/diagnosis/97/
the_mmse_test. The MMSE is a commonly used instrument for measuring cognitive function.
Palmerston Association Inc. www.palmerston.org.au/_literature_92767/MSE_DVD_-_Booklet.
Understanding the Mental State Examination (MSE): A basic training guide is funded by the
Australian Government under the Improved Services for People with Drug and Alcohol Problems
and Mental Illness through the Department of Health.
University of Bristol. http://www.bristol.ac.uk/medical-school/hippocrates/psychiatry/mse_etc/. This
website contains teaching resources developed by the University of Bristol for their
undergraduate medical students and offers valuable information on mental health assessment.
Chapter 6
Assessing Risk
WHAT IS RISK ASSESSMENT?
‘Risk assessment’ refers to the role of the health professional assessing
possible risk to the overall health and safety of a person and those around
them. Risk assessment is important so that health professionals can decide
on an appropriate plan of action with, and for, the person to reduce the
likelihood of an adverse event occurring. The health professional needs to
establish a therapeutic working relationship with the person and assess
their needs, with a focus (where possible) on strengths, coping strategies
and social supports. ‘Risk management’ is the process wherein a plan of
care is designed to address identified needs and to continue to assess and
evaluate the efficacy of planned interventions.
WHY ASSESS RISK?

Risk assessment does not replace care planning. It is a useful aspect of
the overall process of care planning. Risk assessment ought to be done
with the person; it is not something that is done to the person. The core
issue with risk assessment is to establish the level of risk (low, medium or
high) so that plans can be made to protect the person (i.e. keep them
safe) and others. Further, establishing what strengths and resilience the
person has can reduce risks and give the person confidence that they
have some control in their lives. Questions to ask are highlighted in
Box 6.1 (overleaf).
Risk assessment is not about making predictions about certain events
and is only an assessment of the current situation. Remember that when
asking people about their suicidal intent, your assessment relies on what
they tell you, which you have to accept as true. But this may not be the
case.
Risk in mental health contexts generally refers to acute immediate risk
issues, such as the risk of harm to self or others, but it can take many
forms. It includes the risk of:
• absconding (leaving hospital without permission)
• adverse effects of medication (e.g. side effects, toxicity)
• danger to self and others
• falls
• financial, physical or sexual exploitation
• gambling
• harassment or stalking
• homelessness
• not taking psychiatric medication
• notoriety due to bizarre behaviour
• obesity and other illness
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62 Chapter 6 Assessing Risk
BOX 6.1
RISK ASSESSMENT QUESTIONS
• What is the risk?
• Who is at risk?
• What is the chance of the risk occurring?
• How immediate is the risk?
• Over what timeframe is the risk being assessed?
• What factors can increase or decrease the risk (e.g. stressors, people,
situations)?
• Are alcohol or other drugs involved?
• What do we need to do to reduce or manage the risk?
• What is the plan of action?
BOX 6.2
CORE PRINCIPLES FOR WORKING WITH RISK
• Risk is a normal part of life.
• Risk can be minimised but not eliminated.
• Risk changes with time and circumstances.
• Identifying a risk carries a duty to do something about it (risk management
plan).
• The person’s own involvement is vital.
• Risk assessment requires multiple sources of information including from the
person, carers and clinicians.
Source: Morgan 2004
• physical health deterioration

• poverty or self-neglect
• reckless behaviour such as unsafe driving
• sexual promiscuity
• social isolation
• substance abuse
• unemployment
• verbal or physical abuse.
It is important for health professionals to be aware of the less obvious
but significant risks that people with a mental illness face and the effect
that these risks can have on their day-to-day functioning. Being homeless
and socially isolated, or being dependent on drugs or alcohol, increases
day-to-day stresses and can contribute to an increase in distressed
behaviour such as self-harming or an increase in symptoms of mental
illness.
Box 6.2 lists the core principles for working with risk.
TYPES OF RISK FACTOR

Some risk factors are termed static because they are fixed, such as
gender or history of violence. They cannot be changed and give a
Chapter 6 Assessing Risk 63
BOX 6.3
RISK FACTORS IN AGGRESSION/VIOLENCE
• Being male, under 35 years of age
• Having psychosis, dementia, organic brain injury, personality disorder
• History of substance misuse (alcohol or drugs)
• Recent life stressors
• Previous history of violence
• History of prison incarceration
• Unstable living arrangements
• Disengagement from mental health services
Adapted from Hart 2014
BOX 6.4
RISK FACTORS FOR SUICIDE
• Being single
• Being unemployed
• Being divorced or widowed
• Being male, younger than 25 or older than 85 years of age
• Being of indigenous heritage
• Recent life stressors
• History of prison incarceration
• Having a mental illness
• Discharge from a psychiatric inpatient unit within 14 days
• History of substance misuse (alcohol or drugs)
• Expressing excessive guilt
• Poor physical health
• Social isolation
• Expressing hopelessness or helplessness
baseline of how someone might behave. Dynamic risk factors are factors
that can change in duration and intensity, such as hopelessness, agitation
and substance abuse. These can be measured, and it is important to try
to minimise the distress such factors can cause people to reduce a
high-risk event such as violence or suicide.
It is important to be able to recognise the risk factors for violence (see
Box 6.3) and suicide (Box 6.4).
WHEN TO DO RISK ASSESSMENT?

Risk assessment is vital when first meeting a person or when there is a
transfer of care, change in clinical condition or deterioration in mental
state. The most reliable person regarding a risk assessment is the last
person who made the assessment. In a crisis situation a comprehensive
risk assessment is not immediately required; undertake an immediate
high-risk assessment and formulate a plan of care.
WHAT IS IN A RISK ASSESSMENT?

Risk assessment involves collecting relevant background information,
using the risk assessment your organisation prefers, structuring an
individual assessment and formulating a risk management plan.
There are a number of tools to assess risk in clinical settings, but these
are generally about risk of violence or suicide. They can be a useful
adjunct to the risk assessment interview. Remember though that the use
of a rating scale is not a risk assessment in itself.
WHAT TO TELL THE PERSON WHEN UNDERTAKING

A RISK ASSESSMENT
The person needs to be informed at the beginning of the interaction about
(Hart 2014):
• how long the assessment will take or how much time you have available
• that some questions may be uncomfortable to answer but are important
to provide good care
• that the person can refuse to answer questions, but the more
information gained, the better the care that can be provided
• what happens next.
MAKING A FORMULATION AND MANAGEMENT PLAN

The risk formulation usually contains the following elements:
• background: demographics, culture, history of harm to self or others
• current situation: stressors, precipitating events
• risk factors: what they are and what priority they are
• risk status: low, medium and high risk level assessed
• timeframe: when the next assessment is due.
The management plan aims to set out what specifically should happen
to manage the risk identified, future preventive actions, protective factors
the person has to employ, the plan for likely future risk and what the
person can do in a crisis.
An example of a risk assessment and management template can be
found on the following pages.
CASE STUDY
Julie-Anne is a 27-year-old woman with a history of self-harming
behaviour (cutting her arms with a razor blade). A member of the public
calls an ambulance and police to a car park after seeing Julie-Anne sitting
on the ground, drinking from a wine bottle and holding a large kitchen
knife. Julie-Anne has slurred speech, and the paramedic notices a bottle
of rat poison in a shopping bag by her side. Julie-Anne says her boyfriend
has ended their relationship earlier that day and she has nothing left to
live for. Table 6.1 shows how you might formulate the risk in this case.
TABLE 6.1
FORMULATING THE RISK
Who is at risk? Julie-Anne, attending paramedics and police
What is the risk? Risk of self-harm and harm to others
What are the risk factors Intoxication, recent separation, previous history of self-harm, possession
for Julie-Anne? of poison, possession of and holding a large knife, feeling hopeless
What is the level of High
severity of the risk?
MENTAL HEALTH RISK ASSESSMENT AND MANAGEMENT TEMPLATE

General Risk Factors
Background Factors
Major psychiatric illness □Y □N □Unknown
Diagnosed personality disorder □Y □N □Unknown
History of substance misuse □Y □N □Unknown
Serious medical condition □Y □N □Unknown
Intellectual disability/cognitive deficits □Y □N □Unknown
Significant behavioural disturbance (< 18 years) □Y □N □Unknown
Childhood abuse/mistreatment □Y □N □Unknown
Current Factors
Disorientation/disorganisation □Y □N □Unknown
Disinhibition/intrusive/impulsive behaviour □Y □N □Unknown
Current intoxication/withdrawal □Y □N □Unknown
Significant physical pain □Y □N □Unknown
Emotional distress/agitation □Y □N □Unknown
Comments:
Suicide Risk Factors

Background Factors
Previous suicide attempts □Y □N □Unknown
History of self-harm □Y □N □Unknown
Family history of suicide □Y □N □Unknown
Separated/widowed/divorced □Y □N □Unknown
Isolation or lack of support/supervision □Y □N □Unknown
Current Factors
Recent significant life events □Y □N □Unknown
Hopelessness/despair □Y □N □Unknown
Experiencing high levels of distress □Y □N □Unknown
Expressing suicidal ideas □Y □N □Unknown
Self-harming behaviour □Y □N □Unknown
Current plan/intent □Y □N □Unknown

Access to means □Y □N □Unknown
Comments:
Violence/Aggression Risk Factors

Background Factors
Previous incidents of violence □Y □N □Unknown
Previous use of weapons □Y □N □Unknown
Forensic history □Y □N □Unknown
Previous dangerous/violent ideation □Y □N □Unknown
Current Factors
Recent violence □Y □N □Unknown
Command hallucinations □Y □N □Unknown
Violence-related restraining order □Y □N □Unknown
Paranoid ideation about others □Y □N □Unknown
Expressing intent to harm others □Y □N □Unknown
Anger/agitation □Y □N □Unknown
Poor impulse control □Y □N □Unknown
Access to available means □Y □N □Unknown
Contact with vulnerable people □Y □N □Unknown
Comments:
Other Risk Factors

Background Factors
History of absconding □Y □N □Unknown
History of physical/sexual victimisation □Y □N □Unknown
History of gambling or poor control of finances □Y □N □Unknown
History of falls/accidents □Y □N □Unknown
History of exploitation by others □Y □N □Unknown
History of neglect of a serious medical condition □Y □N □Unknown
History of non-adherence to medication/treatment □Y □N □Unknown
Current Factors
Desire to leave hospital □Y □N □Unknown
Vulnerability to sexual exploitation/abuse □Y □N □Unknown
Current delusional beliefs □Y □N □Unknown
Parental/carer status or access to children □Y □N □Unknown
Physical illness □Y □N □Unknown
Self-neglect, poor self-care □Y □N □Unknown
Non-adherence to medications/treatment □Y □N □Unknown
Impaired cognition/judgment □Y □N □Unknown

Impulsive/reckless driving □Y □N □Unknown
Comments:
Protective Factors (List)
Overall Impression
Is the person’s level of risk highly changeable? □Yes □No
Are there factors that contribute uncertainty regarding the level of risk? □Yes □No
Overall Assessment of Risk
Suicide □H □M □L
Self-harm □H □M □L
Violence/aggression □H □M □L
Vulnerability □H □M □L
Absconding □H □M □L
Other (describe) _______________________________________ □H □M □L
___________________________________________________ □H □M □L
Specific Risks To Be Addressed in Management Plan (List)
References
Hart, C. (2014). A pocket guide to risk assessment and management. Oxon, Great Britain:
Routledge.
Morgan, S. (2004). Risk taking. In P. Ryan & S. Morgan (Eds.), Assertive outreach: a strengths
based approach to policy and practice. London: Churchill Livingstone.
Web Resources
HCR-20 Historical Clinical Risk Management Scale. http://hcr-20.com/. This is a 20-item
clinician-rated risk assessment instrument using historical, current and future clinical risk
factors.
Mental health triage in emergency departments. https://www2.health.vic.gov.au/mental-health/
practice-and-service-quality/service-quality/mental-health-triage-service. Information about triage
in mental health in emergency departments from the Victorian Department of Health and
Human Services.
Screening Tool for Assessing Risk of Suicide (STARS). https://www.griffith.edu.au/health/australian-

institute-suicide-research-prevention/publications/stars. This is a three-part clinician-assessed
comprehensive assessment of suicidality.
square – suicide, questions, answers and resources. http://www.square.org.au/wp-content/uploads/
sites/10/2013/05/Risk-Assessment_Black-and-White_May2013_Handout1.pdf. ‘square’ is an
educational resource for primary health care and community specialists and anyone working
with people who are at risk of suicide.
Chapter 7
Behaviours of Concern
INTRODUCTION
This chapter explores behaviours of concern in the context of people
experiencing mental health problems. These behaviours include situations
in which a person is in extreme distress (e.g. having a panic attack, being
violent, intoxicated or suicidal or having experienced a trauma). In such
situations, the role of health professionals is to assess the situation with a
primary focus on risk assessment in terms of the person harming
themselves or others (i.e. the bottom line is to maintain safety for
everyone). A situation where someone is angry or aggressive does not in
itself constitute an emergency if the person can be helped to calm down.
People with borderline personality disorders are also discussed here
because their behaviours often challenge professionals. Such people are
often well known to health professionals, emergency and mental health
services, frequently test professionals’ patience and can reduce their
willingness to engage with them. Specific strategies are suggested here.
WHAT TO DO IF THE PERSON IS SUICIDAL

When you talk to the person, try to be calm, open and honest. Try not to
be judgmental, shocked or take their behaviour personally. Try to see the
situation from their point of view and understand why they feel the way
they do. Let the person know you support them, and listen to them
express their feelings. If the situation is urgent, seek help; for example,
contact emergency services. If the situation is not of immediate urgency,
help the person make a plan about what to do when they feel suicidal.
This will help the person feel supported, safe and more in control of their
situation.
Encourage the person to get support from health professionals such as
their general pratitioner or a mental health professional, and offer to go
with them to their appointments if they are scared or uncomfortable.
Chapter 6 on assessing risk provides further detail about assessment
processes with a person who is actively suicidal.
Box 7.1 (overleaf) lists the dos and don’ts with a person who is suicidal.
WHAT TO DO IF A PERSON IS SELF-HARMING

Self-harm is used to describe a range of intentional behaviours that may
be hidden, impulsive or planned. Behaviours can include:
• cutting
• burning
• scalding
• breaking bones
• swallowing prescription and non-prescription drugs or poisons
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70 Chapter 7 Behaviours of Concern
BOX 7.1
DOS AND DON’TS WHEN A PERSON IS SUICIDAL
Do:
• stay with the person
• ask if the person is suicidal
• ask if the person has a plan
• ask if the person has any weapons (guns, knives) and their location
• ask if the person is on any medication and where those medications are
• ask if the person has taken any medications or other drugs and alcohol, and
what amounts
• ask about the frequency and nature of their suicidal thoughts
• engage in conversation with a view to helping the person realise suicide is not
the only or best option
• acknowledge their distress
• call for help or an ambulance if the person is bleeding or loses consciousness.
Don’t:
• dismiss the person’s reasons for wishing to die
• express frustration with the person
• make judgments about the person’s behaviour (e.g. that they are selfish)
• tell the person they are just attention seeking
• dismiss self-harming behaviour as not requiring help and support (self-
harming behaviour acts as a stress-reduction mechanism for people and is a
hard pattern to break).
• hair pulling
• physical self-mutilation (Hart 2014).
Reasons for such behaviour are complex and can include the need to
relieve stress, punishing self, expressing grief/guilt or trying to remain in
control. Self-harming behaviour is a serious event, and people who do so
are at risk of further episodes and increase their risk of successful
suicide. People who self-harm may also exhibit impulsive behaviours,
such as binge drinking or using non-prescription substances. Remember
that people who self-harm may still have suicidal thoughts, and
assessment of this is required. See Box 7.2 for dos and don’ts if a person
is self-harming.
WHAT TO DO WHEN WORKING WITH PEOPLE WITH A

PERSONALITY DISORDER
The importance of establishing boundaries to sustain a therapeutic
relationship with a person with mental illness was discussed in Chapter 3.
People diagnosed with a personality disorder are often negatively labelled
and the phrase ‘they’re just a PD’ is commonly heard in health and social
service settings. This involves a judgment that the person with this
diagnosis is not really sick but is deliberately misbehaving or does not
deserve treatment. As described in Chapter 4, people with personality
Chapter 7 Behaviours of Concern 71
BOX 7.2
DOS AND DON’TS WHEN A PERSON HAS SELF-HARMED
Do:
• ring an ambulance if the person has ingested poison or overdosed, has a
fluctuating consciousness or is bleeding
• be calm and honest in talking to them
• keep the person physically safe
• show care and compassion
• acknowledge and treat the pain and wound if the person has been cutting.
Don’t:
• take it personally
• be judgmental
• look horrified, angry or disgusted (or other signs of shock)
• tell them they are wasting your time
• tell them they need to get over themselves.
disorders have legitimate mental health problems that are treatable and
exhibit behaviours that are difficult or unhelpful in an effort to manage
their distress. Health professionals need to take care not to engage in
unhelpful behaviours themselves in reacting to stressful interpersonal
situations. Clinician stigma towards these people decreases their chances
of recovery.
People with a personality disorder respond to supportive and consistent
care that accepts their distress but that also focuses on their existing
strengths and the skills they can use to manage their distress. The core
aim of treating people with a personality disorder is to maintain a
therapeutic working relationship and to work with them to reduce their
distress and facilitate better coping.
Many people using health and social services exhibit challenging
behaviours for a variety of reasons. For example:
• frequent presentations to emergency departments
• frequent calls to ambulance or police
• frequent non-life-threatening self-harming behaviours
• repeated overdose of prescription or non-prescription medicines
• alcohol and substance intoxication
• aggressive or violent outbursts.
It is important to remember that when people are in crisis they may
behave in ways that we consider unacceptable but that they may find
helpful, or these behaviours may be the only ones that they have available
to them at that time.
The most common type of personality disorder that health professionals
will come across is the borderline type (BPD). BPD is a legitimate illness
and causes significant morbidity and mortality. Despite what people think,
mental health workers without advanced training can work successfully
BOX 7.3
DOS AND DON’TS WITH PEOPLE WITH A PERSONALITY DISORDER
Do:
• have an agreed written care plan with the person for times of crisis
• have a clear management plan that the whole team agrees to, and regularly
review and revise the person’s goals
• be positive and maintain an attitude of hope
• set appropriate limits and boundaries about acceptable and unacceptable
behaviours
• be honest and open with the person
• respond to the person, not the diagnosis/label
• set realistic and achievable goals with the person
• use clinical supervision to work on interpersonal issues associated with
working with a person (Cleary & Raeburn 2017).
Don’t:
• try to ‘rescue’ the person
• believe you are the only one who can help the person
• offer to see the person outside your working hours
• be defensive or verbally retaliate as a result of feeling ‘attacked’ by the person
• try to be the person’s friend
• agree to keep information provided by the person secret from the rest of the
multidisciplinary team
• avoid the person
• be over-controlling of the person’s behaviour
• use sarcasm or cynical comments in relating with the person
• be jealous of the attention the person receives
• feel that your skills are of no worth in the care of this person.
with people with BPD. Accepting the person and validating their
experiences, showing empathy and consistency and taking a
non-judgmental, collaborative approach to crisis management and
treatment planning can result in positive outcomes. Having a clear care
plan as well as a crisis management plan and close follow-up with the
person is vital to assisting their recovery. Health professionals may
encounter people with a paranoid personality disorder or people who have
antisocial tendencies. Paranoid personality disorder may be misinterpreted
as paranoid psychosis, so careful assessment is required.
See Box 7.3 for dos and don’ts for working with people with a
personality disorder.
WHAT TO DO IF THE PERSON HAS EXPERIENCED AN ACUTE

TRAUMA (PHYSICAL, PSYCHOLOGICAL OR SEXUAL ASSAULT)
A traumatic event can be defined as an experience that causes physical,
emotional or psychological harm or distress to a person. It is an event that
BOX 7.4
DOS AND DON’TS IF THE PERSON HAS EXPERIENCED AN ACUTE TRAUMA
Do:
• establish if the person has been physically hurt and needs medical attention
• talk to the person, but don’t pressure them to talk
• stay with the person and reassure them that help is being arranged or on
its way
• keep the person warm
• reassure the person that what they are feeling is normal given what has
happened to them.
Don’t:
• minimise what has happened or what the person has witnessed
• offer the person alcohol
• tell the person to pull themselves together or that they will ‘get over it’
• ask them questions repeatedly.
is perceived and experienced as a threat to one’s safety or to the stability

of one’s world.
A traumatic event is one in which the person may have, for example:
• been involved in a traffic or physical accident
• witnessed a traffic accident
• been physically or sexually assaulted
• been mugged or robbed or have been a victim of domestic violence
• witnessed a terrible event (e.g. fire, shooting, bank hold-up, hit and run)
• been involved in severe weather events (e.g. bushfire, flood, cyclone).
People respond to such unexpected events in different ways, but in the
initial phase they experience physical shock and may appear dazed and
feel numb. They may physically tremble, be very distressed or agitated,
cry or wail, wander around in a confused state, or sit without appearing to
realise what is happening around them. This is entirely normal in relation
to what has happened to them. Box 7.4 lists the dos and don’ts if the
person has experienced an acute trauma.
After the Crisis Has Passed

After the initial shock of the trauma, people commonly experience
symptoms of anxiety, fear, dizziness, breathlessness, pounding heart and
insomnia. It is useful to encourage them to attend to normal daily
activities as much as they can, to be as physically active as possible and
to eat and drink well to promote a beneficial daily routine. Further support
may be required, but most people recover on their own within a few
weeks. If in doubt, the person should be encouraged to see a health
professional for support.
WHAT TO DO IF THE PERSON IS AGGRESSIVE OR VIOLENT

How to Tell if Someone Is Potentially Violent
If a person is angry and potentially violent, they are likely to exhibit some
of the following:
• being verbally threatening or sarcastic
• being withdrawn
• dilated pupils
• furrowed brows
• grinding their teeth
• having poor concentration
• pacing or other signs of restlessness
• shouting or talking very quietly
• staring or exhibiting prolonged eye contact
• swearing
• voicing delusions or hallucinations with violent content.
Note that more than one attribute often applies.
De-Escalation: Act Don’t React!

De-escalation is a process intended to reduce tension in a situation and
prevent the situation from deteriorating, therefore avoiding violence and
people being hurt and traumatised. Never approach an angry person
without backup and do not attempt to restrain someone on your own,
unless life is in immediate danger. Call for assistance if you need to. If
you are in imminent danger, remove yourself from the situation to
somewhere safe and raise the alarm.
In interactions, remember to speak slowly and calmly, in a quiet voice
but loud enough to be heard. Introduce yourself to the person by saying
your name and explain your actions. One person should assume control
of a potentially disturbed situation. The lead person needs to manage the
environment (e.g. remove bystanders, create space, direct security
guards, call the police).
De-escalation is a process that involves a delimiting of the situation,
clarification of the problem for the person and moving to a resolution
(Bowers 2014). Delimiting involves conducting a safety assessment of the
situation, involving supports such as security guards or police and
creating a safe distance between yourself and the person. The clarification
phase involves finding out what the problem is. ‘What is the matter?’-type
enquiries attempt to sort out any confusion, remind the person where they
are and remind them of any relationship you have with them. Find out
from the person what they want. Maintain respect and empathy at all
times. The resolution phase is the final stage where you can suggest a
flexible approach to deal with the person’s complaint and offer as many
options as possible in the context of safety. Where you can’t be flexible,
explain why. Take your time and actively listen to the person. In some
situations violence will eventuate, and safety concerns must always take
precedence.
An essential component in de-escalation is to remain calm and be
engaged and empathic with the person. Try not to show your anxiety, but
do show that you care.
Box 7.5 (overleaf) lists the dos and don’ts in an aggressive or violent
situation.
DEBRIEFING
After any incident, debriefing is a useful way to allow the emotions of the
event to be discussed and dealt with. It is also an important process to
gain insights into the sequence of events, mistakes that were made and
associated learning. The purpose of debriefing is to:
• establish what happened and how people perceived the event and their
level of comfort/discomfort
• make changes to prevent or reduce similar events in the future
• increase the preparedness of those being debriefed for further such
incidents.
Workplaces ought to have comprehensive debriefing processes to
support staff and people in their care when unwanted events occur. It is
important to check what these are where you work.
WHAT TO DO IF THE PERSON IS ACUTELY PSYCHOTIC

If a person is acutely psychotic, be very clear about what the purpose of
your interaction is (e.g. to establish rapport, to help them remain calm, to
encourage the taking of medication, to request that they come with you to
hospital, to conduct a mental state assessment, or to gain information
about family so they can be informed of the person’s whereabouts). It is
likely that the person may be too thought-disordered to maintain
concentration or stay on track in a conversation. Box 7.6 (overleaf) lists
the dos and don’ts if a person is psychotic.
WHAT TO DO IF THE PERSON IS HAVING A PANIC ATTACK

A panic attack is an episode of intense fear. It is generally triggered by
negative thoughts and accompanied by one or more symptoms such as:
• chest pain
• choking
• dizziness
• fear of dying
• fear of losing control
• heart palpitations
• intense feelings of dread
• nausea
• shortness of breath
BOX 7.5
DOS AND DON’TS IN AN AGGRESSIVE OR VIOLENT SITUATION
Under stress, people often behave in ways that are thought to be helpful to all
concerned at the time but in fact have the opposite effect and make the
situation worse. The following dos and don’ts are intended to guide your
interaction in situations of violence.
Body Posture and Eye Contact
Do:
• allow the person more personal space than you might normally
• lower your voice; often the upset person will lower their voice in response
• try to relax your posture and stand at a slight angle with your arms by your
sides, but make sure your stance is such that you can retreat if necessary
• make intermittent eye contact
• appear calm and genuinely interested in the person.
Don’t:
• cross your arms
• stand with your legs well apart and front-on to the person
• keep your hands in your pockets
• stare at the person
• try to touch the person.
Engagement and Communication
Do:
• introduce yourself by name
• speak clearly and slowly
• explain your actions
• attempt to establish rapport
• encourage the person to talk and to tell you how they view the problem
• give clear, brief instructions
• take your time (don’t try to rush things along)
• emphasise your concern and desire to work together
• offer options that are realistic
• focus on the person, nod when they talk, accept their concerns as valid and
demonstrate empathy
• use open questions and say ‘Go on … tell me more about that …’
• match the person’s arousal but not their anger (e.g. ‘It sounds like we need to
sort this out straightaway’).
Don’t:
• ask ‘why’ questions (they are more likely to provoke the person)
• tell the person you know how they feel (you don’t)
• disagree with the person
• tell the person to calm down
• shout or talk to the person loudly (unless it is to be heard)
• make promises you cannot keep
• make threats (e.g. ‘If you don’t comply, you will be taken to hospital against
your will/detained/secluded’)
• use sarcasm, humour or minimise what they are saying (e.g. put-downs such
as ‘Don’t be silly’ or ‘That’s ridiculous’), which can make things worse.
BOX 7.6
DOS AND DON’TS IF A PERSON IS ACUTELY PSYCHOTIC
Do:
• establish if the person is oriented
• listen to the person
• acknowledge that the person may be feeling frightened/scared/upset/angry/
confused
• speak slowly, calmly and clearly
• acknowledge that what is happening is real to the person (i.e. don’t try to talk
them out of it or deny it is real, which is likely to make things worse)
• try to find some common ground through chatting
• say ‘I know the voices are real to you’
• try to establish how much insight the person has (i.e. awareness of their
illness)
• say you are trying to understand what is happening for them
• acknowledge how they are feeling (e.g. ‘Those thoughts must be frightening to
you’).
Don’t:
• argue with the person or disagree with their reality
• tell them that they are sick/mad/loony
• make glib remarks (e.g. ‘You’ll be right’)
• tell them to pull themselves together
• express frustration.
• sweating
• trembling or shaking
• urge to escape.
Panic attacks are frightening, but fortunately they are physically
harmless episodes. They can occur at random or after a person is
exposed to various events that may bring on an attack. They peak in
intensity very rapidly and go away with or without medical help. People
experiencing panic attacks may fear they are dying, that they are
suffocating or that they are having a heart attack. They may voice fears
that they are ‘going crazy’ and seek to remove themselves from whatever
situation they are in.
Some people may begin breathing very rapidly and complain that their
heart is ‘jumping around in their chest’. Then, within about an hour, the
symptoms fade away.
About 5% of the population will experience panic attacks during their
lifetime. People who have repeated attacks require further evaluation from
a mental health professional. Panic attacks can indicate the presence of
depression, panic disorder or other forms of anxiety-based illnesses.
If you are not sure whether the person is having a panic attack or a
heart attack, call an ambulance and apply first aid—airway, breathing,
circulation—until help arrives.
Box 7.7 lists the dos and don’ts if the person is having a panic
attack.
BOX 7.7
DOS AND DON’TS IF A PERSON IS HAVING A PANIC ATTACK
Do:
• take some deep breaths yourself and remain calm and in an open posture
• encourage the person to take slow, deep breaths
• remind the person that the attack will pass and cannot harm them
• acknowledge their acute distress
• try to remove the person to a quiet place with some privacy
• stay with the person until they calm down.
Don’t:
• rush the person in any way
• express frustration
• tell the person they are being ridiculous
• give orders
• tell the person to snap out of it or calm down (they can’t)
• encourage the person to face their fears (this is not the right time).
WHAT TO DO IF THE PERSON IS INTOXICATED

WITH DRUGS OR ALCOHOL
Box 7.8 lists the dos and don’ts if a person is intoxicated.
BOX 7.8
DOS AND DON’TS IF A PERSON IS INTOXICATED
Do:
• talk in a slow, clear and simple manner
• summon help immediately
• observe the person closely
• maintain the person’s airway and breathing
• maintain the physical safety of the person and those around them
• conduct a full physical examination, including a urine screen
• assess the level of use in the past month, including the type of drug, volume,
frequency and route of administration (oral, intramuscular, intravenous)
• observe closely and document for signs of withdrawal such as tremor, sweating
of hands and face, insomnia, fatigue, anxiety, irritability and physical cramps.
Don’t:
• attempt to engage in lengthy discussions while the person is intoxicated
• invade their personal space.
Note: Acute withdrawal requires hospital care due to the risk of seizures and
severity of withdrawal symptoms.
About Methamphetamine Intoxication

People intoxicated with methamphetamine can be unpredictable in their
behaviour—often highly agitated or distressed—and you must assume
that they are a serious safety risk to themselves and others including
pre-hospital personnel. They may be significantly impaired cognitively and
be unable to take direction. Involvement of the police and ambulance
services is advised.
About Alcohol Withdrawal

Withdrawal usually occurs within 24 hours of the last drink. Symptoms
can include tremor (‘the shakes’), increased blood pressure,
sleeplessness, anxiety and loss of appetite.
About 15% of chronic alcohol users will experience seizures within a
couple of days of abstinence.
A small percentage of people experience delirium tremens 3 to 10 days
after their last drink. This is characterised by agitation, disorientation,
visual hallucinations (often spiders or insects), fever and paranoia, and
requires hospitalisation.
CONCLUSION
Behaviours of concern can involve any situation where a person is highly
distressed. It will take time and education to learn how to manage such
situations effectively. Appearing calm, interested and confident is the best
first impression to give to a person in distress. Remember always to seek
assistance from others if you are unsure what to do.
References
Bowers, L. (2014). A model of de-escalation. Mental Health Practice, 17(9), 36–37.
Cleary, M., & Raeburn, T. (2017). Personality disorders. In K. Evans, D. Nizette, & A. O’Brien
(Eds.), Psychiatric and mental health nursing (4th ed.). Sydney: Elsevier.
Hart, C. (2014). A pocket guide to risk assessment and management in mental health. Oxon:
Routledge.
Web Resources
Bowers’ de-escalation model. http://www.safewards.net/images/pdf/Talk%20Down%20
poster_print%20out.pdf. A poster of ‘talk down’ tips for people in crisis.
Mindframe, Suicide. http://www.mindframe-media.info/for-media/reporting-suicide/facts-and-stats.
Facts and statistics about suicide in Australia.
National Education Alliance of Borderline Personality Disorder Australia (NEA.BPDAust).
www.bpdaustralia.com. This website provides the lastest research and information from around
the globe about borderline personality disorder.
Sane Australia BPD. https://www.sane.org/mental-health-and-illness/facts-and-guides/borderline
-personality-disorder?gclid=CNK0ovP1_9MCFUpWvQodXaEEog. Information about borderline
personality disorder including facts, myths, symptoms and how to get help.
Chapter 8
Mental Health Talking-
Based Therapies
INTRODUCTION
A range of therapeutic interventions can be delivered through the
interpersonal relationship between a mental health professional or health
worker and the person with the lived experience. This ‘therapeutic
relationship’ is based on communication and relies on the skills, values
and knowledge of the mental health professional. Chapter 3 outlines some
of the prerequisite tools and resources needed to build the therapeutic
relationship in order to provide therapeutic interventions. Talking therapies
(counselling) delivered through a therapeutic relationship can reduce
distress in people, increase a person’s sense of wellbeing and enable the
development of more-effective coping skills and problem solving.
ESSENTIAL SKILLS IN THE THERAPEUTIC RELATIONSHIP

Basic skills of communication are fundamental to the therapeutic
relationship. Listening and knowing how to listen attentively (active
listening) sends the message to the person that you are hearing them and
acknowledging/accepting what they are saying. This technique builds
empathy and increases understanding.
Open communication, problem identification and goal setting are also
important. Problem solving can progress from this basic skill.
Communication skills are vital in providing counselling and specific
counselling therapies. Counselling and therapies can be undertaken with
individuals or in groups and generally involve:
• talking, which is the vehicle to help a person to understand themselves
better and/or to change unwanted or unhelpful thoughts or behaviours
• specific time set aside to talk in a comfortable, quiet place
• other techniques to help people to overcome stress, emotional
problems, relationship problems or troublesome habits (e.g. excessive
worrying or excessive anxiety) and gain insight.
CONTEXTS FOR THERAPEUTIC INTERVENTION

While the therapeutic relationship and communication are essential for all
mental health care (including assessment and monitoring mental state),
their importance and effect is paramount in a range of specific
interventions:
• crisis intervention
• stress management
• sensory modulation
80
Chapter 8 Mental Health Talking-Based Therapies 81
• relaxation education
• psychoeducation
• assertiveness training
• psychotherapy, individual and group therapy.
PSYCHOTHERAPIES
Psychodynamic Psychotherapy
Psychodynamic psychotherapy:
• focuses on the feelings we have about people with whom we are close
(i.e. family and friends)
• involves discussing past experiences and how these may have led to
our present situation
• involves new understandings, which allow the person to gain insights
about how they feel and to make choices about the future.
Psychodynamic psychotherapy can be brief (one or two sessions) and
focus on specific issues, or it can take place over longer periods of time
(months to years in some cases).
Behavioural Psychotherapy
Behavioural psychotherapy focuses on changing patterns of behaviour
that are bothersome to the person (e.g. avoiding certain situations such
as heights, shopping centres or flying). It is often used to change
behaviour in children through the use of star charts and other techniques
to encourage desirable behaviours. People learn to overcome their fears
by spending increasing amounts of time in the situation they fear and by
learning ways of reducing their anxiety (e.g. relaxation and breathing
training). Homework exercises enable new skills to be practised (e.g.
breathing and keeping a diary to record feelings, thoughts and anxiety
levels).
Behavioural psychotherapy is particularly effective for anxiety, panic
attacks, phobias, obsessive-compulsive disorders and various kinds of
social or sexual difficulties. Relief from symptoms often occurs quickly.
COGNITIVE THERAPY
Cognitive therapy focuses on changing thinking patterns. It involves close
attention to the way we think about certain things, particularly focusing on
thinking that affects us in a negative way and causes us to experience
distressing emotions. Cognitive therapy:
• aims to replace unhelpful thoughts and feelings with more realistic and
positive ones
• uses principles from behavioural learning theory and cognitive
psychology
• is present- and future-oriented, and is not concerned as much with
childhood or past experiences
82 Chapter 8 Mental Health Talking-Based Therapies
• is thought to be very helpful with people who are depressed, are

anxious or have personality disorders, and in some cases it is effective
with people with schizophrenia
• is often used in combination with psychoactive medications
• is goal-oriented and time-limited, usually over a couple of months.
Cognitive therapy is mostly used in conjunction with behavioural
therapy (cognitive behaviour therapy—CBT) so that thoughts and
behaviour are congruent.
SOLUTION-FOCUSED THERAPY
Solution-focused therapy was originally designed for brief therapy (i.e. a
few sessions). It is now also used over longer periods to help people to
solve their own problems. Solution-focused therapy:
• focuses on the solution, with little emphasis on the problem
• differs from other approaches such as cognitive therapy in that it
doesn’t assume that a person has faulty thinking
• assumes the person is the expert, that change is inevitable and that
only small changes are required.
What works for the person is a key element, as is building on a
person’s strengths and abilities. Talking focuses on present-oriented and
future-oriented situations and experiences, using questions to develop a
full understanding of the person’s perspective. It has wide applications in
health care settings, from substance abuse and depression to chronic
pain.
ACCEPTANCE AND COMMITMENT THERAPY

Acceptance and commitment therapy is based on the concept of
‘mindfulness’, which is a mental state of full awareness that requires a focus
on ‘being in the moment’. This focus allows the person to calm and ground
themselves. In this state the person is more able to accept their current
situation and commit to an action; this assists the person to have more
control and fulfillment in their life. This therapy is helpful to people with a
wide range of concerns including anxiety, phobias, post-traumatic stress
disorder and abuse histories. There is a range of information and resources
available on the ACT Mindfully website at <www.actmindfully.com.au>.
MOTIVATIONAL INTERVIEWING
This therapy aims to overcome ambivalence that a person may have
about making change in their life. It helps the person explore from their
perspective the good and not so good reasons involved in making a
change. It relies on identifying the person’s readiness to change and then
using supportive and persuasive strategies to help the person clarify their
options and actions in making changes. This therapy is helpful to people
with a wide range of concerns including drug and alcohol misuse,
Chapter 8 Mental Health Talking-Based Therapies 83
excessive smoking and people who are ambivalent about other lifestyle
changes.
DIALECTICAL BEHAVIOUR THERAPY

Originally developed to treat people with borderline personality disorders,
dialectical behaviour therapy has also been found to be very effective in
people who self-harm and in treating mood disorders. Dialectical
behaviour therapy:
• combines aspects of cognitive behaviour therapy with mindfulness and
distress tolerance
• helps people recognise various viewpoints of a situation and to reduce
‘black and white’ (things are either perfect or awful) thinking
• focuses on becoming aware of experiences in a more realistic way and
separating experiences from worries about the past or future
• uses individual sessions and group meetings (up to two hours in length)
to gain self-awareness, improve communication skills and learn how to
reduce emotional distress (Palmer 2017).
FAMILY THERAPY
Family therapy is mostly used in families with children who are having
problems, such as families with young offenders, and for treating
gambling and eating disorders. Family therapy:
• focuses on relationships within families and within relationships
• sees the family or the couple together
• involves talking about issues in an open and honest way to develop new
ways of viewing and solving problems
• usually takes place over a few months, with two therapists attending all
the sessions.
NARRATIVE THERAPY / NARRATIVE PRACTICES

Narrative therapy had its origins in family therapy and is used in situations
where people may have difficulty in expressing themselves. The narrative
approach:
• focuses on a person’s ‘own story’ and how this shapes their lives
• identifies a person’s specific problems and how the problem has
affected them (hence externalising the problem and separating it as
coming from inside the person)
• encourages reflection of a person’s values, hopes and potential
• through dialogue, aims to reauthor a person’s experience.
The role of the counsellor is to facilitate the person examining,
reflecting and changing how they perceive a problem, therefore
encouraging new meanings for that person. This is an evolving modality;
recent focus on the experience of ‘moments’ assists the person to
84 Chapter 8 Mental Health Talking-Based Therapies
understand their feelings and their story in an ‘embodied’ way, which

enables the person to notice a problem and intervene (when they
experience the feeling) (Zimmerman & Beaudoin 2015).
CREATIVE THERAPIES
Other forms of therapy include creative therapies, which involve art,
crafts, music or dance. The group engages creatively and members
express themselves through creative outlets.
CONCLUSION
The impact and effectiveness of talking therapies as an adjunct to drug
therapies (or when indicated as the preferred intervention) cannot be
underestimated; a novice practitioner can be a great support just by
listening and validating the person and their story. Experience and
education in any of these therapies will enable the practitioner to have
increased therapeutic capacity to support people with their recovery.
References
Palmer, C. (2017). Therapeutic interventions. In K. Evans, D. Nizette, & A. O’Brien (Eds.),
Psychiatric and mental health nursing (4th ed.). Sydney: Elsevier.
Zimmerman, J., & Beaudoin, M.-N. (2015). Neurobiology for your narrative: How brain science
can influence narrative work. Journal of Systemic Therapies, 34(2), 59–74.
Web Resources
Acceptance and commitment therapy / mindfulness. www.actmindfully.com.au. This website
provides information about the aims of these therapies and tips for delivering them.
Beck Institute for Cognitive Behavior Therapy. www.beckinstitute.org. The Beck Institute is a
leading international source for training, therapy and resources in CBT. The website offers links
to its newsletter, blog, videos and podcasts.
beyondblue. www.beyondblue.org.au. This website provides information about a range of
anxiety-related and depression-related help, as well as treatment-focused and consumer-focused
resources.
Dulwich Centre. www.dulwichcentre.com. The Dulwich Centre website provides information about
narrative therapy.
Narrative Therapy Centre of Toronto. www.narrativetherapycentre.com. The Narrative Therapy
Centre of Toronto provides online resources for learning about narrative therapy and narrative
collective practice.
New Zealand Guidelines Group. www.tepou.co.nz. This website includes a brief review of recent
literature on the evidence about using cognitive behaviour therapy, dialectical behaviour therapy
and motivational interviewing, as well as cultural issues in therapies and on the therapeutic
alliance.
Chapter 9
Managing Medications
INTRODUCTION
Psychiatric medications are prescribed by health professionals including
psychiatrists, general practitioners and nurse practitioners authorised to
dispense medications to treat symptoms of mental illness. This chapter
describes general management issues for health professionals, issues
concerned with concordance (compliance/adherence) with medication
regimens, commonly used medications to treat these symptoms and
associated side effects; it also outlines the difficulties facing people
required to take these medicines for long periods of time. The information
contained in this chapter will also be useful in advising carers about the
responsibilities they may have regarding medications for a person in their
care. See Appendix 3 for a list of commonly used prescription
abbreviations.
Recently, the effectiveness of psychiatric medications—in particular,
antidepressants—has been challenged. However, antidepressants remain
a useful treatment for the majority of people with moderate and severe
depression though are not without side effects.
CATEGORIES OF MEDICATION
There are four essential pharmacological categories of medication used to
treat mental illness:
• anxiolytics (antianxiety drugs)
• antidepressants
• antipsychotics
• mood stabilisers.
Medications can have two names—the generic name (i.e. the active
compound of the drug) and the trade name (i.e. the registered brand
name given by a particular drug company). For example, diazepam is the
name of the actual drug, but Valium is a brand name for this drug. In
Australia, generic-named medications are often cheaper than their
brand-name counterparts. In this chapter, the generic name is listed first,
with the brand name in parentheses.
Anxiolytics
Anxiolytics are used primarily in emergency and mental health settings for
relieving acute panic and anxiety, insomnia, obsessive-compulsive
disorder and alcohol withdrawal. Diazepam is the most well known
anxiolytic and belongs to the benzodiazepine family. These drugs are
often colloquially referred to as ‘benzos’. They act by enhancing the
effects of GABA (gamma-aminobutyric acid), a neurotransmitter in the
85
86 Chapter 9 Managing Medications
BOX 9.1
SIDE EFFECTS OF ANXIOLYTICS
Side effects include:
• drug dependency (i.e. being unable to stop taking the drug)
• impaired memory and concentration
• sedation
• feelings of being ‘cut off’ from one’s own feelings
• low mood
• poor motor coordination
• mood swings, irritability and anger.
central nervous system. Diazepam is a very useful drug because it has

muscle-relaxant effects, stops seizures, reduces anxiety and promotes
calm. Other commonly used anxiolytics include:
• alprazolam (Xanax)
• temazepam (Normison)
• nitrazepam (Mogadon)
• oxazepam (Serepax)
• bromazepam (Lexotan)
• clonazepam (Rivotril)
• flunitrazepam (Rohypnol)
• lorazepam (Ativan)
• triazolam (Halcion).
In small doses, these drugs have a calming and slowing-down effect; in
high doses, they are sedating. Side effects are common and include
headache, nausea, hypotension (low blood pressure) and unsteadiness.
People taking anxiolytics are encouraged to take care when driving or
operating machinery. Anxiolytics may also be used to treat acute
psychosis in psychiatric wards as an adjunct to antipsychotics. Anxiolytics
are sometimes used in the acute phase of delirium as well.
In the short term these drugs relieve anxiety and insomnia but should
only be prescribed for two to three weeks because of the risk of
dependency. Further, higher doses are required over time to achieve an
equivalent initial therapeutic effect. Abrupt discontinuation can result in
increased anxiety, sleep disturbance, irritability, increased anxiety, hand
tremor, sweating, concentration problems, aching limbs and nausea,
which can be very unpleasant. Withdrawal from long-term use requires
medical supervision and should be gradual to avoid difficult withdrawal
symptoms. The serious side effects listed in Box 9.1 are often seen in
people taking benzodiazepines for long periods of time. Often people have
started these drugs without having been prescribed them by a health
professional.
Chapter 9 Managing Medications 87
Drug Interactions
Benzodiazepines can be dangerous when combined with other drugs
such as alcohol or methadone. These can potentiate the respiratory
depressant effect of benzodiazepines, which sometimes results in
vomiting, respiratory obstruction and death.
Antidepressants
Antidepressants are used to relieve depressive symptoms including
suicidal thoughts and feelings. They are also prescribed to treat anxiety,
panic disorder and obsessive-compulsive disorder. There is an array of
antidepressants available today in four main groups:
• selective serotonin reuptake inhibitors (SSRIs)
• serotonin and noradrenaline reuptake inhibitors (SNRIs)
• tricyclics—an older group and less commonly prescribed today
• monoamine oxidase inhibitors (MAOIs)—an older group, uncommonly
prescribed to new patients.
Antidepressants are prescribed for the following conditions:
• moderate to severe depression
• severe anxiety and panic attacks
• the depressed phase of a bipolar episode
• obsessive-compulsive disorders
• chronic pain
• eating disorders
• post-traumatic stress disorder.
Antidepressants are not necessary for people experiencing a mild
depression or a normal grief reaction after the death of a loved one. Such
experiences are understood to be within the normal range of behaviour
given a major loss. However, if depression persists beyond a four- to
six-month period, assessment and treatment is advised. Commonly used
antidepressant medications are listed in Table 9.1.
Selective Serotonin Reuptake Inhibitors
SSRIs are believed to work by preventing the reuptake of serotonin
(5-hydroxytryptamine or ‘5-HT’) in the central nervous system. Side
TABLE 9.1
COMMONLY USED ANTIDEPRESSANT MEDICATIONS
Generic Name Brand Name Group
Fluoxetine Prozac SSRI
Paroxetine Aropax SSRI
Venlafaxine Efexor SNRI
Reboxetine Edronax SNRI
Amitriptyline Endep Tricyclic
BOX 9.2
SEROTONIN SYNDROME
Serotonin syndrome, a potentially life-threatening emergency resulting from
excessive serotonin activity, can result from other antidepressants being
combined with SSRIs (e.g. MAOIs) or being administered while the person is
taking St John’s wort. Overdose of a single antidepressant can also cause this
syndrome. Serotonin syndrome can lead to hyperthermia (overheating), kidney
failure and death if left untreated. Emergency interventions include ceasing
administration of SSRIs and administering anticonvulsants and clonazepam to
reduce agitation and induce calm. Taking amphetamines such as MDMA
(‘ecstasy’) while also taking SSRIs can result in serotonin syndrome. Symptoms
of serotonin syndrome are:
• confusion
• mania
• agitation, restlessness
• sweating
• an urgent need to urinate and frequently
• tremor
• nausea
• diarrhoea
• headache.
effects of SSRIs include nausea, diarrhoea, agitation and headaches.

Serotonin syndrome is a potentially life-threatening emergency resulting
from excessive serotonin activity (see Box 9.2).
Serotonin and Noradrenaline Reuptake Inhibitors
SNRIs are a relatively new form of antidepressant that work on both
noradrenaline and 5-HT neurotransmitters. They typically have similar
side effects to SSRIs and may require a slow reduction in dosage before
the drug is ceased to prevent a withdrawal syndrome.
Sexual side effects, such as loss of libido, failure to reach orgasm and
erectile dysfunction, are also common.
ANTIDEPRESSANT DISCONTINUATION SYNDROME. If people stop taking

antidepressants abruptly a range of distressing and bothersome,
but non-life-threatening, symptoms may be experienced. The following
medications appear to be associated with this syndrome: citalopram
(Celexa), escitalopram (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox),
paroxetine (Aropax) and sertraline (Zoloft).
Symptoms may include a flu-like reaction, as well as a variety of
physical symptoms—headache, gastrointestinal distress, faintness and
strange sensations of vision or touch. Sometimes people also experience
anxiety and depression, which makes it hard to differentiate whether a
person is becoming ill again or has discontinuation symptoms. It is very
important to explain to people considering reducing or coming off their
BOX 9.3
SIGNS OF TRICYCLIC OVERDOSE
Signs include:
• agitation
• confusion
• drowsiness
• bowel and bladder paralysis
• dysregulation of body temperature and blood pressure
• dilated pupils.
Source: Elder et al 2011
medication that they need the support of their medical and nursing staff
in tailoring a reduction slowly, over time. Discontinuation symptoms can
also be experienced when reducing or ceasing SNRIs.
Tricyclics
Tricyclic antidepressants are the oldest group of medications, and
their mode of action is thought to be due to their blockade of the
reuptake of the neurotransmitters noradrenaline and serotonin in the
central nervous system. More-recent drugs are more selective in
blocking specific neurotransmitters, have fewer side effects and are less
risky if a person were to overdose, and so are more likely to be used as
a first choice of antidepressant. However, tricyclics remain the drug of
choice for some people, especially those who have responded well to
them, who have a serious depressive illness and who experience few
bothersome side effects. Side effects include increased heart rate,
drowsiness, dry mouth, constipation, urinary retention, blurred vision,
dizziness, seizures and confusion. Tricyclics are toxic so can be lethal
in overdose. Tricyclic toxicity is a medical emergency and requires
immediate medical intervention. Box 9.3 lists the major signs of tricyclic
overdose.
Mirtazapine is a commonly used tetracylic antidepressant with common
and unwanted side effects including weight gain and increased appetite.
Monoamine Oxidase Inhibitors
MAOIs are rarely prescribed today because they induce life-threatening
high blood pressure if foods containing tyramine (e.g. aged cheeses, red
wine, broad beans) are eaten when taking an MAOI, although some
newer MAOIs do not require a special diet—for example, moclobemide
(Aurorix). MAOIs may be used as a last resort if no other medications
have been useful. Their mode of action is by blocking the enzyme
monoamine oxidase, which breaks down the neurotransmitters dopamine,
serotonin and noradrenaline. Health professionals are more likely to
encounter older people who are taking tricyclics and MAOIs because they
have been effective for them in the past or they have been taking them
TABLE 9.2
FIRST-GENERATION AND SECOND-GENERATION ANTIPSYCHOTICS
Generic Name Brand Name
Typical or first-generation antipsychotics Chlorpromazine Largactil
(less frequently used now) Haloperidol Serenace
Trifluoperazine Stelazine
Atypical or second-generation Aripiprazole Abilify
antipsychotics (first choice drugs) Amisulpride Solian
Clozapine Clozaril
Olanzapine Zyprexa
Quetiapine Seroquel
Risperidone Risperdal
for a long time. Side effects include dry mouth, sedation, constipation,
hypotension, seizures and urinary retention.
Antipsychotics
Antipsychotics are prescribed for treating schizophrenia in the acute and
maintenance stages. They are also prescribed to treat mood disorders
where psychosis is present and for mania in bipolar disorder Over the
past 15 years new antipsychotics (the atypicals or second-generation
antipsychotics) have been introduced; these have equal efficacy to the
traditional antipsychotics (typical or first-generation antipsychotics), yet
they have fewer but different side effects. Table 9.2 lists antipsychotics.
How Antipsychotics Work
Antipsychotics reduce or eliminate delusions, hallucinations, abnormal
mood and thought disorders. They also reduce the likelihood of further
episodes of psychosis. Their mode of action is blockage of dopamine and
5-HT2A receptors within the central nervous system. However, because
these drugs work on other dopaminergic pathways in the brain, a range of
unpleasant motor (movement) side effects can be experienced, known as
extrapyramidal side effects (EPSEs) (see Table 9.3, overleaf). Health
professionals including general practitioners, nurses, paramedics and
physiotherapists are well placed to assess for abnormal movement
disorders and to implement appropriate management strategies. A recent
study found that the most commonly reported side effect of psychotropics
was sedation (77%), and weight gain was ranked as the most bothersome
(23%) (Ashoorian et al 2015). Sexual dysfunction is also common and
needs to be discussed before beginning treatment. When a person starts
taking antipsychotics, health professionals have a responsibility to provide
education, monitoring and ongoing support about weight gain and how to
reduce it. Health professionals ought to partner the person with a
physiotherapist, exercise physiologist and dietician to facilitate effective
weight management.
TABLE 9.3
EXTRAPYRAMIDAL SIDE EFFECTS OF ANTIPSYCHOTICS
Extrapyramidal Prevalence (With Time It Takes to
Side Effect Signs and Symptoms Older Drugs) Develop Treatment
Dystonia Muscular spasm in any part of the body such Approximately 10%, but Acute dystonia can occur Anticholinergic drugs given orally,
as eyes rolling upwards (oculogyric crisis) more common in young within hours of starting intramuscularly or intravenously
Head and neck twisted (torticollis) males, in the antipsychotics (minutes depending on the severity of
In extreme cases, the back may arch or the neuroleptic-naïve and for intramuscular or symptoms (remember the person
jaw may dislocate with high-potency intravenous use) may be unable to swallow)
Acute dystonia can be both painful and drugs (e.g. haloperidol) Tardive dystonia occurs Response to intravenous
frightening Dystonic reactions are after months to years of administration will be seen in
Person may need assistance breathing rare in the elderly antipsychotic treatment five minutes
Response to intramuscular
administration takes around 20
minutes
Parkinsonism Tremor and/or rigidity Approximately 20%, but Days to weeks after Several options are available
Bradykinesia (decreased facial expression, more common in antipsychotic drugs are depending on the clinical
flat monotone voice, slow body elderly females and started or the dose is circumstances: reduce the
movements, inability to initiate movement) those with pre-existing increased antipsychotic dose; change to
Bradyphrenia (slowed thinking) neurological damage an atypical drug; or prescribe
Salivation (e.g. head injury, an anticholinergic medication
Parkinsonism can be mistaken for depression stroke)
or the negative symptoms of schizophrenia
Continued on following page

TABLE 9.3
EXTRAPYRAMIDAL SIDE EFFECTS OF ANTIPSYCHOTICS (Continued)
Extrapyramidal Prevalence (With Time It Takes to
Side Effect Signs and Symptoms Older Drugs) Develop Treatment
Akathisia A subjectively unpleasant state of inner Approximately 25% Acute akathisia occurs Reduce antipsychotic dose
restlessness where there is a strong desire within hours to weeks of Change to an atypical
or compulsion to move starting antipsychotics antipsychotic
Foot tapping when seated or increasing the dose Low-dose benzodiazepine
Constantly crossing/uncrossing legs Tardive akathisia takes
Rocking from foot to foot longer to develop and
Constantly pacing up and down can persist after
Akathisia can be mistaken for psychotic antipsychotics are
agitation and has been linked with suicide withdrawn
and aggression towards others

Sometimes mistaken for anxiety
Tardive dyskinesia A wide range of movements can occur such 5% of people per year of Months to years Stop anticholinergic if prescribed
as lip smacking or chewing, tongue antipsychotic exposure Approximately 50% of Reduce dose of antipsychotic
protrusion, choreiform movements (pill More common in elderly cases are reversible Change to atypical drug
rolling or piano playing) and pelvic women, those with Clozapine is the most likely drug to
thrusting affective illness and be associated with resolution of
Severe orofacial movements can lead to those who have had symptoms
difficulty speaking, eating or breathing acute EPSEs early on Other drugs such as valproate and
Movements are worse under stress in treatment clonazepam may be prescribed,
but evidence is poor
Source: Usher 2017
Anticholinergic Drugs
These drugs are specifically used to reduce the distressing and unwanted
motor side effects of antipsychotic medication. They block the
neurotransmitter acetylcholine at the muscarinic receptor site. However,
they also have side effects that include dry mouth, constipation and
dizziness. Anticholinergic drugs include benzhexol (Artane) and
benztropine (Cogentin).
Table 9.4 lists other side effects of antipsychotics, with associated
management strategies.
Atypical antipsychotics also have serious side effects including weight
gain, diabetes and metabolic syndrome (clozapine, olanzapine,
risperidone). Metabolic syndrome is a cluster of risk factors, for insulin
resistance, obesity and hyperlipidaemia and is discussed in more detail in
Chapter 11. Weight gain is caused by side effects that cause craving and
never feeling full after eating. Sexual dysfunction is common in people
taking antipsychotics. A change of medication may alleviate this side
effect. Other interventions may include drug holidays and psychological
interventions but have mixed unconfirmed results (Bella & Shamloul
2013).
Clozapine is used to treat symptoms of schizophrenia when other
antipsychotics have not alleviated symptoms. A serious side effect of
clozapine is agranulocytosis (affects 1–2% of people). Regular blood
screening is required—weekly for 18 weeks and monthly thereafter. Other
serious risks include seizures, heart inflammation and high blood sugar
levels. It should not be used in people with dementia. Clozapine interacts
with many other drugs (see Box 9.4). Careful monitoring of clozapine is
TABLE 9.4
MANAGEMENT OF OTHER SIDE EFFECTS OF ANTIPSYCHOTICS
Side Effect Management Strategy
Increased appetite, Get regular exercise, avoid sweet or fatty foods, eat a high-fibre diet,
weight gain drink low-calorie drinks
Nausea Take medication with food or before going to bed
Constipation Increase fluid intake, eat a high-fibre diet (more fruit and
vegetables), take fibre supplements
Postural hypotension Get up slowly from lying or sitting, avoid very hot showers or baths,
drink adequate fluids, avoid caffeinated drinks, avoid alcohol and
marijuana
Drowsiness Take a divided dose or a single dose before going to bed
Dry mouth Ensure regular fluid intake, suck on ice cubes, avoid sweet drinks,
use sugarless gum or lollies, use antiseptic gargles or brush teeth
regularly (to limit tooth decay), limit alcohol or caffeine (both
cause dehydration), use artificial saliva (available from a chemist)
Sensitivity to sunburn Avoid direct sunlight, wear a hat and long sleeves, use sunscreen
Source: Usher et al 2009
BOX 9.4
INTERACTIONS BETWEEN CLOZAPINE AND OTHER DRUGS
POTENTIAL TO INCREASE CLOZAPINE LEVELS
• SSRIs, for example:
• fluvoxamine (very large effect)
• sertraline (large doses)
• Ciprofloxacin
• Cimetidine
• Some macrolide antibiotics, for example:
• erythromycin
• clarithromycin
• Caffeine (large doses)
POTENTIAL TO DECREASE CLOZAPINE LEVELS
• Carbamazepine
• Rifampicin
• St John’s wort
• Omeprazole
• Phenytoin
POTENTIAL TO DEPRESS BONE MARROW
• Carbamazepine
• Trimethoprim/sulfamethoxazole
• Nitrofurantoin
• Cytotoxic and immunosuppressant medication
POTENTIAL TO DEPRESS RESPIRATION
• Benzodiazepines
POTENTIAL FOR ANTICHOLINERGIC SIDE EFFECTS
(CONSTIPATION, URINARY RETENTION, DELIRIUM)
• Anticholinergic tricyclic antidepressants, for example:
• amitriptyline
• Anticholinergic antipsychotics, for example:
• chlorpromazine
• pericyazine
• EPSE medication, for example:
• benzhexol
• benztropine
• Sedating antihistamines, for example:
• diphenhydramine
• cyproheptadine
• promethazine
• Gastrointestinal antispasmodics, for example:
• atropine
• hyoscine
BOX 9.4
INTERACTIONS BETWEEN CLOZAPINE AND OTHER DRUGS (Continued)
POTENTIAL FOR HYPOTENSION
• Antihypertensives
• Tricyclic antidepressants
• Some antipsychotics, for example:
• chlorpromazine
• pericyazine
POTENTIAL FOR CHANGES DUE TO SMOKING
• Starting or stopping smoking can cause dramatic changes in clozapine blood
levels
Source: SA Health 2017
required as serious side effects can occur if a person suddenly stops

medication or starts after a period of not taking clozapine.
Neuroleptic Malignant Syndrome
This is a condition where the person develops stiffness and fever, usually
after beginning antispychotics. It requires immediate medical attention,
hospital observation and maintenance of adequate hydration.
Depot Antipsychotic Medication

Depot medication is a long-term (two to four weeks) medication that is
given to those who are unwilling or unable to maintain a daily regimen of
taking medication orally. Depot medication is administered by deep
intramuscular injection into the ventrogluteal area using a Z-track
technique according to the manufacturer’s recommendations (Coskun
et al 2016). The injection site needs to be rotated to avoid long-term
damage to the area (Yilmaz et al 2016). Those coming off depot
medication need to be monitored closely because the effects of
discontinuation will be delayed. Common depot medications include:
• flupenthixol decanoate (Depixol)
• fluphenazine decanoate (Modecate)
• zuclopenthixol decanoate (Clopixol)
• risperidone (Risperdal).
PRN Medication
PRN (‘as needed’) medication is used as an adjunct to medication
treatment in managing acutely unwell people when they are agitated or
distressed due to the severity of their symptoms. PRN medication should
only be given after alternative interventions such as helping the person
with self-soothing strategies have been tried. Common reasons for
administering PRN medication include irritability, self-harming behaviour,
distressed mood, agitation, threatening behaviour, insomnia and at the
person’s request. Commonly administered medications in this form are
BOX 9.5
PRINCIPLES OF GOOD PRACTICE: PRN
• Remain focused on the needs of the person.
• Include PRN as part of the clinical management plan.
• Review prescriptions regularly.
• Keep rigorous documentation about the reasons for and effects of PRN.
• Train all staff in the use of PRN.
• Use PRN as a last resort.
Adapted from Baker 2016
antipsychotics (haloperidol or olanzapine), benzodiazepines (lorazepam)

and sleeping tablets (zopiclone) to calm the person emotionally and to
settle behaviour. PRN medication can be given orally or by intramuscular
injection. Users need to be monitored for mental and physical status
when PRN medication is administered. There is no clear theoretical basis
for administering PRN medication, and care should be person-centred
and with the person’s involvement. Principles of good practice for using
PRN are listed in Box 9.5.
Pharmacological Management of Crystalline

Methamphetamine (Ice) Intoxication
Acute methamphetamine psychosis is one of the most damaging
consequences of amphetamine use. It is a major safety issue for the
person, their family and health care staff. Acute behavioural disturbance
due to amphetamine stimulant intoxication is managed through
pharmacological intervention to reduce the person’s level of arousal and
potential for aggression and violence. At mild arousal levels oral
benzodiazepine diazepam 5–20 mg is indicated or olanzapine 5–10 mg
orally. Review after 30 minutes and repeat oral administration if
ineffective. Higher levels of arousal where the person is hostile and
distressed or paranoid can indicate oral olanzapine 10–20 mg wafer plus
diazepam 5–20 mg orally with the potential to be repeated. If the person
is refusing oral medication, and is hostile and aggressive, then administer
olanzapine 10 mg intramuscularly or droperidol 2.5–10 mg. Concurrent
clonazepam 1–2 mg intramuscularly (separate syringe) or midazolam
0.1 mg/kg body weight can be administered if rapid sedation is required.
Physical monitoring of blood pressure, respiratory function, heart rhythm
(by ECG) and EPSE is vital.
Health professionals should follow their own hospital or health service
policy when managing people intoxicated with crystal methamphetamine.
MOOD STABILISERS
Mood stabilisers are the medications prescribed to maintain a balanced
mood for people with intense or shifting moods. Lithium (carbonate),
a naturally occurring salt, is used in treating acute mania and for the
ongoing maintenance of those with a history of mania, as is sodium
BOX 9.6
SIDE EFFECTS OF MOOD STABILISERS
Common side effects include:
• sleepiness
• dizziness
• a metallic taste in the mouth
• increased appetite and weight gain
• a feeling of sickness, nausea
• skin rashes
• changes in blood count
• irregular menstrual periods in females.
Very rare side effects include:
• pancreatitis (less than one in 10,000 cases)
• abdominal pain, nausea and vomiting
• liver failure (less than one in 50,000 cases)
• weakness, loss of appetite, lethargy and drowsiness.
valproate. Just how lithium works is not clear, but it is known to mimic
the effect of sodium, thereby compromising the ability of neurons to
release, activate or respond to neurotransmitters. Some of the
anticonvulsants, such as sodium valproate (Epilim), carbamazepine
(Tegretol) and lamotrigine (Lamictal), are also commonly used as mood
stabilisers, particularly in bipolar disorder.
Box 9.6 lists common side effects of mood stabilisers.
The therapeutic range for lithium is 0.6–1.2 mmol/L for acute mania
and 0.6–0.8 mmol/L for maintenance, but more conservative levels are
increasingly being used. Symptoms of lithium toxicity rarely appear at
levels below 1.2 mmol/L but are common above 2.0 mmol/L. Therefore,
as the therapeutic and toxic levels are so close, extreme care must be
taken in monitoring the person’s blood level regularly, especially during
the early phases of treatment. If the level exceeds 1.5 mmol/L, the next
dose should be withheld and a doctor notified. Levels are usually
monitored weekly until stable, and then monthly.
Box 9.7 lists signs of lithium toxicity. Lithium toxicity is a medical
emergency and requires immediate medical intervention (i.e. call an
ambulance). It is important to educate about the side effects and signs of
toxicity. Users must be informed of the need for regular blood-level
testing. Also encourage users to drink about 10 glasses of water every
day, and ensure they know to take their medication regularly, even when
they are feeling well, and that machinery should not be operated until the
initial drowsiness subsides. If relevant, also discuss the risks of taking
lithium during pregnancy.
Anticonvulsants
A number of anticonvulsant drugs have also been used to treat mania,
especially when lithium is ineffective. These drugs are now rapidly
BOX 9.7
SIGNS OF LITHIUM TOXICITY
Signs of lithium toxicity in the early stages include:
• anorexia
• nausea
• vomiting
• diarrhoea
• coarse hand tremor
• twitching
• lethargy
• slurred speech
• hyperactive deep tendon reflexes
• ataxia
• tinnitus
• vertigo
• weakness
• drowsiness.
Signs of lithium toxicity in the later stages include:
• fever
• decreased urinary output
• decreased blood pressure
• irregular pulse
• electrocardiograph changes
• impaired consciousness, seizures and coma.
Lithium toxicity can be a life-threatening event.
BOX 9.8
SIDE EFFECTS OF ANTICONVULSANTS
Side effects include:
• carbamazepine: blood dyscrasias, drowsiness, nausea, vomiting, constipation
or diarrhoea, hives or skin rashes and hepatitis
• valproate: prolonged bleeding time, gastrointestinal tract upset, tremor, ataxia,
somnolence, dizziness and hepatic failure
• topiramate: cognitive impairment, sedation, nausea, weight loss, dizziness,
vomiting, rash, agitation and paraesthesias.
becoming the drug of choice for many people. Carbamazepine, valproate

and topiramate are examples of commonly used anticonvulsants. These
drugs have been found to have acute antimanic and mood-stabilising
effects. They are not, however, antidepressants. Box 9.8 lists side effects
of anticonvulsants.
DRUGS USED TO MANAGE DEMENTIA

There are different medications and treatment regimens for dementia.
Medications cannot halt the progress of dementia but merely slow its
progression. The main types of cholinesterase inhibitor that can be

used are:
• donepezil (Aricept)
• rivastigmine (Exelon)
• galantamine (Reminyl).
Other drugs include memantine (Namenda) and risperidone
(Risperdal). These medications are prescribed to treat symptoms related
to memory, language, judgment and thinking, but there is no cure.
Cardiac conditions can be worsened by these drugs, so regular heart
monitoring is required. Memantine can improve mental function and the
ability to perform daily activities for some people and is used in moderate
to severe stages of dementia. Risperidone is useful in managing agitation
and behavioural disturbances in people with dementia. A range of
non-pharmacological interventions can support the person with dementia
and their family to reduce symptoms and improve quality of life. These
include behavioural, environmental and psychological strategies.
TOOLS FOR ASSESSING SIDE EFFECTS OF MEDICATIONS

Assessment tools include:
• the LUNSERS (Liverpool University Neuroleptic Side Effect Rating
Scale) (Morrison et al 2001)
• the AIMS (Abnormal Involuntary Movements Scale), which is a widely
used tool for use with people on long-term antipsychotic medications
and is designed to assess for signs of tardive dyskinesia (see <http://
www.cqaimh.org/pdf/tool_aims.pdf>).
GENERAL MANAGEMENT ISSUES

Taking medicines every day for more than a few days is difficult for most
people to do. People with a mental illness, however, are no more likely
not to take their medications than the general public. People with chronic
illnesses such as diabetes and hypertension (high blood pressure) also
have difficulty in taking medications regularly but face dire health
consequences when they stop taking, or forget to take, their regular
doses. Tips to assist those taking psychiatric medications are listed in
Appendix 4.
Medication concordance, or medication compliance, refers to a person
adhering to a specified regimen of taking medication. Maintaining
adequate levels of medication through regular tablet taking is essential for
people with a serious mental illness such as schizophrenia. Medication
nonconcordance is one of the most common reasons for recurrence of
psychotic symptoms and readmission to hospital.
There are many reasons why people discontinue psychiatric
medications or refuse to take them. For example, a person may:
BOX 9.9
ASSESSMENT OF MEDICATION MANAGEMENT
Questions to ask the person directly include:
• What type of medication are you on?
• What is the dose?
• How often is the medication supposed to be taken?
• When do you take it?
• What does it do?
• What side effects are there?
• Do you alter the doses or do you follow the prescription exactly?
• Are you on any over-the-counter (OTC) medications? (Note that some OTC
medications such as St John’s wort and cough and cold medicines cannot be
taken when a person is on psychiatric medication.)
Observe the person for their ability to:
• read the directions on the medicine container
• see the pills
• discriminate between pills of a different colour
• handle the pills
• count out the pills or measure liquids
• remember the regimen.
• not think they are ill

• forget to take their medication
• believe they are better and do not need their medication anymore
• mistrust health professionals
• experience or have experienced uncomfortable, disabling or frightening
side effects
• think the medication has not worked quickly enough
• not have the money to buy medication, run out of or lose their
medication or have their medication stolen
• have friends and family telling them they do not need medication
• be ashamed of having an illness and don’t want to be seen as weak
• be homeless and have difficulty storing or establishing a routine to
remember to take their medication
• sell their medication on the street to make money.
Each of the above reasons is real and logical to the person involved,
and such feelings need to be taken seriously and talked through. Making
negative judgments about people taking or not taking psychiatric
medications raises barriers between health professionals and those with
whom they work. Box 9.9 lists questions that the person can be asked
when assessing medication management, and Box 9.10 (overleaf) lists
strategies for medication concordance.
BOX 9.10
STRATEGIES TO ENCOURAGE MEDICATION CONCORDANCE
• Spend time establishing how the person feels about medications and their
illness.
• Tailor the medication regimen to the person’s schedule.
• Educate the person about self-monitoring of symptoms and side effects of the
medication.
• Give the person a medication container (dosette) and show them how to
use it.
• Establish regular contact with the person.
• Establish what factors would motivate concordance (e.g. being able to work,
engage in community activities, socialise).
• Examine what factors inhibit taking medication (e.g. uncomfortable side effects
such as nausea, visible side effects such as tremor of the hands).
• Encourage the person to have regular contact with their general practitioner for
health checkups and the mental health treating team for monitoring.
• Provide information about individual-oriented and recovery-oriented groups
and associations for the person to access.
• Provide education in verbal and written form to the person in small amounts
and frequently.
• Encourage the person to ask questions and request more information.
• Provide information to the person’s family, carers and friends about
medications and side effects, and about the importance of medications in
maintaining wellness.
SPECIAL POPULATIONS
Pregnancy and Breastfeeding
The major period for teratogenic (drug-induced and abnormal) effects in
an unborn child is the first eight weeks of gestation. Difficult ethical issues
involve weighing the health of the mother in relation to the risk for the
unborn child. Specialised medical advice needs to be provided to women
who are pregnant or breastfeeding and experiencing symptoms of mental
illness. Breastfeeding may not need to be discontinued (e.g. if there is
insufficient evidence that it will harm the baby), but such a decision
needs to be made by specialist medical staff.
Younger People
Prescribing psychiatric medications to children and adolescents is
controversial. The central concerns include efficacy, long-term use and
the effect on normal growth and development.
Older People
Both the physiological changes of ageing and existing medical conditions
complicate the administration of medications to this population. Reduced
cardiac output and reduced liver and kidney function can affect the
transport and absorption of medications, in turn affecting efficacy. Older
people tend to be more sensitive than younger adults to a number of

psychiatric medications, so prescription needs to be tailored to the
minimum dose with the maximum effect and fewest side effects. Risks
associated with polypharmacy (where a person is on a number of
medications for different conditions) can include increased risk of falls,
adverse medication reactions and a reduction in the accurate diagnosis of
mental illness.
CONCLUSION
This chapter has provided an overview of common medications used to
treat mental illness. It is important to work with the person regarding them
taking the right drug at the right time to maintain wellness. An acute
awareness of the side effects and risks of taking psychiatric medications
is a vital aspect of the knowledge and skills of all health workers caring
for people with mental health problems.
References
Ashoorian, D., Davidson, R., Dragovic, M., et al. (2015). A clinical communication tool for the
assessment of psychotropic medication side effects. Psychiatry Research, 230(2), 643–657.
Baker, J. (2016). Cochrane find no evidence for as required PRN medication for mental health
inpatients. Online. Available: https://www.nationalelfservice.net/treatment/medicine/cochrane-fin
d-no-evidence-for-as-required-prn-medication-for-mental-health-inpatients 20 September 2017.
Bella, A. J., & Shamloul, R. (2013). Psychotropics and sexual dysfunction. Central European
Journal of Urology, 66(4), 466–471.
Coskun, H., Kilic, C., & Senture, C. (2016). The evaluation of dorsogluteal and ventrogluteal
injection sites: a cadaver study. Journal of Clinical Nursing, 25, 1112–1119.
Elder, R., Evans, K., & Nizette, D. (Eds.), (2011). Psychiatric and mental health nursing (2nd ed.).
Sydney: Elsevier.
Morrison, P., Gaskill, T., Meehan, T., et al. (2001). The use of the Liverpool University Neuroleptic
Side Effect Scale (LUNSERS) in clinical practice. Australian and New Zealand Journal of Mental
Health Nursing, 9(4), 166–176.
SA Health. (2017). Clozapine. Online. Available: www.sahealth.sa.gov.au/clozapine 20 September
2017.
Usher, K. (2017). Psychopharmacology. In K. Evans, D. Nizette, & A. O’Brien (Eds.), Psychiatric
and mental health nursing (4th ed.). Sydney: Elsevier.
Usher, K., Foster, K., & Bullock, S. (2009). Psychopharmacology for health professionals. Sydney:
Elsevier.
Yilmaz, D., Khorshid, L., & Dedeoğlu, Y. (2016). The effect of the Z-track technique on pain and
drug leakage in intramuscular injection. Clinical Nurse Specialist, 30(6), E7–E12.
Web Resources
Alzheimers Australia, ‘Fight Alzheimer‘s Save Australia’. https://www.fightdementia.org.au/
about-dementia/health-professionals/clinical-resources.
Liverpool University Neuroleptic Side Effect Rating Scale: LUNSERS. https://innovation.ox.ac.uk/
outcome-measures/liverpool-university-neuroleptic-side-effect-rating-scale-lunsers/.
Mental Health Foundation of Australia. www.mentalhealthvic.org.au. This site explains various
medications.
National Prescribing Authority (Australia). www.nps.org.au/medicines.
Chapter 10
Culture and Mental Health
INTRODUCTION
In this chapter the social construct of culture is defined and ways of
engaging with people who have mental illness or mental health problems,
which take into account the person’s cultural background, are examined.
The New Zealand model of ‘cultural safety’ is presented as an exemplar
of how mental health professionals can practise in ways that demonstrate
cultural competence and how mental health services can provide a
culturally inclusive environment in which mental health care and
treatment can be delivered. Practical examples of culturally competent
practice and culturally inclusive environments are also included.
WHAT IS CULTURE?
Culture is a socially defined, dynamic and ever-changing phenomenon
that refers to the history, beliefs, language, practices, dress and customs
that are shared by a group of people, and that influences the identity,
behaviour and values of the members. There is a caveat on this definition,
though, because it cannot be assumed that all members of one culture
necessarily share identical worldviews on any or all issues. This is
particularly so for second-generation immigrants who move between their
culture of origin at home and the adopted culture in which they live.
Consider, for example, a young person who was born in New Zealand to
Vietnamese parents who immigrated in the 1980s. The young person
moves between the Vietnamese culture at home and the wider New
Zealand culture outside the home. Consequently, the person’s cultural
practices will be influenced by the context and environment in which
they occur.
Commonly, culture is equated with ethnicity, but this is a limited
interpretation. Other cultural groupings also exist based on social
demographics such as employment, religion or lifestyle. Box 10.1 lists
examples of social groups that are united by shared understandings that
influence worldview, norms and social interactions.
Being a member of a cultural group doesn’t in itself pose mental health
risks. However, if membership of a group leads to social-exclusion or
stigma based on the person’s cultural identity, then negative mental
health outcomes may result. For example, lesbian, gay, bisexual, trans
and intersex (LGBTI) people who experience stigma, prejudice,
discrimination and abuse on the grounds of being LGBTI are five times
more likely to attempt suicide than the general population. The incidence
for suicide attempt by transgender people is 11 times that of the general
population (National LGBTI Health Alliance 2016).
103
104 Chapter 10 Culture and Mental Health
BOX 10.1
EXAMPLES OF SOCIAL GROUPS UNITED BY SHARED UNDERSTANDINGS
Cultural groups can be defined by:
• ethnicity (a common shared view about ancestry)
• race (biologically determined by genetic inheritance)
• sex (however the person identifies)
• gender (cultural understandings of masculinity and femininity)
• sexual orientation (gay, lesbian, bisexual, heterosexual)
• life-span phase (infancy, old age)
• religion and spirituality (organised/informal)
• geographical location (metropolitan, regional, remote)
• socioeconomic status.
CULTURAL DIVERSITY IN AUSTRALIA AND NEW ZEALAND

For more than 200 years immigration has expanded the populations of
Australia and New Zealand and thereby contributed to the diverse ethnic
cultural makeup of these two nations. In 2016 the population of Australia
was approximately 24.2 million, with 2.5% identifying themselves as
Indigenous Australians, 30.2% as being born overseas and 46.3% with at
least one parent born overseas. Collectively, Australians speak more than
300 languages (50 of which are indigenous), and 23.8% of Australians
speak a language other than English at home (Australian Bureau of
Statistics 2017).
Similarly, in the New Zealand population of 4.4 million people, 15%
identify as Māori and 74% as of European descent, with the remaining
20% comprising Asian, Pacific and African peoples (110%—possibly
explained by some people identifying with more than one ethnicity).
Additionally, 23% of New Zealanders were born overseas and 17.5% of
people speak two or more languages (Statistics New Zealand 2013). And
when the diversity of other cultural groups (as outlined in Box 10.1) is
added to the ethnic diversity of these two nations, it is clearly evident that
multiculturalism and cultural diversity is a defining feature of both
Australia and New Zealand.
CULTURE AND RISK OF MENTAL ILLNESS

Some people, as a consequence of their cultural heritage and history, are
at increased risk of being diagnosed with a mental illness. Colonisation,
for example, has had a devastating effect on the health of the indigenous
peoples of Australia and New Zealand. At particular risk are people from
backgrounds that are culturally and linguistically diverse (CALD) from the
mainstream dominant culture, including immigrants, refugees and
indigenous peoples. In Australia the National Health and Medical
Research Council (2006 p 19) identified the factors in Box 10.2 (overleaf)
as increasing a person’s risk for mental illness.
Chapter 10 Culture and Mental Health 105
BOX 10.2
RISK FACTORS FOR DIAGNOSIS OF MENTAL ILLNESS
• Previous experience of trauma or flight
• Experience of racism or discrimination
• Cultural bereavement or dislocation from community
• Lack of cultural capital within the community (established networks)
• Experience of institutional racism and lack of cultural competence within the
health system
• Change of traditional roles within the family, and lack of social and family
support networks
• Loss of status (e.g. employment)
• Loss of self-esteem, feelings of powerlessness and communication difficulties
EXPLANATORY MODELS OF MENTAL ILLNESS

It is important to recognise that, in the main, theories of mental illness
were developed in the Western world, which for the most part is
composed of individualistic cultures—that is, a society in which the
smallest socioeconomic unit is the individual and the autonomy of the
individual is paramount (Rothwell 2010 p 22). Different interpretations of
health and explanations for mental illness exist between cultures that are
individualistic and cultures that are collectivist—that is, a society in which
the smallest socioeconomic unit is the family and commitment to the
group is paramount (Rothwell 2010 p 22).
Western medicine, with its individualistic view of health, ascribes
responsibility for health to the individual, whereas collectivist cultures
emphasise the role of family and community. For example, traditional
Māori beliefs regard health as being influenced by the four domains
of mind, spirit, family (extended) and the physical world (Ministry of
Health 2016). Consequently, caution must be exercised when applying
theories from Western medicine, which are derived from research
conducted in individualist societies, to people from collectivist societies
such as Australian Aboriginal or Torres Strait Islander peoples, New
Zealand Māori, immigrants and refugees. Also, in practice, this may
mean that decisions about mental health care and treatment for a
person whose culture is collective will be made by the extended family
and not by the individual, as is the practice in Western individualised
cultures.
Furthermore, in traditional Australian Aboriginal culture, illness,
including mental illness, is usually attributed to external forces or reasons.
This, therefore, makes the Western model of attributing mental illness to
an internal disease process inappropriate or irrelevant to the beliefs of
most Aboriginal people (Westerman 2010). Additionally, some
phenomenon, such as seeing the spirit or hearing the voice of a deceased
loved one, is a common experience for Aboriginal people (Aboriginal
Mental Health First Aid Training and Research Program 2008), yet this
could be diagnosed as a hallucination by Western medicine.
CULTURAL SAFETY
The Aboriginal Health Council of Western Australia (2013) in its Cultural
Safety Training Program uses the definition proposed by Williams, who
said cultural safety is:
… an environment, which is safe for people; where there is no assault,

challenge or denial of their identity, of who they are and what they
need. It is about shared respect, shared meaning, shared knowledge
and experience, of learning together with dignity and truly listening.
(Williams 1999 p 2)
Cultural safety is a concept derived from the discipline of nursing in

New Zealand in the late 1980s in response to recruitment and retention
issues regarding Māori nurses and the poor health status of New
Zealand’s indigenous people. The model integrates cultural safety with the
Treaty of Waitangi and Māori health. Previously, professional codes of
ethics directed health professionals to care for people regardless of their
sex, race, culture, educational or religious backgrounds, whereas the New
Zealand cultural safety model directs nurses to take regard of these by
acknowledging and responding to difference, and to ‘take into account all
that makes [human beings] unique’ (Nursing Council of New Zealand /
Te Kaunihera Tapuhi o Aotearoa 2011 p 7).
The New Zealand model comprises three phases of preparation for
culturally safe practice (see Table 10.1). First, cultural awareness
sensitises students and health professionals to their own cultural heritage
and to difference. This is followed by cultural sensitivity, which alerts
students and health professionals to the legitimacy of difference. Finally,
cultural safety is achieved when the person perceives that the health care
was delivered in a manner that respected and preserved their cultural
integrity. This is an important feature of the New Zealand model (i.e. that
cultural safety is identified by the person receiving care, not the health
professional providing care). It is the person who determines whether or
TABLE 10.1
PHASES OF PREPARATION FOR CULTURALLY SAFE HEALTH CARE PRACTICE
Phase Description
Cultural awareness Awareness of difference and own cultural heritage
Cultural sensitivity Acceptance of the legitimacy of difference
Cultural safety Occurs when the person perceives health care to be delivered in a manner
that preserves and respects cultural heritage
Source: Nursing Council of New Zealand / Te Kaunihera Tapuhi o Aotearoa 2011
BOX 10.3
CULTURAL COMPETENCE: REQUIRED VALUES OF HEALTH PROFESSIONALS
A culturally competent health professional is:
• aware of, respects and accepts difference, including
• an awareness of their own ancestral history
• an awareness of their own values and what shapes them
• a non-judgmental attitude (difference is neither right nor wrong)
• an ability to treat others with respect
• flexible and responsive to the unexpected
• willing to learn and undertake continuing professional development
• willing to work with ambiguity
• able to manage the dynamics of difference
• confident in working with people from CALD backgrounds
• able to be an advocate with or on behalf of people in their care.
Sources: Australian Institute of Health and Welfare 2015; National Health and Medical Research
Council 2006
not they have been cared for in a culturally appropriate (safe) way.
Finally, the model requires not only that health professionals be culturally
competent but also that health services provide a culturally inclusive
environment.
CULTURAL COMPETENCE
Culturally competent health professionals possess a set of qualities that
enable them to deliver care in a culturally safe manner. They possess the
attributes outlined in Box 10.3.
A CULTURALLY INCLUSIVE ENVIRONMENT

A culturally inclusive environment is one in which the organisation
has structures in place to ensure difference is respected, discrimination
is not tolerated and the special needs of people from CALD
backgrounds are accommodated. It possesses the attributes outlined
in Box 10.4.
WORKING WITH PEOPLE FROM AN INDIGENOUS OR

CALD BACKGROUND
When working with people from an indigenous or CALD background it is
important to be prepared. Use the information in Boxes 10.3 and 10.4 to
reflect on your own cultural competence and to assess how culturally
inclusive your workplace is. Additionally, you can prepare yourself by
undertaking training courses (e.g. a ‘cross-cultural competency’ or a
‘working with an interpreter’ course) and by becoming familiar with the
indigenous and multicultural services in your organisation and within the
community. These services and agencies can assist communication and
understanding. Importantly, avoid using stereotypes, be flexible in your
BOX 10.4
FEATURES OF A CULTURALLY INCLUSIVE ENVIRONMENT
A culturally inclusive environment is one in which:
• difference is acknowledged, valued and respected
• difference is accommodated (i.e. the organisation is structured to respond to
individual needs such as access to interpreters and gender-appropriate health
professionals)
• policies are in place to protect people in care (e.g. equal opportunity) and
these policies are followed, including consequences if they are not
• cultural knowledge is institutionalised in policy and practice
• cultural self-assessments are conducted
• people with mental illness and staff feel free to
• express their cultural identity
• express their opinions and values
• engage in cultural practices (e.g. prayer)
• feel safe from unfair criticism, abuse or harassment.
Sources: Australian Institute of Health and Welfare 2015; Flinders University 2012
approach, demonstrate a willingness to learn and be open to the fact that

the person’s view of health may differ from your own and/or the
mainstream view.
Nevertheless, while a cultural safety model directs health professionals
to seek understanding of difference, and to accept and work with
difference, such acceptance must not be undertaken in the absence of
critique. Some practices, which are purported to be cultural, can
transgress the values and laws of the wider society. For example, customs
like denying education to girls, or sexual relationships between adults and
children, must be challenged, rather than accepted without being
questioned.
WORKING WITH INTERPRETERS

When English is not the person’s first language or a cultural consultant is
required, an interpreter can facilitate communication and understanding
(including verbal, non-verbal and written). This applies to indigenous
peoples as well as people from a CALD background. When available,
always use a professionally trained interpreter, either in person, via a
telephone interpreter service or via a teleconference. Avoid using family
members or ancillary or other staff members, except in an emergency.
They may have a conflict of interest or may not be able to accurately
translate medical or psychiatric terminology, and the person may withhold
information because of their relationship with the person. See Boxes 10.5
and 10.6 (overleaf) for guidelines regarding working with an interpreter
and when to engage one.
BOX 10.5
WHEN TO ENGAGE AN INTERPRETER
• When the person requests one
• When health care staff cannot understand the person
• At intake or admission to the health service
• During assessment, including initial assessment and mental status examination
• During ongoing treatment
• For family assessment
• During specialist and multidisciplinary assessments
• For explanation of assessment outcomes, diagnosis, treatment, medication or
side effects
• To explain legal rights and changes of legal status
• When obtaining informed consent for procedures deemed necessary
• For risk assessment
• In a crisis situation
• When debriefing clients following critical incidents
• In ongoing reviews whether at the service agency or during a home visit
• For the development of an individual service plan or individual program plan
and including allied health programs and interventions
• For discharge planning
• In monitoring clients who are in inpatient units or receiving intensive treatment
• During rehabilitation and disability support process sessions
• In related settings such as in child and adolescent mental health services
• In case conferences at schools and other agencies that involve the client and
family
Source: Victorian Transcultural Psychiatry Unit (VTPU) 2006
BOX 10.6
GUIDELINES FOR CONDUCTING AN INTERVIEW WITH AN INTERPRETER
PRE-INTERVIEW
• Always use a professionally trained interpreter, except in an emergency.
• Be prepared. Have the contact details of the interpreter service and telephone
interpreter service on the health unit’s list of frequently used numbers.
• If possible, book the interpreter well in advance to ensure the availability of the
most suitable interpreter.
• Match the person and interpreter as closely as possible. Seek more than a
language match. Consider also ethnicity, religion, migration history and political
context.
• Avoid using family members or ancillary or other staff members, except in an
emergency.
• Consider whether the interpreter needs to be a specific gender. Ask the
person with mental illness about gender preference.
• Check whether the interpreter and the person know each other socially or
have a relationship.
• Optimise seating and other spatial arrangements.
• Set a time for a pre-brief and post-interview discussion with the interpreter.
• Consider safety. Identify a code word to use if the meeting needs to be stopped.

BOX 10.6
GUIDELINES FOR CONDUCTING AN INTERVIEW WITH AN INTERPRETER (Continued)
DURING THE INTERVIEW
• Introduce everyone and their role.
• Explain the purpose of the interview.
• Explain that confidentiality will be observed.
• Explain that the interpreter and the health professional may take notes during
the interview.
• Explain that everything will be translated.
• Ensure that only one person speaks at a time.
• Address questions to the person, not the interpreter. Speak to the person in
the first person.
• Look at the person when the interpreter is reporting the person’s response.
• Avoid using technical language, jargon or slang.
• Use short sentences and pause frequently to enable the interpreter to
translate.
POST-INTERVIEW
• Have a debrief discussion with the interpreter.
• Give and seek feedback on how the interview went.
• Ask the interpreter for their comments and concerns.
• Identify safety issues.
Sources: Australian Psychological Society 2013; Victorian Transculural Psychiatry Unit (VTPU)
2006
CASE STUDY: NEW ZEALAND MĀORI

Traditional Māori views of health acknowledge the link between the mind, the spirit,
the connection with family (whānau) and the physical world in a way that is
seamless and natural. Until the introduction of Western medicine, there was no
division between these four domains. Consequently, Māori philosophy towards health
is based on a wellness (holistic health) model in which whānau (family health),
tinana (physical health), hinengaro (mental health) and wairua (spiritual health)
comprise the four cornerstones (or sides) of Māori health. Many Māori believe the
major deficiency in modern health services is in taha wairua (the spiritual
dimension).
Māori view mental health as the capacity to think and to feel that mind and body
are interconnected and one, and therefore inseparable. Thoughts, feelings and
emotions are integral components of the body and soul. This is how Māori see
themselves in the universe, how they interact with that which is uniquely Māori, and
the perceptions that others have of Māori (Ministry of Health 2016).
CASE STUDY: INDIGENOUS AUSTRALIANS

Generally, Australian Indigenous culture is holistic; therefore, concepts of mental
illness must ‘take into account the entirety of one’s experiences, including physical,
mental, emotional, spiritual and obviously cultural states of being’ (Westerman 2010
p 215). Indigenous Australians attribute illness to external events, which are likely to
be culturally based, with mental illness viewed as a sickness of spirit, heart and
mind. Common attributions for illness, including mental illness, are ‘doing something
wrong culturally’ or ‘being paid back’ for wrongdoing. This reflects the intertwining of
spirituality and, particularly, relationships with family, land and culture (Westerman
2010).
CONCLUSION
Like health care in general, culturally safe mental health care is based
on social justice and equity principles that advocate the importance of
knowledge acquisition, mutual respect and negotiation (Multicultural
Mental Health Australia 2010). This chapter has outlined strategies that
facilitate culturally safe mental health care and has presented the New
Zealand model of cultural safety as a framework for providing culturally
appropriate care and treatment in mental health settings. The model
proposes that for health services to be culturally safe, they need to be
provided in an environment that is culturally inclusive and delivered by
health professionals who are culturally competent. The model is equally
applicable in mental health contexts as it is in general health settings.
References
Aboriginal Health Council of Western Australia. (2013). Cultural safety training. Online. Available:
http://www.ahcwa.org.au/cst 24 September 2017.
Aboriginal Mental Health First Aid Training and Research Program. (2008). Cultural considerations
and communication techniques: guidelines for providing mental health first aid to an Aboriginal
or Torres Strait Islander person. Melbourne: Aboriginal Mental Health First Aid Training and
Research Program. Online. Available: https://mhfa.com.au/resources/mental-health-first-ai
d-guidelines#mhfaatsi 18 August 2017.
Australian Bureau of Statistics. (2017). Catalogue Number: 20171.0 – Census of population and
housing: reflecting Australia – Stories from the Census, 2017. Online. Available: http://
www.abs.gov.au/ausstats/[email protected]/Lookup/by%20Subject/2071.0~2016~Main%20
Features~Cultural%20Diversity%20Article~20 18 August 2017.
Australian Institute of Health and Welfare. (2015). Cultural competency in the delivery of health
services for Indigenous people, Closing the Gap Clearinghouse, Issue paper no. 13. Online.
Available: http://www.aihw.gov.au/uploadedFiles/ClosingTheGap/Content/Our_publications/2015/
ctgc-ip13.pdf 18 August 2017.
Australian Psychological Society. (2013). Working with interpreters: A practice guide for
psychologists. Melbourne: APS. Online. Available: http://www.mhima.org.au/pdfs/APS-Working-
with-Interpreters-Practice-Guide-for-Psychologists2013.pdf 18 August 2018.
Flinders University. (2012). Cultural diversity and inclusive practice toolkit. Adelaide: Flinders
University. Online. Available: http://www.flinders.edu.au/equal-opportunity/cdip/cdip_toolkit/
cdip_toolkit_home.cfm 18 August 2017.
Ministry of Health. (2016). Māori health. Online. Available: http://www.health.govt.nz/our-work/
populations/maori-health 18 August 2017.
Multicultural Mental Health Australia. (2010). National cultural competency tool for mental health
services. Online. Available: http://framework.mhima.org.au/Default.aspx?PageID=6320437&A
=SearchResult&SearchID=98793936&ObjectID=6320437&ObjectType=1 18 August 2017.
National Health and Medical Research Council. (2006). Cultural competence in health: a guide for
policy, partnership and participation. Canberra: NHMRC. Online. Available: https://
www.nhmrc.gov.au/guidelines-publications/hp19-hp26 18 August 2017.
National LGBTI Health Alliance. (2016). The statistics at a glance: the mental health of lesbian,
gay, bisexual, transgender and intersex people in Australia. Online. Available: http://
lgbtihealth.org.au/statistics/ 18 August 2017.
Nursing Council of New Zealand / Te Kaunihera Tapuhi o Aotearoa. (2011). Guidelines for cultural
safety, the Treaty of Waitangi and Māori health in nursing education and practice (2nd ed.).
Wellington: NCNZ. Online. Available: http://ndhadeliver.natlib.govt.nz/delivery/
DeliveryManagerServlet?dps_pid=IE6429026&dps_custom_att_1=ilsdbviewed 18 August 2017.
Rothwell, J. D. (2010). The company of others. New York: Oxford University Press.
Statistics New Zealand. (2013). 2013 Census. Online. Available: http://www.stats.govt.nz/
Census/2013-census/profile-and-summary-reports/infographic-culture-identity.aspx 18 August
2017.
Victorian Transcultural Psychiatry Unit (VTPU). (2006). Working with interpreters: a resource for
service providers engaging with interpreters in transcultural situations. Melbourne: VTMH.
Online. Available: http://vtmh-workingwithinterpreters 18 August 2017.
Westerman, T. (2010). Engaging Australian Aboriginal youth in mental health services. Australian
Psychologist, 45(3), 212–222.
Williams, R. (1999). Cultural safety: what does it mean for our work practice? Darwin: Northern
Territory University.
Web Resources
Australian Indigenous Healthinfonet. www.healthinfonet.ecu.edu.au. This site provides
comprehensive and up-to-date information for anyone interested in the health of Indigenous
Australians. It aims to contribute to ‘closing the gap’ in health between Indigenous and
non-Indigenous Australians by informing practice and policy in Indigenous health by making
research and other knowledge readily accessible.
Māori Health. www.maorihealth.govt.nz. This site provides information about Māori health and
highlights the policies, programs and people who are addressing Māori health.
Multicultural Mental Health Australia. www.mmha.org.au. Multicultural Mental Health Australia
provides national leadership in building greater awareness of mental health and suicide
prevention among Australians from CALD backgrounds.
Nursing Council of New Zealand / Te Kaunihera Tapuhi o Aotearoa. http://nursingcouncil.org.nz/
Publications/Standards-and-guidelines-for-nurses. This site provides guidelines for cultural
safety, the Treaty of Waitangi and Māori health in nursing education and practice.
Victorian Transcultural Mental Health. www.vtmh.org.au. The VTMH is a statewide unit that
supports area mental health and psychiatric disability support services in working with CALD
people and carers throughout Victoria.
Chapter 11
Co-occurring Medical Problems
INTRODUCTION
This chapter explores common medical problems that coexist in people
with mental illness. All health professionals and workers in social services
and residential support settings will encounter people with physical
conditions who also have a mental health problem. Health professionals
including general practitioners, physiotherapists and nurses are well
placed to provide holistic care for both physical and mental health care
needs and therefore to screen and make a management plan for people
with physical health problems. While the physical health needs of people
with mental illness is now receiving more attention, recent research
identified physical health as a neglected area of care in mental health
services (Gray & Brown 2017).
THE EXTENT OF THE PROBLEM

People with mental illness experience much higher rates of disability and
mortality. ‘For example, persons with major depression and schizophrenia
have a 40% to 60% greater chance of dying prematurely than the general
population, owing to physical health problems that are often not treated,
such as cancers, cardiovascular diseases, diabetes and HIV infection’
(World Health Organization 2012 p 7). Although the rate of death due to
heart disease has decreased in the general population over the past 20
years, this has not occurred in people with an enduring mental illness.
The need to recognise the physical needs of people with mental illness
has been emphasised in Australia and New Zealand (National Health and
Medical Research Council 2013, National Mental Health Commission
2012). Depression also predisposes people to myocardial infarction and
diabetes, both of which conversely increase the likelihood of depression
(Shah et al 2011, World Health Organization 2012). The following health
conditions are common to people living with enduring mental illness, who
are much more likely to experience such conditions compared with the
rest of the population:
• gum disease and loss of teeth (Kisely et al 2016)
• respiratory disease
• diabetes
• sexual dysfunction
• hyperlipidaemia (high levels of lipids (fats) in the bloodstream)
• cardiovascular disease including hypertension and cardiac arrhythmias
• gastrointestinal disorders and bowel cancer (De Hert et al 2011).
There is some evidence that people seriously affected by chronic
symptoms of schizophrenia have a diminished response to pain, although
113
114 Chapter 11 Co-occurring Medical Problems
a comprehensive picture is unclear and reasons are speculative (Engels

et al 2014). Health professionals—in particular, physiotherapists—need to
have a heightened awareness of this in the physical care of people with
mental illness.
Obesity continues to be a significant health condition for people with
mental illness. Both lifestyle factors such as poor diet and lack of exercise
(Hjorth et al 2014) and features of illness such as lack of motivation and
concentration increase weight gain. Without early intervention, when a
person commences on antipsychotics they are invariably going to gain
weight. Clozapine and olanzapine are strongly associated with weight gain,
but a number of other antipsychotics are also responsible (De Hert et al
2011). Mirtazapine, an antidepressant, is also known to increase appetite,
resulting in weight gain.
People with schizophrenia are almost three times more likely to die of
natural causes—particularly of heart conditions—than people in the
general population (National Mental Health Commission 2012). Metabolic
syndrome and diabetes mellitus are also strongly associated with mental
illnesses such as mood disorders and schizophrenia due to the serious
permanent side effects of antipsychotic medications prescribed. Obesity,
cigarette smoking and alcohol and substance abuse are all significant
health risks for people with enduring mental illnesses such as
schizophrenia, depression and bipolar affective disorder. These issues
place people with mental illness as a significantly vulnerable group, with
associated social, economic and health burdens on society as a whole
(World Health Organization 2012).
All those working with people with mental health problems can facilitate
optimal health by enquiring about physical health complaints as well as
use of alcohol, tobacco and illicit substances. Encouraging and assisting
people to access health services and having health checkups can reduce
the long-term damaging effects of such behaviours. Practice and primary
health care nurses are ideally positioned to screen for high blood
pressure, respiratory problems, diabetes and metabolic syndrome.
DIABETES MELLITUS
Prevalence of diabetes mellitus in those with mental illness is double that
of those in the general population. A link between type 2 diabetes and the
antipsychotic medications olanzapine and clozapine has been suggested
(Holt & Mitchell 2014). Screening of people on antipsychotics should
include regular monitoring of blood, including glucose, because all
antipsychotics (atypical and typical) increase the possibility of developing
diabetes. Lack of physical exercise and poor diet exacerbate the risk of
diabetes and metabolic syndrome.
METABOLIC SYNDROME
Metabolic syndrome can be defined as a cluster of risk factors for obesity,
insulin resistance and cardiovascular disease. Antipsychotic medications
Chapter 11 Co-occurring Medical Problems 115
have been associated with hyperlipidaemia. The presence of metabolic

syndrome can be detected through medical history taking, anthropometry
(body mass index (see Box 11.1) and hip/waist circumference), blood
pressure measurement and measurement of lipid values and blood or
plasma glucose. Box 11.2 lists the diagnostic criteria for metabolic
syndrome.
BOX 11.1
BODY MASS INDEX
BMI is determined by a person’s weight in kilograms divided by their height in
metres squared. The formula is:
Weight (kg)
BMI =
Height (m)2
The BMI is designed for men and women over the age of 18. A healthy BMI is
between 20 and 25. A result below 20 indicates that the person may be
underweight, while a result above 25 indicates that the person may be overweight.
A BMI over 30 indicates a risk of developing metabolic syndrome. The BMI is of
limited use across populations who may be much smaller in height or heavier in
weight than Caucasians but is an easy tool to use in the first instance.
Girth measurement (the measurement around the waist) is a basic indicator of
risk of heart disease, with men at risk above 102 cm and women above 88 cm.
BOX 11.2
DIAGNOSTIC CRITERIA FOR METABOLIC SYNDROME
Diagnostic criteria include:
• a waist circumference > 94 cm for men and > 80 cm for women
• BMI over 30
• raised blood triglyceride and raised cholesterol levels (measured through blood
tests)
• raised blood pressure (BP): systolic BP > 130 mmHg or diastolic BP >
85 mmHg (or treatment for hypertension in the past)
• raised fasting plasma glucose > 5.6 mmol/L (or previously diagnosed type 2
diabetes).
PREVENTION AND MANAGEMENT: ONGOING MONITORING

Ongoing physical monitoring of the person is important, as regular
monitoring of basic observations can greatly assist the early recognition,
prevention and management of chronic health issues. Health
professionals can carry out basic observations such as:
• weight, including BMI
• BP, temperature, respirations
• oral care (teeth, lips, gums)
• skin care, rashes, infections
• foot care, including nails.
FACTORS AFFECTING POOR PHYSICAL HEALTH

There are many factors that contribute to a person having poor overall
health. Having a mental illness often means that medication is a
significant component of treatment, which can negatively affect a person’s
physical health. People with mental illness may experience symptoms
such as suspicious thoughts, paranoia, depression or poor motivation,
making them less likely to leave their homes to go for a walk or plan
shopping trips that involve a number of different shops. They are more
likely to make short local trips and buy food that requires little preparation
because of their reduced cognitive ability and associated lack of
motivation. Physical symptoms from co-occurring illnesses such as pain,
reduced mobility and respiratory problems can further reduce physical
activity and increase social isolation.
Healthy foods are often expensive in comparison with ready-made frozen
foods or fast foods, and people with mental illness are likely to be on low
incomes, compounding their health risks. A diet low in fibre, vegetables and
fruit, and little physical exercise, increases the likelihood of cardiovascular
disease, high blood pressure and stroke. Hence, an interplay between
behaviours such as smoking, alcohol and substance abuse, combined with
symptoms of mental and physical illness, create health problems and poor
quality of life for those people living with mental illness. For a number of
reasons, people with mental illness may not regularly visit health
professionals, in particular general practitioners (see Box 11.3).
BOX 11.3
WHY PEOPLE WITH MENTAL HEALTH PROBLEMS DO NOT RECEIVE ADEQUATE
PHYSICAL HEALTH CARE
Possible reasons include:
• a tendency by mental health professionals to focus on mental health issues,
with less focus on other health issues
• reluctance of general practitioners to take comprehensive care of people with
an enduring mental illness
• screening for physical problems is not carried out routinely
• time and resources for general health checkups are not always available in
mental health service settings
• a lack of support regarding medication issues
• fragmentation of the health care system, with physical and mental health
services not well integrated
• inaccurate self-assessment of symptoms and poor reporting by people with
mental illness
• lack of awareness of physical symptoms due to high pain tolerance associated
with the use of antipsychotic medication
• a lack of continuity of care and follow-up due to itinerancy
• difficulties in making changes to lifestyle (e.g. stopping smoking, changing diet
or reducing drug or alcohol intake).
Sources: Connelly & Kelly 2005; Lambert et al 2003

STRATEGIES FOR IMPROVING PHYSICAL HEALTH

Exercise is an effective strategy for improving general physical and
emotional health. Walking is the easiest activity for encouraging people
with mental illness to exercise. Engaging people in community walking
groups can increase exercise and also provides opportunities for
socialisation. Reducing cigarette smoking (by connecting people with
national ‘Quit’ programs) is also an important lifestyle change, together
with attention to a healthy diet. Reminding people about the availability of
free health checks and providing information about community health
centres can also be useful.
It is vital that health professionals engage with people with mental
illness about practical ways to increase their physical health and assist
them to develop plans for self-care management of their mental health.
Referral to an exercise physiologist is a useful mechanism to support the
person’s physical and mental health. Other strategies include encouraging
annual medical and dental checkups, including full blood tests and
electrocardiograms, and providing brochures about prostate checks,
mammograms, cervical smear (pap) tests and bone density tests for
people older than 50. Encouraging people to attend their closest general
practice clinic and to visit them on a regular basis can facilitate an
effective working relationship and allow for early recognition of symptoms.
A Primary Care Focus

People with mental health problems often have physical health needs that
are not being adequately screened for and treated (Galletly et al 2012).
While almost 90% of people living with psychosis saw a general
practitioner in the past year, more than 60% said they did not have a
health check of any kind (Morgan et al 2011). Comorbidity between
mental and substance misuse disorders is also common globally. People
with a substance misuse disorder have high comorbid rates of mental
disorders. Substances include alcohol, tobacco, marijuana and other illicit
substances such as methamphetamine and cocaine. Box 11.3 lists the
main reasons why people with mental health problems do not receive
adequate physical health care.
There is a strong relationship between the severity of comorbidity and
the severity of substance misuse disorders. For these reasons we need
better primary health care approaches to address the poor physical health
of people with mental illness.
Using screening tools, undertaking physical health checks and
enquiring about a person’s wellbeing can have significant benefits for
people with comorbid health problems.
Assessment scales include:
• the AUDIT alcohol assessment scale (see <www.therightmix.gov.au>)
• the CAGE alcohol screening test—a short, four-question test that diagnoses
alcohol problems over a lifetime (see <www.healthyplace.com>).
CONCLUSION
This chapter has explored the physical, social and behavioural problems
that people with mental health problems often face. Awareness of these
additional challenges among those who work with people with mental
health problems provides opportunities to provide support, encourage
attendance at health centres and plan strategies to reduce the harm
caused by poor diet and using tobacco, drugs and alcohol.
References
Connelly, M., & Kelly, C. (2005). Lifestyle and physical health in schizophrenia. Advances in
Psychiatric Treatment, 11, 125–132.
De Hert, M., Correll, C. U., Bobes, J., et al. (2011). Physical illness in patients with severe mental
disorders. Prevalence, impact of medications and disparities in health care. World Psychiatry,
10, 52–77.
Engels, G., Francke, A., Meijel, B., et al. (2014). Clinical pain in schizophrenia: a systematic
review. Journal of Pain, 15(5), 457–467.
Galletly, C. A., Foley, D. L., Waterreus, A., et al. (2012). Cardiometabolic risk factors in people with
psychotic disorders: The second Australian national survey of psychosis. Australian and New
Zealand Journal of Psychiatry, 46, 753–761.
Gray, R., & Brown, E. (2017). What does mental health nursing contribute to improving the
physical health of service users with severe mental illness? A thematic analysis. International
Journal of Mental Health Nursing, 26(1), 32–40.
Hjorth, P., Davidsen, A., Kilian, R., et al. (2014). A systematic review of controlled interventions to
reduce overweight and obesity in people with schizophrenia. Acta Psychiatrica Scandanavia,
130(4), 279–289.
Holt, R. I., & Mitchell, A. J. (2014). Diabetes mellitus and severe mental illness: mechanisms and
clinical implications. Nature Reviews. Endocrinology, 11(2), 79–89.
Kisely, S., Sawyer, E., Siskind, D., et al. (2016). The oral health of people with anxiety and
depressive disorders – a systematic review and meta-analysis. Journal of Affective Disorders,
200, 119–132.
Lambert, T. J. R., Velakoulis, D., & Christos Pantelis, C. (2003). Medical comorbidity in
schizophrenia. Medical Journal of Australia, 178, S67–S70.
Morgan, V. A., Waterreus, A., Jablensky, A., et al. (2011). People living with psychotic illness:
report on the second Australian national survey. Canberra: Commonwealth of Australia.
National Health and Medical Research Council. (2013). Australian dietary guidelines. Canberra:
NHMRC.
National Mental Health Commission. (2012). A contributing life: the 2012 national report card on
mental health and suicide prevention. Sydney: NMHRC.
Shah, A. J., Veledar, E., Hong, Y., et al. (2011). Depression and history of attempted suicide as
risk factors for heart disease mortality in young individuals. Archives of General Psychiatry,
68(11), 1135–1142.
World Health Organization. (2012). Risks to mental health: an overview of vulnerabilities and risk
factors. World Health Organization, 28(4), 805–817.
Web Resources
Healthy Active Lives (HeAL). www.iphys.org.au. HeAL is a statement that aims to reverse the trend
of people with mental illness dying early by addressing risks for future physical illnesses early
and proactively.
Mental Health Partnerships. http://mentalhealthpartnerships.com/resource/physical-health-checks
-for-people-with-smi/. This is a brief tool that enables health professionals to work with
consumers to screen physical health and take evidence-based action when variables are
identified to be at risk.
National Health Service (UK). http://www.nhs.uk/Tools/Pages/Toolslibrary.aspx. This website has
multiple tools for people to self-assess against common physical and mental health problems.
National Institute of Drug Abuse. http://www.drugabuse.gov/publications/research-reports/

comorbidity-addiction-other-mental-illnesses. This website provides information on comorbid
drug abuse and mental illness.
Smokefree (NHS). http://smokefree.nhs.uk/?&gclid=CLXOno_NnKkCFQNP4QodhErpuA. This
website provides quit smoking assistance, assessment tools and information.
Chapter 12
Loss and Grief
INTRODUCTION
Change, transition and loss are constant features of everyday life. Loss
can have a major impact on the person involved (e.g. the death of a
parent) or it may be less significant (e.g. moving house, losing your
wallet). The experience of grief and mourning following a significant loss
can be intense, including distressing affective, cognitive and behavioural
responses. Nevertheless, as upsetting as they are, such reactions are
normal and are not necessarily evidence of a mental health problem.
Health professionals constantly work with people who are experiencing
loss and, thereby, may find themselves in the unique position of being a
key support person in a significant experience for someone who is
grieving. This chapter examines the concept of loss and bereavement and
identifies ways that health professionals can understand and best assist a
bereaved person.
UNDERSTANDING LOSS, GRIEF AND MOURNING

Loss involves the separation from a person or an object that has meaning
to the person and to which the person feels strongly connected (Bull
2013). The loss may be tangible (e.g. the death of a loved one) or
intangible (e.g. loss of self-esteem following redundancy). The period in
which the person experiences grief (affective) reactions and engages in
mourning behaviours is referred to as ‘bereavement’. Table 12.1 (overleaf)
distinguishes between the terms ‘loss’, ‘grief’, ‘mourning’ and
‘bereavement’.
While loss and grief experiences are distressing, they are a normal
human response and not usually indicative of mental illness. Grief
responses are individual and vary with each person—that is, the
magnitude of the loss and the meaning the loss has for the bereaved
person. Responses can include feelings of deep sadness, anger, guilt and
despair; cognitive reactions can include disbelief, confusion and
ruminations about the loss. Mourning responses include physical
reactions such as fatigue and a hyper-startle response, and behavioural
responses like social withdrawal and sleep disturbances. Some
behavioural responses are life enhancing (e.g. crying and talking about
the loss) and facilitate grieving, but others are life depleting (e.g.
excessive drinking or making suicidal gestures) and potentially harmful for
the person (Bull 2013).
Mourning responses are culturally determined. For example, traditional
indigenous cultures often have more prescribed mourning practices than
those found in Anglo-European Australian or New Zealand cultures.
Tangihanga, the Māori approach to the process of grieving, includes
120
Chapter 12 Loss and Grief 121
TABLE 12.1
LOSS, GRIEF, MOURNING AND BEREAVEMENT
Term Definition
Loss Being parted from someone or something that the person values
Grief The affective (emotional) component of mourning, including the painful affects
(feelings) associated with the loss (e.g. sadness, anger, guilt, shame, anxiety)
Mourning The behavioural component of bereavement, which includes biological reactions,
behavioural responses and cognitive and defensive reactions related to the loss
Bereavement The experience of grief and mourning
protocols and practices to not only mourn the person who has died but
also the ancestors who have passed before them (Higgins 2011).
MODELS AND THEORIES OF LOSS AND BEREAVEMENT

Models and theories of loss and bereavement have been proposed since
the middle of the 20th century in order to understand and thereby assist
the bereaved. Kübler-Ross’s influential model identified the phases a
dying person experiences as they approach their death. These phases
included denial, anger, bargaining, depression and acceptance (Kübler-
Ross 1969). Kübler-Ross never intended her model to apply to all losses,
and nor did she describe the phases as sequential, though some health
professionals have applied the model in this way (Kübler-Ross and
Kessler 2014).
Another contemporary model of grieving has been proposed by William
Worden (2010). He identifies the tasks of mourning as:
• Accept the reality of the loss.
• Experience the pain of grief.
• Adjust to the environment where the ‘loss’ is missing.
• Emotionally relocate the ‘loss’ and move on with life.
According to Worden, accomplishing these tasks marks the completion
of grieving, though he does not prescribe a period within which this
should occur, and nor does he propose that everyone complete this grief
experience. Rather, Worden stresses that mourning is a long-term,
sometimes lifelong, process. Additionally, Worden states that the
completion of grieving does not return the person to their
pre-bereavement state—rather, the bereaved person is now able to think
about the loss without intense pain and has integrated the experience into
their new post-bereavement life.
Finally, while theories and models of loss and mourning provide useful
insights into the experience of the bereaved, they must be used cautiously
because everyone’s loss experience is different. Grieving is not a linear
experience, grief has no end point, culture influences grief and mourning
responses and loss is not always a negative experience (e.g. when death
follows a long period of suffering or disability).
122 Chapter 12 Loss and Grief
BOX 12.1
STRATEGIES FOR SUPPORTING THE GRIEVING PERSON
Supportive strategies include the following.
• Contact the person as soon as you hear of the death and express your sorrow
for their loss—give a hug if appropriate.
• Maintain contact by
• visiting (visits don’t have to be lengthy)
• telephoning, writing or sending a card if you are unable to visit.
• Listen if the person wants to talk about the deceased or tell their story again
and again—listening is possibly the most important thing you can do.
• Talk about the person who has died.
• Accept extreme behaviours (e.g. crying, screaming, being quiet, laughing).
• Accept expressions of anger, guilt and blame.
• Indicate that grief takes time.
• Include children in the grieving process.
• Be sensitive about dates that might be upsetting or significant for the bereaved
person such as anniversaries, birthdays or Mother’s Day.
• Offer practical help such as cooking a meal, child minding or walking the dog.
• Try to understand and accept the person—everyone’s grief response is
different.
Source: GriefLink 2017a
UNCOMPLICATED GRIEF
Grief is the normal affective response to loss. Most people’s grief will be
uncomplicated. Nevertheless, the person’s bereavement experience may
be distressing and disrupt their lives in the short term, such as after a
natural disaster like an earthquake, or following the death of a loved one.
The person’s grief may also be upsetting for bystanders (including health
professionals), who can feel helpless because they are unable to relieve
the person’s pain. During this period, the bereaved require support as
they accept the reality of the loss and adjust to living their life without the
person or lost object. Strategies that support people experiencing
uncomplicated grief are listed in Box 12.1.
Some strategies, however, are not supportive of grieving and may
actually hinder uncomplicated grief. Unhelpful strategies, identified by
(Grieflink 2017a), are listed in Box 12.2 (overleaf).
COMPLICATED GRIEF
Complicated grief may affect between 10% and 20% of people who are
grieving. It is difficult to distinguish complicated from uncomplicated grief,
especially in the first six months, because intense emotional, cognitive
and behavioural responses to loss are normal and are observed in both
circumstances. Nevertheless, indicators for complicated grief include
suicidal thoughts and gestures, depressive disorders, post-traumatic stress
reactions and persistent grief reactions. People whose grief is complicated
may engage in life-depleting behaviours such as compulsive or excessive
BOX 12.2
STRATEGIES THAT MAY BE UNHELPFUL TO THE GRIEVING PERSON
Unhelpful strategies include:
• avoiding talking about the deceased person
• using platitudes and clichés
• offering false reassurance
• telling the person: ‘I know how you feel’
• inhibiting the person’s grief experience by offering advice about what they
should think, feel or do
• ceasing contact with the person if the going gets ‘too heavy’
• advising the person on how to grieve, or trying to explain or rationalise their
feelings
• having expectations of how the person should grieve and judging the person
by these expectations
• taking over and doing things the person can do for themselves
• making comparisons between the person’s and others’ losses
• using theories of grief to predict experience
• changing the subject (it dismisses the importance of what the person is
saying)
• comparing your losses to the bereaved person’s loss
• talking about your own grief experiences (unless the bereaved person finds
this relevant to their situation and invites you to tell your story).
Source: GriefLink 2017a
behaviours like overeating, shopping or gambling, or agitated, aggressive

and demanding behaviours (Bull 2013).
In the latest edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5; American Psychiatric Association 2013) the diagnosis of
‘persistent complex bereavement-related disorder’ has been added as an
appendix. The inclusion of this new diagnosis arose from concerns by
researchers and clinicians about the inappropriate association of complicated
grief with anxiety, depression and post-traumatic stress disorder.
Nevertheless, despite the inclusion of this disorder the American Psychiatric
Association recognises that further research of this construct is required to
establish the validity of bereavement-related disorders (Bull 2013).
LOSS IN SPECIAL CIRCUMSTANCES

For some people, grief and mourning may be affected or exacerbated by
additional contributing factors. For example, losses experienced by people
with mental illness may be disenfranchised or not acknowledged because
of societal attitudes to mental illness; loss for indigenous peoples may be
compounded by cultural expectations and the prevalence of multiple
intergenerational losses in some communities.
Loss for People Living With Mental Illness

As with any illness, there are losses associated with experiencing a mental
illness (e.g. loss of independence, social connection, income and
wellbeing). However, with mental illness, additional losses may occur due
to the stigma associated with the illness, including loss of one’s sense of
confidence, social standing, self-esteem and self-image. Furthermore,
people with a severe and enduring mental illness may experience further
losses, particularly in relation to changes in employment, independent
living, social relationships and life goals.
This type of loss is what Doka (1993, 2016) refers to as
disenfranchised loss—one that is not recognised or supported by other
members of society (Doka 2016). Doka suggests that disenfranchisement
occurs when a person experiences a loss but ‘does not have a socially
recognised right, role or capacity to grieve’, resulting in the person having
‘little or no opportunity to mourn publicly’ (Doka 1993 p 128). In
disenfranchised loss, other people do not acknowledge the nature of, or
the meaning of, the loss for the bereaved person, which inhibits the
person’s ability to openly grieve for their loss, or to seek and receive
support from others in their mourning. Examples of losses that can be
disenfranchised include miscarriage, the death of an ex-partner and
adoption.
Loss Across the Life Span

While children experience similar feelings of loss and grief as adults, they
may express them in behaviours (e.g. bed wetting or sleep disturbances)
rather than words. They need assistance in expressing their feelings and
thoughts, as well as reassurance that their distress is reasonable and
acceptable. Similarly, teenagers may display their distress behaviourally
(e.g. mood changes, withdrawal). At the other end of the spectrum the
losses experienced by elderly people can be multiple and cumulative
(death of friends, loss of health/independence), which can complicate
their grieving.
Trauma and Loss

Significant trauma across the life span can have enduring consequences
for many people. Childhood abuse or neglect places children at risk of
developmental delay and physical and mental illnesses (Rossiter & Scott
2017). Immigrants and refugees who have experienced violence when
fleeing from their homeland may experience symptoms of post-traumatic
stress disorder that can continue long after the original threat has
passed (Nickerson et al 2014). This has led to the emergence of
‘trauma-informed care’, a model of care that aims to avoid further
traumatising people who have already been victims of violence (Isobel
& Edwards 2016, Muskett 2013). In its narrowest interpretation
trauma-informed care involves avoiding the use of practices like seclusion
and restraint, which can further traumatise the person. However, the
model also requires an understanding of the impact of the trauma on the
person’s life, and ensuring that the person feels safe in order to foster
hope for recovery. Furthermore, avoiding the use of coercive practices like
seclusion and restraint, and using strategies that empower the person
and facilitate recovery, are the best-practice goal for the mental health
care of all.
Loss Following Suicide

Grief following loss of a loved one to suicide can be complicated and
intense due to the circumstances of the death and feelings of guilt,
shame, blame and anger that can be experienced by the person’s
surviving family and friends. Health professionals can assist a person
bereaved through suicide by offering compassion, non-judgmental
support, an opportunity to tell their story (repeatedly if necessary) and
recognition and validation of the person’s experience of loss. Providing
information about support services for survivors of suicide may also be
helpful (Support After Suicide 2017).
Loss for Indigenous Peoples

Losses experienced by indigenous peoples are complex, multifaceted and
frequently have intergenerational consequences. In addition to the losses
that are experienced by all people, Māori and Australian Aboriginal and
Torres Strait Islander peoples experience additional losses as a
consequence of a history of colonisation, past trauma and separation from
family, land and culture. This has led to ‘unresolved or ongoing grief
[being] common in Aboriginal communities because of the unfinished
business of colonisation and the Stolen Generations’ (Mental Health First
Aid 2008).
For social and historical reasons, indigenous peoples may experience
multiple losses and more-frequent death of relatives than the wider
population, hence they are engaged in more frequent ‘sorry business’.
Furthermore, not only have indigenous peoples suffered major losses but
they have also suffered the loss of the practices and rituals that enable
them to deal with those losses (GriefLink 2017b, Higgins 2011).
Suggested strategies for responding to losses among indigenous peoples
are summarised in Table 12.2.
ASSISTING A BEREAVED PERSON

Health professionals are in the unique position of being a caregiver in the
loss and bereavement experience of a person who may well be a stranger
to them, and being able to facilitate the person’s grieving. Two areas in
which the contribution of health professionals can make a difference are
breaking bad news and providing support for bereaved people.
Breaking Bad News

At times, health professionals will need to break bad news to people and
their families. How this news is delivered can significantly influence the
bereaved person’s experience. Box 12.3 provides tips for health
professionals when delivering bad news.
TABLE 12.2
STRATEGIES FOR RESPONDING TO LOSSES AMONG INDIGENOUS PEOPLES
Strategies for Indigenous Peoples How Non-Indigenous People Can Help
Create awareness about the impact of Continue to change non-indigenous history books
losses and the unresolved grief on Develop loss and grief counselling courses for
people indigenous and non-indigenous people
Create and develop grieving ceremonies Ensure healing centres deal with indigenous health
suited to today issues from a holistic perspective
Re-create women’s business/ceremonies Develop loss and grief programs and workshops as a
Re-create men’s business/ceremonies part of the curriculum within primary and secondary
Re-create rites of passage (young people) schools
Assist towards a true reconciliation, with the full
understanding that both groups—non-indigenous
and indigenous peoples—have deep grief
Throughout all levels of the medical profession, teach
students about the complexities of indigenous and
non-indigenous grief
Source: GriefLink 2017b
BOX 12.3
DOS AND DON’TS FOR BREAKING BAD NEWS
Do:
• start from where the person is, asking: ‘What do you already know?’
• prepare the person for what they are about to hear—for example, by saying: ‘I
am afraid the news is not good’
• give the key facts briefly, and then pause and check for understanding
• elicit concerns and feelings (this validates the loss)
• give permission for feelings to be expressed (e.g. offer a box of tissues)
• allow time for questions by asking: ‘Is there anything else you would like to
know?’
• give the person time and space, and ensure news is delivered in a private
setting
• offer further contact (if the person wants it).
Don’t:
• use the telephone, unless there is no other option
• use euphemisms and platitudes, as they minimise the loss
• use jargon (instead, use words the person will understand)
• rush, as the person needs time to absorb the information
• give bad news in a public place
• say you understand how the person feels, as each loss is unique.
Professional Support for Bereaved People

When providing support to a bereaved person, it is important not to
interpret intense grief and mourning reactions as symptoms of mental
illness. Health professionals can provide support for people experiencing
uncomplicated grief by: being there for the person; allowing the person to
express emotional pain; being sensitive to cultural considerations in death

and dying and acknowledging the meaning of death and dying in different
cultures; acknowledging difficulties; and exploring opportunities for
advanced professional training (Morrison 2012 pp 166–169). Bull (2013)
identifies guidelines (based on Worden’s model) that health professionals
can use to support a person who is grieving (see Box 12.4).
BOX 12.4
HOW HEALTH PROFESSIONALS CAN SUPPORT SOMEONE WHO IS GRIEVING
HELP THE GRIEVER ACTUALISE THE LOSS
• Help the griever express their loss. Health professionals can provide a ‘fresh’
listening ear for the story of loss.
HELP THE GRIEVER IDENTIFY AND EXPERIENCE FEELINGS
• Be willing to empathise with the griever’s painful feelings.
• Responses such as ‘It seems like you are really missing …’ or ‘I imagine that
you must be very lonely since … died’ help name and express feelings
associated with loss.
HELP FIND MEANING IN THE LOSS
• Meaning-making in grief is highly individual, but health professionals can
facilitate the process.
• Ask the griever what their loss has meant to them, and share stories of how
others have found meaning.
• Share your own perceptions of meaning (e.g. ‘It sounds like your life would
never have been as happy without your relationship with …’).
• Introduce the griever to meaning-making exercises (e.g. Neimeyer 2007,
2010).
FACILITATE EMOTIONAL RELOCATION OF THE DECEASED OR LOST OBJECT
• Support the griever in remembering and reminiscing about who/what has been
lost.
• Support the griever regarding concrete efforts to remain connected to the lost
person or thing.
• Be cautious about a griever’s efforts to quickly find a ‘replacement’.
PROVIDE TIME TO GRIEVE
• Recognise that active grieving can take time (one to two years, or longer).
• Avoid giving messages that people should ‘be over’ their grief.
• Remember and support continuing grief at special times (e.g. on the
anniversary of a death, birthdays or holidays).
• Educate the griever’s support system (family, friends) that grieving takes time.
INTERPRET NORMAL BEHAVIOUR
• Help the griever to understand and ‘make sense’ of their often intense grief
responses.
• Assure the griever that their reactions are not uncommon while still
acknowledging how they might be upset or worried about their reactions.
• Connect the griever with those who have had similar experiences (e.g. support
groups).

BOX 12.4
HOW HEALTH PROFESSIONALS CAN SUPPORT SOMEONE WHO
IS GRIEVING (Continued)
ALLOW FOR INDIVIDUAL DIFFERENCES
• Recognise the great diversity of grieving responses.
• Avoid imposing a ‘prescription’ about how grievers should react.
• Educate those around the griever that differences in grieving styles and
methods are to be expected.
CONSIDER DEFENCES AND COPING STYLES
• Watch for potentially unhelpful grief responses such as excessive use of
alcohol or drugs, withdrawal, refusal to be reminded of the loss or ‘burying’
oneself in work or some other activity.
• Within a trusting relationship, help the griever explore more useful ways of
coping.
IDENTIFY GRIEF COMPLICATIONS AND REFER
• Monitor for grief complications (see ‘Complicated grief’ in this chapter).
• In keeping with professional ethics, recognise your own practice limitations.
• Refer grievers with complications for more advanced assistance.
Source: Bull 2013, adapted from Worden 2010
LOOKING AFTER YOURSELF

Finally, while loss and bereavement are a normal part of life for all people,
health professionals are exposed to other people’s losses on a regular
basis, which can lead to intense emotional reactions to the distress
observed (Morrison 2012 p 178). Furthermore, health professionals may
have experienced a loss similar to that of the person they are caring for,
which can reactivate the health professional’s own previous grief reaction.
Consequently, working with people experiencing loss can be stressful,
and health professionals need to be mindful of managing their own
mental health. This can be achieved through self-awareness, acquiring
knowledge about loss and grief (e.g. regarding cultural expectations and
practices) and developing helping skills (e.g. listening and acceptance) to
assist the grieving person and their families (Morrison 2012).
Furthermore, clinical supervision can be used to examine one’s
professional and personal reactions when working with a grieving person
and to critically reflect on how this affects the health professional’s clinical
practice. And, if you experience a distressing personal response while
caring for a bereaved person, there are counselling services in the
workplace and the community that you can access for support.
CONCLUSION
Loss is a distressing and relatively common human experience. Though
upsetting, most people’s bereavement experience is uncomplicated, with only
a small number of people experiencing a complicated grief reaction requiring
professional intervention. The nature of the work undertaken by health
professionals means you may play a role in the loss experiences of the
people to whom you provide care. In such situations, health professionals can
assist the bereaved by validating the loss through listening, acknowledging
the person’s feelings, facilitating mourning behaviours and making referrals to
self-help support groups or counselling if appropriate.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(DSM-5). Washington DC: American Psychiatric Publishing.
Bull, M. (2013). Loss. In P. Barkway (Ed.), Psychology for health professionals (2nd ed.). Sydney:
Elsevier.
Doka, K. (1993). Disenfranchised grief: a mark of our time. Paper presented at the 8th Biennial
Conference of the National Association for Loss and Grief (NALAG). Yeppoon, Queensland, pp
128–132.
Doka, K. (2016). Grief is a journey. New York: Atria Books.
GriefLink. (2017a). Helping the bereaved. Online. Available: http://www.grieflink.asn.au/helping
-the-bereaved.aspx 15 August 2017.
GriefLink. (2017b). Grief reactions associated with indigenous grief. Online. Available: http://
grieflink.org.au/TopicPersonAboriginal.aspx 15 August 2017.
Higgins, R., 2011, ‘Tangihanga death customs’. Te Ara – The Encyclopedia of New Zealand.
Online. Available: https://www.teara.govt.nz/en/tangihanga-death-customs/print 15 August 2017.
Isobel, S., & Edwards, C. (2016). Using trauma informed care as a nursing model in an acute
mental health unit: A practice development process. International Journal of Mental Health
Nursing, 26(1), 88–94.
Kübler-Ross, E. (1969). On death and dying. London: Macmillan.
Kübler-Ross, E., & Kessler, D. (2014). On grief and grieving. London: Simon and Schuster.
Mental Health First Aid. (2008). MHFA guidelines for providing mental health first aid to Australian
Aboriginal and Torres Strait Islander peoples. Online. Available: https://mhfa.com.au/mental
-health-first-aid-guidelines#mhfaatsi 15 August 2017.
Morrison, P. (2012). Crisis and loss. In R. Elder, K. Evans, & D. Nizette (Eds.), Psychiatric and
mental health nursing (3rd ed.). Sydney: Elsevier.
Muskett, C. (2013). Trauma-informed care in inpatient mental health settings: A review of the
literature. International Journal of Mental Health Nursing, 23(1), 51–59.
Neimeyer, R. A. (2007). Meaning reconstruction and the experience of loss. Washington DC:
American Psychological Association.
Neimeyer, R. A. (2010). Lessons of loss: a guide to coping. New York: Routledge.
Nickerson, A., Liddell, B., Maccallum, F., et al. (2014). Posttraumatic stress disorder and
prolonged grief in refugees exposed to prolonged grief. BMC Psychiatry, 14(106), 1–11.
Rossiter, R., & Scott, R. (2017). Trauma, crisis, loss and grief. In K. Evans, D. Nizette, & A.
O’Brien (Eds.), Psychiatric and Mental Health Nursing. Sydney: Elsevier. Ch 7.
Support After Suicide. (2017). Understanding suicide and grief. Online. Available:
www.supportaftersuicide.org.au 15 August 2017.
Worden, W. (2010). Grief counseling and grief therapy: a handbook for the mental health
practitioner (4th ed.). New York: Springer.
Web Resources
Australian Centre for Grief and Bereavement. www.grief.org.au. This website provides education,
publications and resources about loss for health professionals and the wider community.
Centre for Loss and Grief (NALAG Australia). http://www.nalag.org.au. NALAG New Zealand:
https://www.grieflink.com/national-association-loss-and-grief-new-zealandnalag-nz. NALAG is an
international voluntary, non-profit organisation that focuses on issues related to loss and grief. It
provides an information resource on death-related grief for the community and professionals.
Skylight NZ. www.skylight.org.nz. This website provides information and resources for children,
families and health professionals dealing with trauma, loss and grief.
Survivors of Suicide. www.survivorsofsuicide.com. This organisation aims to help those who have
lost a loved one to suicide resolve their grief and pain in their own personal way.
Chapter 13
Law and Ethics
INTRODUCTION
This chapter explores core legal and ethical issues concerned with the
care and treatment of people with mental illness within the least restrictive
environment. The intent is to provide an introduction to some of the
issues rather than a comprehensive unpacking of the interplay between
legal and ethical issues.
MENTAL HEALTH LAW

Mental health legislation refers to laws regarding the treatment, care and
rehabilitation of people with mental illness. The legislation is designed to
protect people with mental illness from inappropriate treatment and to
direct the provision of mental health care and the services in which it is
provided. Contemporary mental health legislation is underpinned by a
principle that requires clinicians to use the least restrictive alternatives
and to only use containment and restraint as a last resort. Most mental
health legislative documents cover both the treatment and the care of
voluntary and involuntary patients, and mental health is the only health
care speciality that is governed in part by a framework of legal compulsion
(Maude & O’Brien 2017). In Australia each state and territory currently
has a separate mental health Act with different requirements regarding
treatment and detention.
Involuntary detention continues to be controversial because it involves
removing a person’s freedom and autonomy under the auspices of mental
health legislation. Therefore, the State can compel people with mental
illness to undergo treatment against their will, raising complex legal and
ethical issues. The World Medical Association’s Statement on ethical
issues concerning patients with mental illness (2006) states that
compulsory hospitalisation should only be used when it is medically
necessary and for the shortest possible duration. Laws regarding
involuntary hospitalisation and treatment vary worldwide; however, it is
generally acknowledged that such a decision requires the following criteria
to be satisfied:
1. The person is experiencing mental illness.
2. The person is a danger to self or others.
3. Immediate treatment is required.
4. Appropriate treatment in approved mental health settings is available.
5. The person has impaired decision-making capacity in relation to their
mental illness.
In Australia, New Zealand and other countries, the terms ‘detained,
sectioned, ordered and scheduled’ all refer to involuntary commitment to
130
Chapter 13 Law and Ethics 131
a psychiatric hospital for treatment, or to involuntary treatment in the

community under a community treatment order. In general terms, people
with mental illness can usually be committed for inpatient treatment for a
period such as seven days in the first instance after examination by a
medical practitioner (under some mental health Acts a mental health
nurse can undertake this role). They then must be examined again within
24 hours by a psychiatrist, who can then allow the detention to lapse or
continue the seven-day detention. Further detention of up to 42 days may
occur and, under certain circumstances, forced treatment may be
instituted beyond this time, if it is felt that the person requires ongoing
care and treatment in hospital or the community.
A person in care may apply for a review of their detention to a panel of
mental health professionals and consumer advocates and laypeople in
each state and territory, although their title and makeup are different from
state to state (e.g. in New South Wales and Queensland the panel is
known as the Mental Health Review Tribunal; in Victoria it is known as
the Mental Health Tribunal; in South Australia it is known as the South
Australian Civil and Administrative Tribunal; and in Tasmania it is known
as the Guardianship and Administration Board).
These boards and tribunals assist when a person may be unable to
make decisions for themselves due to mental illness and dangerousness.
The tribunals are commonly involved when people with mental illness
wish to appeal detention orders placed on them by their treating
psychiatrist. All people with mental illness need to be provided with
information about their rights and details of advocacy groups on
admission to a psychiatric inpatient facility.
In New Zealand, in accordance with the Treaty of Waitangi, section 5 of
the New Zealand Mental Health Act requires that the cultural identity of
people with mental illness is respected and attended to (Maude & O’Brien
2017). People with mental illness may not be involuntarily held under
mental health legislation in any jurisdiction on the following grounds:
• political, religious or personal beliefs
• sexual preference
• criminal behaviour
• illegal drug use
• intellectual disability.
People with mental illness who are held against their will in a
psychiatric inpatient facility must be provided with written and verbal
information explaining all procedures, as well as their legal rights and how
they can appeal the decision, in a language they understand. Under
mental health Acts in Australia and New Zealand, health professionals
wishing to administer treatment must gain informed consent from the
person prior to treatment. To give informed consent, the person must
have the ‘capacity’ to make decisions. There are strict criteria regarding
the administration of treatment under mental health Acts if the person is
132 Chapter 13 Law and Ethics
deemed not to hold capacity, including the provision that the treatment
provided must be the least restrictive form of treatment.
Compulsory Community Treatment

Compulsory mental health care in the community has existed for many
decades in Australia and New Zealand and is enacted under community
treatment orders. These orders allow people with mental illness to remain
in the community and attempt to increase engagement with services,
reduce relapse and promote recovery. However, how effective they are for
mental health and wellbeing is under ongoing scrutiny given the human
rights implications (O’Brien 2014). Most community treatment orders
require that the person accepts treatment; if they do not, they can be
removed to a psychiatric treatment facility.
The term ‘absconding’ refers to people who have been placed on an
involuntary treatment order or who have been transported to hospital
under a section of the Act but have left care. The term ‘absent without
official leave’ (AWOL) is also sometimes used, but those on designated
leave from a voluntary hospitalisation may also be deemed AWOL if they
fail to return at a prior agreed designated time.
Role of Paramedics, Ambulance Officers and

Police Officers as Authorised Officers
Authorised officers have a role in the care of people with mental illness as
well as in providing the least restrictive means of taking a person to
hospital. Paramedics, ambulance officers and the police are frequently
involved in transporting people for the purposes of assessment and
treatment and have particular responsibilities that include transporting
people if it appears they may have an illness that the person has caused
themselves or are at significant risk to themselves, the public, or property.
For example, in South Australia under the Mental Health Act 2009,
authority is given to police and ambulance officers to search, restrain and
use reasonable force in transporting those thought to be suffering from a
mental illness for assessment and treatment. It is important to remember
that health professionals, nurses, paramedics and other groups such as
the police have various scopes of practice in relation to specific types of
health and mental health law legislation.
Summary of Rights of People With Mental Illness

In 1991 the United Nations established principles for protecting people
with mental illness. These include the right to:
• confidentiality about their personal information
• voluntary treatment wherever possible
• information about mental health Acts to be given in a verbal and written
form that the person can understand
• no treatment being given without informed consent
• receive appropriate medical treatment

• the least restrictive care and restraints only being used as a last resort
• make a complaint
• specific conditions of treatment if a person is involuntarily held
• live and work in the community (adapted from Singh 2012).
In Australia and New Zealand, mental health legislation is based on
human rights and additional individual rights. These include the right to:
• access to legal representation
• access to a copy of the jurisdiction’s mental health Act
• an appeal
• a second psychiatric opinion.
ETHICAL ISSUES IN MENTAL HEALTH CARE

Ethics in health care refers to determining the right thing to do in difficult
circumstances in accordance with the standards and competencies of
your health profession. All health workers are expected to be aware of the
professional standards, ethical codes and competencies related to the
focus of their practice (see Chapter 3). Ethical codes provide guidance to
health professionals regarding their obligations to the public and the
boundaries of their practice. Box 13.1 lists the main terms in ethics in
mental health settings.
Exceptions to Confidentiality
An exception to confidentiality is termed the ‘Tarasoff rule’, which is
based on a famous American case that resulted in the death of a woman
whose ex-boyfriend had confided to his treating psychologist that he
would kill her, which subsequently happened. Under the law at that time,
the psychologist was not required to inform authorities or the person in
potential danger. After a number of appeals to the original decision, a
therapist now has a duty to protect an intended victim where information
is disclosed in the context of a health setting. Thus, disclosure of
confidential information in the public interest will only be justified in
exceptional circumstances where the risk to one person or the public is
severe. Other exceptions can include: where the patient (or his/her parent
or legal guardian in the case of a person who is a minor or a mentally
incompetent adult) consents to the disclosure of the information; where
health professionals have knowledge of firearm injuries or possession of
firearms; and where mandatory reporting of suspected child abuse is
concerned.
The Ethics of Restraint

Restraint of people with mental illness is used to control and contain
dangerous and disruptive behaviour. As described earlier, mental health
law allows the police, paramedics and ambulance officers to restrain and
BOX 13.1
SUMMARY OF THE MAIN TERMS IN ETHICS IN MENTAL HEALTH SETTINGS
• Privacy. Information provided to health professionals is safeguarded and kept
private from the general public. Privacy refers to spoken and written material
and all forms of health care records (e.g. prescriptions, x-rays, case notes).
• Confidentiality. Health professionals should keep information secret about
people in their care unless it needs to be shared for the purposes of giving
care; in this case personal information may be passed on.
• Veracity. Health professionals should tell the truth to people in their care and
not withhold or mislead in regard to giving information.
• Autonomy. This refers to a person’s self-determination and ability to make
decisions for themselves.
• Informed consent. This refers to providing information about the nature of the
person’s illness, the therapeutic procedures, care and treatment, including the
risks, benefits and outcomes of various treatment options.
• Paternalism. This refers to decisions made by medical practitioners or other
health professionals that are deemed to be in the best interests of the person
in the context of their illness. This is a controversial issue and a common
ethical dilemma because when the principle of paternalism is applied, the
principle of autonomy may be overridden.
• Beneficence. Health workers should attempt to ‘do good’ to people in their
care.
• Nonmaleficence. Above all, health workers should do no harm. Health
professionals have a duty of care to not cause harm to those in their care and
to prevent or avoid harm occurring.
• Justice. Care should be provided that is fair and given equally to others.
use reasonable force to contain and transport people for treatment.

Restraint must be exercised within a context of the least restrictive
environment (to protect a person’s autonomy), as well as the duty of care
that must be extended by the health professional or police officer. ‘Duty of
care’ is a legal term referring to the obligations required by people in a
workplace that they adhere to a standard of reasonable care in their
day-to-day work. For mental health and other health professionals this
includes a need to:
• act in the best interests of others
• not act or fail to act in a way that could cause harm
• always act within your own competence and do not do something that
you cannot do safely.
Therefore, if needing to physically hold or lift a person, you must have
the skills and knowledge to undertake the activity. If you do not, you
could be in breach of your duty of care. The use of any form of
restraint—physical (physical holding), mechanical (shackles, cuffs or
netting), chemical (the administration of medication to control a person’s
behaviour) and confinement as in seclusion—must be used as a last

resort when all other options (e.g. talking, diversion) have been
exhausted. Restraint should occur for the shortest possible time and there
must be careful adherence to procedures. Queensland’s recently revised
Mental Health Act 2016 specifically addresses the use of mechanical
restraint, seclusion and physical restraint as measures to be strictly
controlled and minimised. Such restrictive practices can only be used
under certain circumstances, are time-limited and can only happen in
association with a reduction and elimination plan, the purpose of which is
to eliminate the use of restraint for the person in care.
Comparison of Individual and Professional Views

Based on the following case study, Table 13.1 compares individual and
professional views of ethical principles in mental health.
CASE STUDY: ETHICAL DECISION MAKING

Jane is an 18-year-old woman who has been taken by ambulance to an emergency
department in Adelaide, South Australia. Her mother called emergency services
when Jane admitted taking 30 paracetamol tablets. Jane was unwilling to go to
hospital, but paramedics insisted, using their rights to transfer a person to hospital
for assessment if they believe a person may be suffering from a mental illness. Jane
has asked ambulance staff not to tell her mother of her suicidal ideation or previous
self-harming (cutting) behaviour. Jane is unwilling to stay in hospital and despite
health professionals seeking her consent to stay in hospital, she refuses and is
detained under the relevant mental health legislation for treatment for her mental
health problems.
COMMENT
Confidentiality requires that the health professionals do not inform the mother about
this information, as the daughter has requested. The person is an adult in a legal
sense and so has autonomy regarding her decisions. Duty of care also requires that
paramedics and ambulance officers inform the treating medical and mental health
team of her suicidal ideation. Under mental health legislation in Australia and New
Zealand, treatment can be given involuntarily for mental health issues only, not
medical care per se. Medical care can be given involuntarily under duty of care and
urgent necessity.
CONCLUSION
There are many competing issues for carers, people with mental illness
and health professionals when caring for people with mental illness, and
these are not easily resolved in many cases. This chapter has provided an
overview of the central issues regarding ethics, mental health law and
people with mental illness. The challenge remains to treat people with
mental illness with the least restriction on their autonomy while ensuring
they receive the best possible care to facilitate recovery and stability in
their lives.
TABLE 13.1
INDIVIDUAL AND PROFESSIONAL VIEWS OF ETHICAL PRINCIPLES IN
MENTAL HEALTH
Ethical Mental Health Human Rights
Principle Jane’s View Professional’s View Issues
Autonomy ‘I want to stay at home ‘Jane is extremely depressed The right to
and decide for myself and does not have the determine one’s
about what treatment, capacity to make own health
if any, I need.’ decisions in her best decisions
interests.’
Beneficence ’To “do good”, you should ’To “do good”, we must The right to choose
help me make my own ignore Jane’s stated between different
decisions and let me wishes and prevent her treatment options
stay at home.’ from harming herself.’
Nonmaleficence ‘If you admit me to ‘If we do not admit Jane, we The right to freedom
hospital, you will be will cause greater harm of movement
“doing me harm”.’ by allowing her physical
condition to deteriorate,
running the risk that she
will attempt suicide.’
Justice ‘I have the same right as ‘While Jane is not able to The right to refuse
anyone else to make make the best decisions treatment
my own decisions. for her health, we must
Other people can’t be make them for her.’
forced to go to hospital
if they don’t want to.’
Adapted from Happell et al 2008 p 92.
References
Happell, B., Cowin, L. S., Roper, C., et al. (2008). Introducing mental health nursing; a consumer
oriented approach. Sydney: Allen & Unwin.
Maude, P., & O’Brien, A. (2017). Professional, legal and ethical issues. In K. Evans, D. Nizette, &
A. O’Brien (Eds.), Psychiatric and mental health nursing (4th ed.). Sydney: Elsevier.
O’Brien, A. (2014). Community treatment orders in New Zealand: regional variability and
international comparisons. Journal of Psychiatric Mental Health Nursing, 13(3), 356–363.
Singh, B. (2012). The active participants in mental health services. In G. Meadows, B. Singh, & M.
Grigg (Eds.), Mental health in Australia. Melbourne: Oxford University Press.
World Medical Association. (2006). Statement on ethical issues concerning patients with mental
illness. Online. Available: http://www.wma.net/en/30publications/10policies/e11/ 1 November
2013.
Web Resources
Australian Mental Health Acts
Mental Health Act 2014 (WA). https://www.slp.wa.gov.au/legislation/statutes.nsf/main_
mrtitle_13534_homepage.html.
Mental Health Act 2014 (Vic). https://www2.health.vic.gov.au/mental-health/practice-and
-service-quality/mental-health-act-2014.
Mental Health Act 2009 (SA). https://www.legislation.sa.gov.au/LZ/C/A/Mental%20Health%20
Act%202009.aspx.
Mental Health and Related Services Act (as in force at 1 September 2017) (NT). https://
legislation.nt.gov.au/Legislation/MENTAL-HEALTH-AND-RELATED-SERVICES-ACT.
Mental Health Act 2015 (ACT). http://www.health.act.gov.au/our-services/mental-health/
mental-health-act-2015.
Mental Health Act 2013 (Tas). http://www.dhhs.tas.gov.au/mentalhealth/mental_health_act/
mental_health_act_2013_new_mental_health_act.
Mental Health Act 2007 (NSW). http://www.legislation.nsw.gov.au/#/view/act/2007/8/whole.
Mental Health Act 2016 (Qld). https://www.health.qld.gov.au/clinical-practice/
guidelines-procedures/clinical-staff/mental-health/act.
Other Resources
Code of conduct for paramedics in Australia. https://www.paramedics.org/our-organisation/
governance/code-of-conduct/.
Code of ethics for nurses in Australia. http://www.nursingmidwiferyboard.gov.au/
Codes-Guidelines-Statements/Professional-standards.aspx.
Guardianship and Administration Board (Tasmania). www.guardianship.tas.gov.au. These boards
can make decisions for the benefit of people who have a disability and who are unable to make
reasonable judgments about lifestyle and financial matters.
Nursing Council of New Zealand Codes of Conduct. http://www.nursingcouncil.org.nz/Nurses/
Code-of-Conduct. As the statutory authority, the council governs the practice of nurses. The
council sets and monitors standards in the interests of the public and the profession. The
council’s primary concern is public safety. This link takes you to the council’s available
publications.
Royal College of Psychiatrists. www.rcpsych.ac.uk. This is a British website with readable,
user-friendly and accurate information about mental health problems.
South Australian Civil and Administrative Tribunal. http://www.sacat.sa.gov.au/about-sacat.
SACAT is a state tribunal that helps people in South Australia to resolve issues within specific
areas of law.
United Nations Convention on the rights of person with disabilities. https://www.un.org/
development/desa/disabilities/about-us.html.
Chapter 14
Settings for Mental Health Care
INTRODUCTION
Mental health services in developed countries have undergone major
reform in recent decades, and the World Health Organization (2013)
has called for this reform to be worldwide. Reform has led to the
mainstreaming of mental health services (i.e. providing mental health care
within the general health system, not within separate psychiatric services)
and a shift from the traditional biomedical treatment approach to a model
in which recovery is the focus (Commonwealth of Australia 2015, New
Zealand Ministry of Health 2014).
Reform policy directs that ‘[p]eople with mental health problems and
mental illness will have timely access to high quality, coordinated care
appropriate to their condition and circumstances, provided by the most
appropriate services’ (Australian Government Department of Health
2016a) and the World Health Organization (2013) recommends that
‘mental health care is available at the community level for anyone
who may need it’. In Australia and New Zealand, the reform agenda has
led to the transformation and expansion of the settings in which mental
health care is delivered. This chapter provides an overview of these
settings.
MENTAL HEALTH CARE

Contemporary mental health services provide a wide range of
interventions and programs including: assessment and treatment;
emergency and crisis care; prevention and early intervention programs;
mental health promotion initiatives; support for people and families who
have ongoing mental health needs; and rehabilitation and recovery
programs. Services that embrace a recovery framework also emphasise
mental health and do not just focus on treating the symptoms of the
person’s mental illness.
Mental health services are provided in diverse settings by a broad range
of health workers including allied health professionals, care workers,
general practitioners (GPs), mental health nurses, psychiatrists and
psychologists. Services and programs are delivered in both public and
private hospitals, by government and non-government organisations and
in both community and institutional settings.
COMMUNITY SETTINGS
The preferred contemporary setting for providing mental health care is in
the community (Sharrock et al 2017, World Health Organization 2013).
Community mental health services include primary care, mental health
promotion, early intervention, acute treatment and community support
138
Chapter 14 Settings for Mental Health Care 139
services, and may be provided by public or private sector organisations

(Australia Government Department of Health 2016a, New Zealand
Ministry of Health 2016).
CARE COORDINATION
The predominant model of public sector mental health care that is
provided at the community level is care coordination (formerly called ‘case
management’) (Sharrock et al 2017). In the public sector care
coordination is mostly undertaken by mental health services, while in the
private sector GPs and other private practitioners undertake this. Care
coordination functions include:
• collaboration
• monitoring wellbeing and recovery
• identifying and working with risk
• collaborating with other agencies (Sharrock et al 2017).
Generally, public sector community mental health services are
structured into multidisciplinary teams that provide mental health care to
specific population groups. While the structure of these teams and the
names of the teams differ between health services, most community
mental health services provide three types of intervention:
• crisis intervention
• treatment for people with acute mental illness
• ongoing care for people with enduring mental illness.
ASSESSMENT AND CRISIS INTERVENTION TEAMS

Assessment and crisis intervention services provide a single point of first
contact with the mental health team and are generally available 24 hours
a day, seven days a week. Referrals are accepted from any source. These
services provide community-based mobile emergency response, crisis
assistance, initial assessment, short-term case management, admission to
psychiatric inpatient units and referral for treatment within the community.
COMMUNITY TREATMENT TEAMS

Community treatment services provide community-based multidisciplinary
care coordination and consultancy services to people with mental illness
and their family or carers. In addition to providing treatment for the
mental illness, emphasis is placed on assisting people with mental illness
to develop skills in self-care and independent living in their own
environment, thereby encouraging integration within the community and
recovery. They have a crisis, care coordination and rehabilitation role,
which means the person is engaged with one mental health professional
throughout the episode of care—that is, through the crisis and
rehabilitation phases and for ongoing case management.
140 Chapter 14 Settings for Mental Health Care
OUTREACH/MOBILE ASSERTIVE CARE TEAMS

Mobile assertive care services provide intensive and medium-term support
to people with a severe and disabling mental illness. The services provide:
intensive, mobile, community-based care coordination; specialist care
regarding self-care, medication and treatment options; close liaison with
other support services; linkage and advocacy with external agencies or
services; and carer support and education. Outreach teams for homeless
people provide mental health services for a population that might not
otherwise access these services.
GENERAL PRACTITIONERS
GPs are frequently the first point of contact for people with mental health
problems or mental illness. GPs can refer the person either to a private
mental health practitioner or to the local public mental health service.
Also, people who have been treated by public sector mental health
services will often be discharged into the care of their GP for ongoing
case management.
PRIVATE PRACTITIONERS
Psychiatrists, psychologists, mental health nurse practitioners and other
allied health professionals in private practice provide treatment,
counselling and case management services. Generally, private health
insurance is required to access these services, though some private
services are publicly funded.
In Australia seeing a psychologist in private practice attracts a Medicare
payment if the GP develops a ‘GP mental health care plan’ for the person
(Australian Government Department of Health 2015). In New Zealand
private psychologists and mental health nurses deliver mental health
services in primary care settings, including services such as health
promotion, prevention, early intervention and treatment for mental health
or addiction (New Zealand Ministry of Health 2017a).
MENTAL HEALTH NURSE INCENTIVE PROGRAM

Another model of care coordination in Australia is the Mental Health
Nurse Incentive Program. It was established in 2007 by the federal
government and provides a non-MBS (Medical Benefit Scheme) incentive
payment to general practices, private psychiatric services and other
appropriate community providers to employ mental health nurses to help
provide coordinated clinical care for people in the community who have
severe mental illness and complex needs (Australian Government
Department of Health 2016b).
To work under this scheme a registered nurse needs to be
credentialled as a mental health nurse with the Australian College of
Mental Health Nurses (ACMHN 2017a, Sharrock et al 2017).
Credentialled mental health nurses are employed to work with people
with mental illness, their families and carers in a range of settings—

including GP practices, private clinics, supported accommodation and
private homes—to provide coordinated clinical care for people living in
the community who have mental health disorders or a mental illness.
Mental health nurses employed through this initiative provide a range of
services to enhance continuity of care, which are geared towards each
person’s particular needs. Services include:
• care coordination
• therapeutic interventions
• regular review of the person’s mental state
• medication monitoring and management
• providing information about physical health care to people with mental
illness and carers
• providing education and acting as a resource regarding mental health
and mental illness to other professionals within the practice (ACMHN
2017b).
PHARMACISTS
Pharmacies are an easily accessible community resource. The
Pharmaceutical Society of Australia (2017) has developed a framework
to help pharmacists work in partnership with people with mental illness,
carers and care coordinators. While recognising that medication may not
be the primary or sole option for treating mental illness, the society’s aim
is for pharmacists to work in partnership with people with mental illness
to provide direct (medication management and advice) and indirect
(education and health promotion) services and, thereby, facilitate recovery.
NON-GOVERNMENT ORGANISATIONS
Non-government organisations (NGOs) play a significant role in providing
psychosocial, support and rehabilitation services to people with
mental illness, including employment, accommodation, social support,
information, family respite and day and recreation programs. NGOs are
generally run by not-for-profit organisations with the support of government
funding. This sector has grown significantly in recent decades.
The support provided by NGOs assists people who are living with
severe and enduring mental illness to: improve their quality of life; acquire
suitable accommodation; participate to their maximum extent in social
and recreational activities; pursue education and employment
opportunities; and achieve an optimal level of independent living in the
community. Programs also provide community access, community
development and outreach support. NGOs also provide leadership and
are frequently at the forefront of: innovations in service delivery; workforce
culture change; effective partnerships with people with mental illness,
carers, families and communities; and putting recovery into action (SA
Health 2017, New Zealand Ministry of Health 2014).
COMMUNITY DISABILITY SUPPORT PROGRAMS

The National Disability Support Scheme (NDIS) provides support for
Australians aged under 65 years living with a disability (including mental
illness) and their families and carers to assist the person to build the skills
and capability to enable them to participate in the community and
employment. Services include:
• access to mainstream and community services and supports
• assistance in maintaining informal support arrangements
• access to reasonable and necessary funded supports (NDIS 2017).
In New Zealand community support for people living with mental illness
(and other disabilities) and their carers is provided by the Ministry of
Health. The service is currently undergoing reform to increase choice and
control in the lives of people living with disabilities and their families. The
reform employs an explicit social investment approach—that is, early
monetary investment to enable better long-term life outcomes for people
with mental illness, and to reduce long-term costs for government (New
Zealand Ministry of Health 2017b).
MUTUAL SUPPORT/SELF-HELP/INFORMATION/
ADVOCACY GROUPS
Mutual support/self-help/information/advocacy groups offer peer-based
support, information and social action services to people with mental
illness and their families and carers. Skylight Australia and Supporting
Families in Mental Illness New Zealand are examples of such
organisations. In addition to providing support, accommodation,
employment training, friendship and psycho-education for their members,
these organisations also play a significant role in advocacy and lobbying
for appropriate services for people with mental illness and challenging the
stigma of mental illness as well as the consequent discrimination
experienced by people with mental illness and carers.
HOSPITAL SETTINGS
Public and private hospitals provide treatment for mental illness in
specialised mental health inpatient units and in general hospital settings.
People with mental illness admitted to inpatient units may be voluntary or
involuntary (compelled to accept treatment under the relevant mental
health Act).
ACUTE INPATIENT UNITS

Acute inpatient units provide care for people requiring hospitalisation.
Care is provided 24 hours a day by a multidisciplinary team of medical
and allied health professionals including mental health nurses,
psychiatrists, psychologists, social workers and occupational
therapists.
Inpatient units are located in specialised psychiatric hospitals and

within acute general hospitals. They provide individual treatment as well
as a comprehensive activities program designed to meet a range of
individual needs. The goals of inpatient therapy include:
• containment
• safe environment
• structure
• support
• involvement
• validation
• maintaining links with the person’s family or others
• developing or maintaining links with the community (Sharrock et al
2017).
SECURE/EXTENDED CARE INPATIENT FACILITIES

Secure/extended care inpatient facilities provide a safe, supportive
environment for people with serious mental illness and whose behaviours
may put themselves or others at risk. The units provide intensive inpatient
treatment and care to people who have persistent severe symptoms that
limit their capacity to live in the community.
INTERMEDIATE CARE CENTRES

Intermediate care centres are ‘step up–step down’ facilities that provide
care for people living in the community who are experiencing early
warning signs of a relapse, and for people leaving hospital who require a
transition before returning home. The care is recovery-focused and
delivered by a nurse-led multidisciplinary team in a homelike, supportive
environment. There is also a focus on improving the person’s connection
with local community services such as health, housing, employment and
recreation (SA Health 2017).
SAFEWARDS MODEL
Safewards is an evidence-based model of care designed to provide
a safe treatment environment for patients and staff across a variety
of inpatient settings. It was developed in the United Kingdom by Bowers
and colleagues (Bowers 2014) and is being adopted worldwide as a
best-practice inpatient model that empowers both patients and staff.
The original research sought to understand why levels of conflict and
containment differed across different inpatient settings. Findings
have identified strategies to reduce risk and coercion in inpatient
units, thereby establishing effective communication pathways and
patient engagement and a care environment that is conducive to
recovery.
MENTAL HEALTH TRIAGE AND

CONSULTATION-LIAISON PSYCHIATRY
Mental health triage has both a clinical and a consultation function
provided at a point of entry to a health service such as in an emergency
department. It provides assessment, consultation, referral and admission
if required. The service is delivered by mental health nurses, psychiatrists
and allied mental health professionals who provide expert consultation
and support to non-mental health professionals in hospital emergency
departments or other settings.
Consultation-liaison psychiatry services are provided for people with a
primary medical condition (e.g. an elderly person who develops a delirium
following general anaesthesia) in general hospital settings. Services are
also available for people who have a known mental illness associated with
or complicated by a medical problem (e.g. a person who develops
metabolic syndrome after taking an atypical antipsychotic medication).
Services provided by a consultation-liaison psychiatry service include:
• mental health assessment and intervention for inpatients, including risk
assessment
• advice on the acute psychiatric management of people who have
attempted suicide or self-harm
• in-service education for staff on mental health issues
• advice on psychopharmacology, psychological interventions and mental
health legislation (Leigh 2015, Sharrock et al 2017).
SPECIAL POPULATIONS
In addition to the mental health settings outlined above, mental health
care is also delivered by specialised services that focus on the needs of
particular populations and are offered across a variety of settings within
both the community and institutions. These include services specifically
for: children and adolescents; youth (e.g. headspace 2017); the elderly;
prisoners; indigenous peoples; people with specific diagnoses (e.g. eating
disorders); people with drug and alcohol problems; people living in
particular geographical areas (e.g. regional, remote and rural populations);
and refugees and immigrants.
CONCLUSION
Contemporary health policy directs mental health service providers to
deliver care for people with mental illness that is responsive to their
(and their carers’) needs, promotes positive outcomes and facilitates
sustained recovery (Australian Government Department of Health 2016a).
To enable this outcome, people with mental illness and carers need
access, in a timely manner, to the most appropriate clinical and
community services.
Settings for delivering mental health care are diverse and include the
community and health care institutions. While care in the community is
advocated as the preferred setting in which to deliver mental health care,
at times some people will require inpatient care. Finally, decisions about
where to deliver care need to be made collaboratively, be person-centred
and be based on the needs of the person and their family/carers to best
facilitate the person’s recovery.
References
Australian College of Mental Health Nurses (ACMHN). (2017a). Credential for Practice Program.
Online. Available: http://www.acmhn.org/credentialing/what-is-credentialing 27 July 2017.
Australian College of Mental Health Nurses (ACMHN). (2017b). The mental health nurse incentive
program. Online. Available: http://www.acmhn.org/career-resources/mhnip/background 27 July
2017.
Australian Government Department of Health. (2015). Better access to psychiatrists, psychologists,
and general practitioners through the MBS (Better Access) Initiative. Online. Available: http://
www.health.gov.au/mentalhealth-betteraccess 27 July 2017.
Australian Government Department of Health. (2016a). Draft fifth national mental health plan: an
agenda for collaborative government action in mental health 2017–2022. Canberra:
Commonwealth of Australia. Online. Available: http://www.health.gov.au/internet/main/
publishing.nsf/content/mental-fifth-national-mental-health-plan 24 July 2017.
Australian Government Department of Health. (2016b). Mental Health Nurse Incentive Program.
Online. Available: http://www.health.gov.au/internet/main/publishing.nsf/content/work-pr-mhnip
24 July 2017.
Bowers, L. (2014). Safewards: A new model of conflict and containment on psychiatric wards.
Journal of Psychiatric and Mental Health Nursing, 21(6), 499–508.
Commonwealth of Australia. 2015. Australian Government’s response to Contributing Lives,
Thriving Communities – Review of Mental Health Programmes and Services. Online.
Available: http://www.health.gov.au/internet/main/publishing.nsf/content/
0DBEF2D78F7CB9E7CA257F07001ACC6D/$File/response.pdf 27 July 2017.
headspace. (2017). National Youth Mental Health Foundation. Online. Available: http://
www.headspace.org.au 27 July 2017.
Leigh, H. (2015). Ch 2 ‘The function of consultation-liaison psychiatry. In H. Leigh & J. Streltzer
(Eds.), Handbook of consultation-liaison psychiatry. California: Springer.
National Disability Insurance Scheme (NDIS). (2017). Online. Available: https://www.ndis.gov.au/
index.html 27 July 2017.
New Zealand Ministry of Health. (2014). Mental health work at the Ministry. Online. Available:
http://www.health.govt.nz/our-work/mental-health-and-addictions/mental-health/
mental-health-work-ministry 27 July 2017.
New Zealand Ministry of Health. (2016). Mental health annual report 2015. Online. Available:
http://www.health.govt.nz/publication/office-director-mental-health-annual-report-2015 27 July
2017.
New Zealand Ministry of Health. (2017a). Primary mental health. Online. Available: http://
www.health.govt.nz/our-work/primary-health-care/primary-health-care-subsidies-and-services/
primary-mental-health 27 July 2017.
New Zealand Ministry of Health. (2017b). Disability services. Online. Available: http://
www.health.govt.nz/your-health/services-and-support/disability-services 27 July 2017.
Pharmaceutical Society of Australia. (2017). Mental health care framework. Online. Available:
https://www.psa.org.au/policies/mental-health-care-framework 27 July 2017.
SA Health. (2017). Intermediate care centres. Online. Available: http://www.sahealth.sa.gov.au/wps/
wcm/connect/public+content/sa+health+internet/health+reform/mental+health+reform/
intermediate+care+centres 27 July 2017.
Sharrock, J., Maude, P., Wilson, L., et al. (2017). Settings for mental health. In K. Evans, D.
Nizette, & A. O’Brien (Eds.), Psychiatric and mental health nursing (4th ed.). Sydney:
Elsevier.
World Health Organization (2013). Comprehensive mental health action plan 2013–2020. Geneva:
WHO. Online. Available http://www.who.int/mental_health/action_plan_2013/en/ 27 July 2017.
Web Resources
Australian Government Department of Health. Mental Health. http://www.health.gov.au/internet/
main/publishing.nsf/Content/Mental+Health+and+Wellbeing-1. The federal government’s mental
health and wellbeing homepage provides access to information about mental health reform,
legislation, policy, resources, initiatives and publications.
Health boards and departments of health. See your local health board or state or territory health
department website for specific details of the mental health services provided and the settings in
which these services are delivered.
Skylight (formerly the Mental Illness Fellowship of Australia Inc). www.skylight.org.au. Skylight is a
not-for-profit non-government organisation that provides self-help, support and advocacy for
people with serious mental illnesses, their families and friends. Skylight’s mission is to ‘increase
opportunities to achieve good mental health; to promote acceptance of mental illness in the
communityl; and provide quality services for people with mental illness, their family and friends.’
Mental Health Foundation of New Zealand (Mauri Tu, Mauri Ora). www.mentalhealth.org.nz. This
charity endeavours to foster positive mental health and wellbeing. It assists individuals, whānau,
organisations and communities to improve and sustain their mental health and reach their full
potential.
New Zealand Ministry of Health. www.moh.govt.nz/mentalhealth. The ministry’s mental health
homepage provides access to information about mental health legislation, policy, resources,
publications and how to access mental health care.
Safewards. www.safewards.net. The Safewards model of mental health care originated in the UK
and is being implemented worldwide. It aims to provide an inpatient environment that is safe for
both clients and staff, and to reduce the use of restrictive interventions such as seclusion and
restraint.
Appendix 1
Surviving Clinical Placement
GET ORGANISED
• Research your placement before you go. Find out what you will be
expected to do on your first day.
• Research how to get to the placement, travel times and parking.
• Make sure your immunisations and other physical health screening,
manual handling, first aid, student ID and police clearances (aged care,
children and vulnerable persons) are all completed, recorded and up to
date before you begin your placement.
• Find out about the prescribed dress code (if not in uniform) and dress
professionally.
• Buy at least two uniforms (new or quality second-hand) for placement.
• Invest in a good pair of shoes to increase comfort and safety, if you will
be on your feet a lot.
• Read as much as you can to prepare yourself for the placement.
• Focus your learning by writing objectives for the placement.
• Use a diary on your phone, computer, iPad, notebook, etc. to record
relevant information.
• During your placement prioritise tasks on a needs basis; don’t drop
everything when you are asked to do something, unless it is clearly an
emergency.
• Find out about commonly used abbreviations in the organisation.
• Be responsible for your own learning.
COMMUNICATION
• Arrive and leave on time.
• Ask for direction about what to do on your first day.
• Find out where you can securely place your belongings.
• Find out about security measures when finishing late at night.
• Check whether you are allowed to carry your mobile phone (turned off)
or whether it will interfere with the operation of electronic equipment.
• If you are not able to attend the placement contact the organisation in
advance.
• Be willing to approach people with mental illness, introduce yourself
and start a conversation. People with mental health problems are no
different from the rest of us.
• Be polite and respectful at all times.
• Record your supervisor/facilitator’s contact details and keep them in a
safe place. Contact them if they haven’t contacted you in the first few
days of your placement.
• Actively seek out your supervisor/facilitator and ask for feedback.
147
148 Appendix 1 Surviving Clinical Placement
• Identify and discuss your learning goals for the placement with your
supervisor/facilitator, including how these can be achieved.
• Clarify expectations about your role and what you are there to achieve.
• Don’t be afraid to say ‘I don’t know’.
• Don’t be afraid to ask questions. There is no such thing as a stupid
question.
• Actively seek feedback on your work from clinicians with whom you work.
• Make the effort to get to know other members of the team.
• Get involved in your allocated team, and talk to all the people in the
multidisciplinary team.
• Use your initiative! Offer your opinion. Share your knowledge of
research into clinical practice.
• If you are feeling vulnerable, talk to someone about it.
PROFESSIONAL BEHAVIOUR
• Demonstrate cultural awareness and sensitivity with everyone you meet.
• Know and adhere to the rules and regulations of the placement facility.
• Be aware of the requirement of privacy and confidentiality.
• Refrain from:
• inappropriate language and behaviour
• being argumentative and disrespectful
• knowingly performing procedures beyond your level of practice.
• Don’t agree to keep a confidence with people for whom you are
providing care.
• Don’t give out personal details such as your surname, mobile telephone
number or address to people for whom you are providing care.
• NEVER post material about your clinical placement in social media or
online. DO NOT post photographs of yourself or people with mental
illness while on placement, comments about hospitals or criticisms of
other staff. Health professionals have been disciplined for inappropriate
postings and you may lose your job or place in your course of study.
WORK/LIFE BALANCE AND YOUR OWN SELF-CARE

• Establish a ritual for when you come home after a shift (e.g. have a
shower, change out of your uniform).
• Enjoy your time off, plan social activities, contact your friends.
• Have regular contact with your peers. This will enhance your own
professional experience.
• Remember that it is normal to have setbacks; make plans to address issues.
• Don’t be too hard on yourself.
• Limit your coffee and alcohol intake.
• Get lots of sleep.
• Avoid taking work home.
• Exercise regularly.
• Learn from your mistakes. You are a ‘newby’! Making mistakes is okay.
• Talk to those close to you if you feel you are not coping.
Appendix 2
Who Does What in
Mental Health?
ACCREDITED EXERCISE PHYSIOLOGIST
An accredited exercise physiologist works with people with mental health
problems to design an exercise treatment plan to increase general fitness,
reduce weight and improve mental wellbeing.
ACCREDITED PRACTISING DIETICIAN

An accredited practising dietician assesses and monitors the mental and
physical health risks associated with food and nutrition. They plan and
manage the nutrition and dietetic care, lifestyle and wellbeing of people
with mental illness. People who have or are at risk of having metabolic
comorbidities, who are overweight or who have commenced new
psychotropic medication, including lithium, can be supported by this
professional group in managing their nutrition.
COMMUNITY VISITOR
A community visitor is a person appointed by justice departments in
Australia and New Zealand to visit inpatient and residential mental health
environments. Community visitors regularly visit these facilities to promote
the rights of the patients and residents, protect their interests and ensure
no one is taking advantage of them.
MENTAL HEALTH NURSE

A mental health nurse has formal qualifications in mental health nursing
with a focus on caring for people with mental health problems. A
credentialled mental health nurse is a specialist mental health nurse with
specific skills and knowledge in mental health nursing. The Credential for
Practice Program is an initiative of the Australian College of Mental Health
Nurses and establishes a nationally consistent recognition mechanism for
specialist mental health nurses.
MENTAL HEALTH SUPPORT WORKER
A mental health support worker usually has certificate or diploma
qualifications in mental health and provides mental health counselling
and support to individuals, families and groups in the community. Mental
health support workers provide treatment referrals for clients as well as
assistance with community education, support and other activities.
MULTIDISCIPLINARY TEAMS IN MENTAL HEALTH

A multidisciplinary team comprises members from different health care
professions with specialised skills and expertise in mental health.
149
150 Appendix 2 Who Does What in Mental Health?
Members collaborate to make treatment recommendations that facilitate

high-quality patient care. Multidisciplinary teams form one aspect of
providing a streamlined patient journey by developing individual treatment
plans that are based on ‘best practice’. Multidisciplinary teams provide
treatment that is focused on both the physical and the psychological
needs of the person diagnosed with mental illness. These teams
increasingly involve peer workers contributing to the promotion of recovery
and advocacy for people with a mental health problem.
OCCUPATIONAL THERAPIST
An occupational therapist has formal qualifications in occupational
therapy and works with individuals and groups to achieve the fullest
potential through using purposeful activities and interventions.
Occupational therapists assist people with mental illness to develop
coping strategies to manage their mental health issues. In inpatient
settings occupational therapists design individual and group programs
and activities to enhance the person’s independence in activities of daily
living.
PEER CONSUMER AND CARER WORKERS

These workers have a personal, lived experience of mental illness and
recovery, or care for a person living with mental illness, and are employed
by public, private and community mental health organisations. Peer
workers can provide information and education about mental illness,
recovery and support services to people with mental illness and their
families, friends and carers. Peer consumer and carer workers work in
partnership with clinical staff to promote hope and recovery. Because of
their life experience, such workers have expertise that professional
training cannot replicate. They have job titles such as consumer or carer
consultant, peer worker and peer support worker. Job specifications and
titles differ in different jurisdictions, and the role of peer workers is rapidly
evolving. Formal peer worker tertiary qualifications are now being offered
in educational institutions.
PHARMACIST
A pharmacist assists people with mental health problems by providing
support, referral and continuity of care. Pharmacists support people
with mental illness regarding medication adherence and staged
supply services. They conduct medication reviews and monitor side
effects.
PSYCHIATRIST
A psychiatrist is a medical doctor with additional training in psychiatry.
Psychiatrists specialise in the prevention, early detection and treatment of
mental illness. Psychiatrists can prescribe medication, while psychologists
cannot.
Appendix 2 Who Does What in Mental Health? 151
PSYCHOLOGIST
A psychologist has formal qualifications in psychology (the study of the
mind and human behaviour) and can evaluate, diagnose and treat
behaviour and mental processes. Clinical psychologists use talking
therapies (e.g. cognitive behaviour therapy and psychotherapy) to alleviate
symptoms of emotional distress.
PSYCHOTHERAPIST
A psychotherapist has formal qualifications in counselling and usually an
additional specialisation in specific interpersonal therapies such as
cognitive behaviour therapy. Psychotherapists use talking therapies to
help a person improve their emotional wellbeing, to improve social skills
and to overcome issues (behaviours, beliefs, compulsions or emotions)
that are causing them distress. Psychotherapy is a deeper form of talking
therapy than counselling and usually takes place over a longer period
(months to years) than counselling (weeks to months).
PHYSIOTHERAPIST
A physiotherapist has formal qualifications in physiotherapy and has
expertise in managing chronic disease, muscular skeletal conditions and
acute and chronic pain common in people with mental health problems.
Physiotherapists also facilitate self-management of existing conditions in
order to improve mental wellbeing.
REGISTERED COUNSELLOR
A registered counsellor provides support to people with mental health
problems through talking about specific problems or life difficulties.
SOCIAL WORKER
A social worker has formal qualifications in social work and works with
individuals and groups who need assistance with social, economic,
domestic or employment issues that may have come about due to mental
illness. The aim of care is to increase mental wellbeing and quality of life.
Appendix 3
Abbreviations in
Medication Administration
DOSE FREQUENCY OR TIMING
Intended Meaning Safe Terms or Abbreviations
(in the) morning morning, mane
(at) midday midday
(at) night night, nocte
twice a day bd
three times a day tds
four times a day qid
every 4 hours every 4 hrs, 4 hourly, 4 hrly
once a week ‘once a week’ and specify the day; e.g. ‘once a
week on Tues’ (or Tuesdays)
three times a week ’three times a week’ and specify the exact days,
e.g. ‘three times a week on Mon, Wed and Sat’
when required prn
immediately stat
before food before food
after food after food
with food with food
ROUTES OF ADMINISTRATION
intramuscular IM
intrathecal intrathecal
intranasal intranasal
intravenous IV
irrigation irrigation
nebulised NEB
nasogastric NG
oral PO
per vagina PV
per rectum PR
subcutaneous subcut
sublingual subling, under the tongue
topical topical
152
Appendix 3 Abbreviations in Medication Administration 153
UNITS OF MEASUREMENT AND CONCENTRATION

gram(s) g
international unit(s) international unit(s)
unit(s) unit(s)
litre(s) L
milligram(s) mg
millilitre(s) mL
microgram(s) microg, µg
percentage %
millimole(s) mmol
DOSE FORMS
capsule cap
cream cream
ear drops ear drops
ear ointment ear ointment, ear oint
eye drops eye drops
eye ointment eye ointment, eye oint
injection injection, inj
metered dose inhaler metered dose inhaler, inhaler, MDI
mixture mixture
ointment ointment, oint
pessary pess
powder powder
suppository sup
tablet tablet, tab
patient-controlled analgesia PCA
nebule NEB
These terms are often written on the medication prescription, the

medication chart, case notes or referral letters written by health
professionals. If in doubt, don’t administer the medication, and check
with a pharmacist or the prescribing doctor. Note that some terms are not
abbreviated, which is also important to know.
Source
Australian Commission on Safety and Quality in Health Care. (2017). Recommendations for
terminology, abbreviations and symbols used in medicines documentation. ACSQHC, Sydney.
Reproduced with the permission of the Australian Commission on Safety and Quality in Health
Care.
Appendix 4
Supporting People With Mental
Illness Taking Medication
Health professionals can support people with mental illness in the
following ways:
• Work with the person with mental illness to identify, manage and report
side effects.
• Help the person with mental illness to find a regular time to take their
medication, and suggest they use their mobile phone to set a reminder.
• Write down which medicines (e.g. cough/cold medicines, anti-
inflammatories) interact with their medications and explain this to the
person.
• Assess each person’s ability to take tablets (see Chapter 9). Suggest
using a dosette or Webster pack if this is appropriate.
• Check that the person with mental illness has in-date medications and
returns out-of-date medicines to the pharmacist for disposal. Out-of-
date medications can be toxic.
• Encourage people with mental illness to do the following:
• Ask their pharmacist to go through what the medication is for, when
to take it and any possible side effects if they are unsure or when
their medication is altered.
• Keep a list of their medication in their purse/wallet/mobile device,
and give a copy to a friend.
154
Further Reading and Resources
FURTHER READING ON MENTAL HEALTH
Burroughs, A. (2003). Running with scissors: a memoir. New York: Picador.
Persaud, R. (ed.) (2007). The mind: a user’s guide. London: Bantam
Press.
Richards, K. (2013). Madness: a memoir. Melbourne: Penguin.
Stork, F. (2016). The memory of light. Lavine.
Swados, E. (2005). My depression: a picture book. New York: Hyperion.
APP RESOURCES IN MENTAL HEALTH

The PsychCentral blog has a list of top 10 mental health apps at <http://
psychcentral.com/blog/archives/2013/01/16/top-10-mental-health-apps/>.
These are based on established interventions but do not make claims about
their impact.
1. BellyBio
2. Operation Reach Out
3. eCBT Calm
4. Deep Sleep with Andrew Johnson
5. WhatsMyM3
6. DBT Diary Card and Skills Coach
7. Optimism
8. iSleepEasy
9. Magic Window – Living Pictures
10. Relax Melodies
WEB RESOURCES ON MENTAL HEALTH

Anxieties.com <www.anxieties.com>. This website provides free anxiety
self-help.
ARAFMI: Mental Health Carers Australia <www.arafmi.org>. This
organisation has a network across Australian states and territories
providing a diverse range of services and support to families and
friends of people with mental illness. Services include respite care,
support groups, counselling (telephone and in person),
psychoeducation and workshops.
Australian Bipolar <www.bipolar.com.au>. This is a bipolar information
website.
Australian College of Mental Health Nurses <www.acmhn.org>. The
college is the peak professional body for mental health nurses in
Australia. It is the only organisation that solely represents mental health
nurses. The college engages with its members and key stakeholders to
advance mental health nursing across Australia.
Australian Drug Information Network (ADIN) <www.adin.com.au>. ADIN
provides a central point of access to internet-based alcohol and drug
information provided by prominent organisations in Australia and
155
156 Further Reading and Resources
internationally. It is funded by the Australian Government Department

of Health and Ageing as part of the National Illicit Drug Strategy and is
managed by the Australian Drug Foundation.
beyondblue <www.beyondblue.org.au>. beyondblue is a national,
independent, not-for-profit organisation working to address issues
associated with depression, anxiety and related substance abuse
disorders in Australia. beyondblue works in partnership with health
services, schools, workplaces, universities, media and community
organisations, as well as people living with depression, to bring together
their expertise on depression.
Black Dog Institute <www.blackdoginstitute.org.au>. The institute is a
not-for-profit, educational, research, clinical and community-oriented
facility offering specialist expertise in depression and bipolar disorder.
Carers Association of SA <www.carers-sa.asn.au>. Carers provide unpaid
care and support to family members and friends who have a disability,
mental illness, chronic condition or terminal illness, or who are frail.
More than one in eight Australians provide care of this kind. The
association’s purpose is to improve the lives of carers by providing
important services such as counselling, advice, advocacy, education
and training. The association also promotes the recognition of carers to
governments, businesses and the public.
Carers Australia <www.carersaustralia.com.au>. The purpose of Carers
Australia, and the network of carers’ associations in each state and
territory, is to improve the lives of carers, and to provide important
services such as counselling, advice, advocacy, education and training.
They also promote the recognition of carers to governments, businesses
and the public.
COMIC (Children of Mentally Ill Consumers) <www.howstat.com/comic>.
COMIC was formed at a forum held in 2000 and is composed of a
group of ‘adult children’ who share a common interest for children of
people with mental illness. The group shares a common perception of
the past failure by the mental health services to acknowledge them as
children with unique needs and offer support. COMIC has begun to
lobby and advocate for the rights of children of people with mental
illness and their parents because of the lack of acknowledgment,
education and assistance by mental health services.
Depression Services <www.depressionservices.org.au>. Depression
Services is committed ‘around the clock’ to improving the mental health
and wellbeing of people affected by depression through providing an
internet-based service offering hope and understanding, information
and support.
headspace <www.headspace.org.au>. This website is for young people
with mental health issues, as well as their families and schools.
Mental Health Foundation of New Zealand <www.mentalhealth.org.nz>.
The foundation’s work focuses on making mental health everybody’s
business. Its work is diverse and expansive, with campaigns and
Further Reading and Resources 157
services that cover all aspects of mental health and wellbeing. A holistic
approach is taken to mental health. The foundation provides free
information and training, and is an advocate for policies and services
that support people with experience of mental illness, and also their
families/whānau and friends.
Mental Health in Multicultural Australia (MHMA) <www.mhima.org.au>.
This website provides national leadership in building greater awareness
of mental health and suicide prevention among Australians from
culturally and linguistically diverse backgrounds.
Royal Australian and New Zealand College of Psychiatrists (RANZCP)
<www.ranzcp.org>. RANZCP is the principal organisation representing
the medical speciality of psychiatry in Australia and New Zealand. It is
responsible for training, examining and awarding the Fellowship of the
College qualification to medical practitioners.
SANE Australia <www.sane.org>. SANE Australia is a national charity
working for a better life for people affected by mental illness.
Schizophrenia.com <www.schizophrenia.com>. This is a non-profit
community organisation providing in-depth information, support and
education related to schizophrenia.
Skylight (formerly the Mental Illness Fellowship of Australia Inc.) <www.
skylight.org.au>. Skylight is a not-for-profit non-government organisation
that provides self-help, support and advocacy for people with serious
mental illnesses, their families and friends. Skylight’s mission is to
‘increase opportunities to achieve good mental health; to promote
acceptance of mental illness in the community, and provide quality
services for people with mental illness, their family and friends’.
Supporting Families in Mental Illness <www.supportingfamiliesnz.org.nz>.
This website provides education, advocacy and support for family/
whānau of people experiencing a major mental illness in New
Zealand.
Victorian Mental Health Carers Network <www.carersnetwork.org.au>. The
network is the peak body of organisations and individuals who support
carers of people with mental health issues in Victoria. It comprises:
carers or former carers linked with carer groups; representatives of
statewide carer organisations with a significant carer focus; workers
from carer support programs; and carer-related academics.
Victoria’s mental health services <www.health.vic.gov.au/mentalhealth>.
This website provides information on Victoria’s mental health services
as well as other information about mental health and illness.
World Health Organization (Program and Projects; Mental Health;
Disorders Management—Depression) <www.who.int/mental_health/
management/depression/en/index.html>; World Health Organization
(Programs and Projects; Mental Health; Disorders Management—
Schizophrenia) <www.who.int/mental_health/management/
schizophrenia/en/index.html>. These sites provide suggested reading
about mental illness.
Glossary
Anxiety: a common human experience that is a normal emotion felt in

varying degrees by everyone; also a state in which people experience
feelings of uneasiness, apprehension and activation of the autonomic
nervous system in response to a vague, non-specific threat.
Bipolar disorder: a diagnosis outlined in DSM-5 where a person has

previously experienced at least one manic episode and a depressive
episode.
Clang association: a disturbance in form of thought in which words are

chosen for their sounds rather than their meanings; includes puns and
rhymes.
Coexist: having more than one disorder at the same time, most commonly
a mental health disorder and a substance misuse disorder. Similar
terms are ‘comorbid’ and ‘dual diagnosis’.
Comorbid: having more than one disorder at the same time, most
commonly a mental health disorder and a substance misuse disorder,
but can include a physical disorder such as obesity or diabetes. Similar
terms are ‘coexisting disorder’ and ‘dual diagnosis’.
Compulsions: repetitive behaviours (e.g. handwashing, checking) or
mental acts (e.g. praying, counting), the goal of which is to prevent or
reduce anxiety or distress, not to provide pleasure or gratification.
Credentialled mental health nurse: a registered nurse with postgraduate
mental health nursing qualifications and experience who has been
awarded a ‘credential’ for specialist practice by the Australian or New
Zealand College of Mental Health Nurses.
De-escalation: behaviour (usually learned; non-verbal or verbal) intended

to reduce conflict to avoid aggression and adverse outcomes.
Delirium: a syndrome that constitutes a characteristic pattern of signs and
symptoms that reduce clarity of awareness and impair the person’s
ability to focus, sustain or shift attention; tends to develop quickly and
fluctuates during the course of the day.
Delusion: a false, fixed belief that is inconsistent with one’s social, cultural
and religious beliefs and that cannot be logically reasoned with.
Depression: a disorder characterised by depressed mood, with feelings of
hopelessness and helplessness, lack of pleasure or interest, appetite
disturbance, sleep disturbance and fatigue.
Echolalia: a disturbance in form of thought in which other people’s words

or phrases are repeated; not the same as repetition of the person’s own
words (perseveration).
158
Glossary 159
Empathy: the capacity for understanding and appreciating the feelings,

ideas and experiences of another. It involves cognition (taking the
perspective of another), emotion and the physical act of observing,
listening and attending.
Engagement: the process of establishing rapport with a person through
interactions based on acknowledging and developing a relationship
based on trust.
Fear: a response to a known threat that manifests in the same way as

anxiety.
Flight of ideas: a disturbance in form of thought in which the person’s
ideas are too rapid for them to express, and so their speech is usually
continuous, fragmented and incoherent.
Generalised anxiety disorder (GAD): excessive anxiety and worry

concerning events or activities (apprehensive expectation). This occurs
more days than not for a period of at least six months, and the person
finds it difficult to control.
Hallucination: a sensory perception/experience that occurs without

external/environmental stimuli. Types of hallucination include visual,
olfactory, tactile, auditory, somatic and gustatory.
Hypomania: a form of elevated mood that is less severe than mania.
Indigenous Australian: a person who identifies as being Aboriginal or

Torres Strait Islander.
Intoxication: a reversible state that occurs when a person’s intake exceeds
their tolerance and produces behavioural and/or physical changes.
Major depressive disorder: a condition involving seriously depressed mood

and other symptoms defined by DSM-5 that affects all aspects of a
person’s bodily system and interferes significantly with their daily living
activities.
Mania: a state of euphoria that results in extreme physical and mental
overactivity.
Mental health: the experience of having a positive sense of self and having
access to personal and social resources with which to fully engage in
life and respond to life’s challenges.
Mental health assessment: a comprehensive, holistic assessment based on
a person’s developmental, family, social, medical, recreational and
employment history. It includes a mental state examination and history
of current functioning and presenting problems. The person and family
members or carers may contribute perspectives to this assessment.
Other standardised assessments (such as specific cognitive or family
assessments) may form part of a comprehensive mental health
assessment.
160 Glossary
Mental illness: an illness, diagnosed by DSM-5 or ICD-10 criteria, that

significantly interferes with person’s cognitive, emotional or social
abilities.
Negative symptoms of schizophrenia: includes signs and symptoms such

as blunting of affect, avolition and anhedonia.
Neologisms: a disturbance in form of thought in which a person creates
new words or expressions that have no meaning to anyone else.
Obsessions: recurrent, persistent thoughts, impulses and images that are

intrusive and inappropriate and cause marked anxiety or distress in a
person.
Obsessive-compulsive disorder (OCD): recurrent obsessions or compulsions
that are severe enough to be time consuming or cause marked distress
or significant impairment in a person.
Perseveration: a disturbance in form of thought in which the person

persistently repeats the same word or ideas; often associated with
organic brain disease.
Personality: expression of our feelings, thoughts and patterns of behaviour
that evolve over time.
Personality traits: aspects of our personality that make us unique and
interesting, differentiating us from each other.
Positive symptoms of schizophrenia: includes signs and symptoms such as
delusions, hallucinations and motor disturbance.
Resilience: a person’s ability to achieve good outcomes in spite of

adversity, serious threats and risks.
Risk assessment or risk management: identifying and estimating risk so
structured decisions can be made as to how best to manage risk
behaviour.
Risk factors: factors that increase vulnerability to mental illness (e.g. social
inequities, stressors or discrimination).
Ruminating: having repetitive and increasingly intrusive negative thoughts
and ideas that can eventually interfere with other thought processes.
Safewards: an evidence-based model of care designed to reduce conflict

and containment in inpatient units.
Schizophrenia: a severe mental disorder characterised by major
disturbance in thought, perception, thinking and psychosocial
functioning.
Strengths: a person’s resilience, aspirations, talents, abilities and
uniqueness; what a person can do (and do well).
Stress: a psychological response to any demand or stressor; can be
experienced as negative (distress) or positive. People can respond
differently to the same stressor.
Glossary 161
Suicide: a serious act of self-harm where the person has acted with the
intention of ending their life.
Thought disorder—form, content and process: thought disorder can be

assessed through the observation of speech, which can identify the
amount and rate of production of thought, continuity of ideas and
language production. Examples of disturbances in thought include
circumstantiality, clang association, derailment (loosening of
associations), echolalia, flight of ideas, neologisms, perseveration,
tangentiality and thought blocking.
Trauma-informed care: a model of care that aims to avoid further
traumatising consumers who have been the victims of abuse or
violence.
Withdrawal: usually, but not always, associated with substance

dependence. Most people going through withdrawal have a craving to
readminister the substance to reduce the symptoms. It is the
development of a substance-specific syndrome due to the cessation of
(or reduction in) substance misuse that has been heavy and prolonged.
Credits
Table 1.1: Australian Bureau of Statistics. (2016). Gender indicators, Australia: Health: mental
health, Cat no 4125.0. www.abs.gov.au/ausstats/[email protected]/Lookup/by%20Subject/
4125.0~August%202016~Main%20Features~Health~2321; Mindframe. (2014). Facts and
stats about mental illness in Australia. www.mindframe-media.info/for-mental-health-and-
suicide-prevention/talking-to-media-about-mental-illness/facts-and-stats.
Box 1.1: Adapted from Gibson, M., Carek, P. J., & Sullivan, B. (2011). Treatment of co-morbid
mental illness in primary care: How to minimise weight gain, diabetes and metabolic syndrome.
International Journal of Psychiatry in Medicine, 41(2), 127–142; Mitchell, A., Vancampfort, D.,
Sweers, K., et al. (2013). Prevalence of metabolic syndrome and metabolic abnormalities in
schizophrenia and related disorders—a systematic review and meta-analysis. Schizophrenia
Bulletin, 39(2), 306–318.
Box 1.2: Adapted from World Federation for Mental Health. (2010). Mental health and chronic
physical illness: The need for continued and integrated care. www.encontrarse.pt/wp-content/
uploads/2016/12/docs_wmfh2010.pdf.
Table 2.2: Adapted from Department of Health. (2011). Framework for recovery-oriented practice.
Melbourne: Mental Health, Drug and Alcohol Division, State Government of Victoria.
Table 3.1: Adapted from Department of Health. (2013). National practice standards for the mental
health workforce 2013. Melbourne: © State Government of Victoria.
Table 4.2: Sadock, B. J., & Sadock, V. A. (2007). Synopsis of psychiatry: behavioral sciences/
clinical psychiatry (10th ed.). Philadelphia: Lippincott, Williams and Wilkins.
Box 6.2: Morgan S. (2004). Risk taking. In P. Ryan & S. Morgan (Eds.), Assertive outreach:
a strengths based approach to policy and practice. London: Churchill Livingstone.
Box 6.3: Adapted from Hart, C. (2014). A pocket guide to risk assessment and management.
Oxon, Great Britain: Routledge.
Box 9.3: Elder, R., Evans, K., & Nizette, D. (Eds.), (2011). Psychiatric and mental health nursing
(2nd ed.). Sydney: Elsevier.
Table 9.3: Usher, K. (2017). Psychopharmacology. In K. Evans., D. Nizette & A. O’Brien (Eds.),
Psychiatric and mental health nursing (4th ed.). Sydney: Elsevier.
Table 9.4: Usher, K., Foster, K., & Bullock, S. (2009). Psychopharmacology for health
professionals. Sydney: Elsevier.
Box 9.4: SA Health. (2017). Clozapine management clinical guideline. www.sahealth.sa.gov.au/
clozapine.
Box 9.5: Adapted from Baker, J. (2016). Cochrane find no evidence for as required PRN
medication for mental health inpatients. https://www.nationalelfservice.net/treatment/medicine/
cochrane-find-no-evidence-for-as-required-prn-medication-for-mental-health-inpatients.
Table 10.1: Nursing Council of New Zealand (NCNZ) / Te Kaunihera Tapuhi o Aotearoa. (2011).
Guidelines for cultural safety, the Treaty of Waitangi and Māori health in nursing education
and practice (2nd ed.). Wellington: NCNZ. http://ndhadeliver.natlib.govt.nz/delivery/
DeliveryManagerServlet?dps_pid=IE6429026&dps_custom_att_1=ilsdbviewed.
Box 10.3: Australian Institute of Health and Welfare. (2015). Cultural competency in the delivery of
health services for Indigenous people, Closing the Gap Clearinghouse, Issue paper no. 13.
www.aihw.gov.au/uploadedFiles/ClosingTheGap/Content/Our_publications/2015/ctgc-ip13.pdf;
National Health and Medical Research Council. (2006). Cultural competence in health: a guide
for policy, partnership and participation. Canberra: NHMRC. www.nhmrc.gov.au/guidelines
-publications/hp19-hp26.
Box 10.4: Australian Institute of Health and Welfare. (2015). Cultural competency in the delivery of
health services for Indigenous people, Closing the Gap Clearinghouse, Issue paper no. 13.
www.aihw.gov.au/uploadedFiles/ClosingTheGap/Content/Our_publications/2015/ctgc-ip13.pdf;
Flinders University. (2012). Cultural diversity and inclusive practice toolkit. Adelaide: Flinders
University. www.flinders.edu.au/equal-opportunity/cdip/cdip_toolkit/cdip_toolkit_home.cfm.
Box 10.5, Box 10.6: Victorian Transcultural Psychiatry Unit (VTPU). (2006). Guidelines for working
effectively with interpreters in mental health settings. Melbourne: VTPU. http://www.vtmh.org.au/
162
Credits 163
training/working-effectively-with-interpreters?A=SearchResult&SearchID=10234691&ObjectID=31
70895&ObjectType=35.
Box 10.6: Australian Psychological Society. (2013). Tips for working with interpreters. http://www
.mhima.org.au/pdfs/APS-Working-with-Interpreters-Practice-Guide-for-Psychologists2013.pdf.
Box 11.3: Connelly, M. & Kelly, C. (2005). Lifestyle and physical health in schizophrenia.
Advances in Psychiatric Treatment, 11, 125–132; Lambert, T. J. R., Velakoulis, D., & Christos
Pantelis, C. (2003). Medical comorbidity in schizophrenia. Medical Journal of Australia, 178,
S67–S70.
Box 12.1, 12.2; Reprinted with permission from GriefLink. (2017). Helping the bereaved. http://
www.grieflink.asn.au/helping-the-bereaved.aspx.
Table 12.2: Reprinted with permission from GriefLink. (2017). Grief reactions associated with
indigenous grief. http://grieflink.org.au/TopicPersonAboriginal.aspx.
Box 12.4: Bull, M. (2013). Loss. In P. Barkway (Ed.), Psychology for health professionals (2nd
ed.). Sydney: Elsevier; adapted from Worden, W. (2010). Grief counseling and grief therapy:
a handbook for the mental health practitioner (4th ed.). New York: Springer.
Table 13.1: Adapted from Happell, B., Cowin, L S., Roper, C., et al. (2008). Introducing mental
health nursing: a consumer oriented approach. Sydney: Allen & Unwin.
Index
Page numbers followed by “f ” indicate figures, “t ” indicate tables, and “b” indicate boxes.
A amitriptyline, 87t
Abilify, 90t anorexia nervosa, 37
Abnormal Involuntary Movements Scale bingeing/purging type, 37
(AIMS), 99 mental health symptoms of, 38
Aboriginal Health Council of Western Australia, physical symptoms of, 37–38
105 restricting type, 37
Cultural Safety Training Program, 106 anticholinergic drugs, 93–95
working with Aboriginal and Torres Strait anticonvulsants, 97–98
Islander people, families and antidepressants, 85, 87–90
communities (national practice commonly used, 87t
standard), 20t monoamine oxidase inhibitors (MAOIs), 87,
Aboriginal Health Council of Western Australia, 89–90
Cultural Safety Training Program, 106 selective serotonin reuptake inhibitors
absconding, defined, 132 (SSRIs), 87–88
absent without official leave (AWOL), 132 serotonin and noradrenaline reuptake
abstract thinking, 56–57 inhibitors (SNRIs), 87–89
acceptance and commitment therapy, 82 tricyclics, 87, 89, 89b
access (national practice standard), 20t antipsychotics, 85, 90, 90t
accredited exercise physiologist, 149 depot, 95
accredited practising dietician, 149 extrapyramidal side effects (EPSEs) of, 90,
acute care setting, general health care for 91t–92t
mental illness in, 4–5 PRN, 95–96
acute inpatient units, 142–143 work of, 90
intermediate care centres as, 143 anxiety
secure/extended care inpatient facilities as, 143 as co-occurring mental illness, 3
acute trauma, 72–73 disorders, 30–31
after crisis has passed, 73 anxiolytics, 85–87
dos and don’ts for, 73b drug interactions of, 87
ADHD, see attention deficit with hyperactivity side effects of, 86b
disorder appearance, in MSE, 52
administration, routes of, abbreviations for, 152t appetite, increased, as side effect, 93t
aetiology aripiprazole, 90t
of anxiety disorder, 30–31 assessment
of PTSD, 32 definition of, 47
affect medical history in, 59
descriptors for, 52–53, 53t of mental health, 47–60, 48f
in MSE, 53 additional information required for, 58–60
aggression, risk factors for, 63, 63b mental health practice and, 24
assessment and management plan of, presenting information in, 58–59
65t–67t psychiatric history in, 59
aggressive person, 74–75 reasons for, 49
dos and don’ts for, 76b of risk, 59, 61–68
agoraphobia, 31 case study, 64
AIMS, see Abnormal Involuntary Movements core issue with, 61
Scale definition of, 61
akathisia, 91t–92t making formulation and management
alcohol intoxication, 78–79, 78b plan in, 64, 65t–67t
alcohol withdrawal, 79 questions, 61, 62b
alprazolam, 86 undertaking, 64
Alzheimer’s disease, 42 what is in, 64
ambulance officers, role of, 132 when to do, 63
amisulpride, 90t social history and, 59–60
165
166 Index
assessment and crisis intervention teams, 139 breastfeeding, medications during, 101
attention deficit with hyperactivity disorder brief psychotic disorder, 34
(ADHD), 36–37 bromazepam, 86
auditory hallucinations, 55 bulimia nervosa, 38
Australian Mental Health and Wellbeing behaviours and, 38
Survey, 2, 2t physical and psychological symptoms of, 38
authorised offices, role of, 132
autism spectrum disorder, 36
autonomy C
defined, 134b CALD backgrounds, see culturally and
individual and professional views of, 136t linguistically diverse (CALD)
promotion, framework for recovery, 12t backgrounds
AWOL, see absent without official leave Canadian Mental Health Alliance, 14
carbamazepine, 96–98
care
B coordination, in mental health, 139
bad news, breaking, 125 in framework for recovery, 12t
dos and don’ts for, 126b planning, process of, 61
Barker, Phil, 13 carer workers, 150
behavioural psychotherapy, 81 case management, 23
behaviours CBT, see cognitive behaviour therapy
attention deficit with hyperactivity disorder, childbirth and mood disorders, 35
36–37 chlorpromazine, 90t
in bulimia nervosa, 38 citalopram, 88
of concern, 69–79 clang association, 55
acute trauma, 72–73, 73b clinical placement, surviving in, 147–148
aggressive, 74–75, 76b communication in, 147–148
intoxicated with drugs or alcohol, 78–79, organisation in, 147
78b professional behaviour in, 148
personality disorders, 70–72, 72b self-care in, 148
self-harming, 69–70, 71b work/life balance in, 148
suicidal, 69, 70b clonazepam, 86
violent, 74–75, 76b clozapine, 90t, 114
in MSE, 52 interaction with other drugs, 94b–95b
beneficence Clozaril, 90t
defined, 134b cluster A personality disorders, 40, 41t
individual and professional views of, 136t cluster B personality disorders, 40, 41t
benzhexol, 93 cluster C personality disorders, 40, 41t
benzodiazepines, drug interactions of, 87 cognitive behaviour therapy (CBT), 33
benztropine, 93 cognitive therapy, 81–82
bereavement, 121t colonisation, 125
assisting, 125–127 communication
models and theories of, 121 in clinical placement, 147–148
professional support for, 126–127 skills of, in therapeutic relationship, 80
self-care in, 128 communication and information management
biomedical approach, 8–9, 9t (national practice standard), 20t
recovery-focused understandings vs, 9t community
bipolar disorder, 34–35 mental illness in, extent of, 1–2
types of, 35 participation, in framework for recovery, 12t
BMI, see body mass index protective factors associated with, 10
body mass index (BMI), 114–115, 115b community disability support programs, 142
borderline personality disorder (BPD), 71–72 community settings, 138–139
boundaries, professional, 26–27 community treatment orders, 132
tips for setting, 28b community treatment teams, 139
BPD, see borderline personality disorder community visitor, 149
breaking bad news, 125 compassionate care, 24
dos and don’ts for, 126b complicated grief, 122–123
Index 167
compulsions, 54 depression, 42t, 43

compulsory community treatment, 132 as co-occurring mental illness, 3
compulsory mental health care, 132 pre- and postnatal, 35–36
concentration, 56 derealisation, 56
units of, abbreviations for, 153t detention
confidentiality involuntary, 130
defined, 134b review of, 131
exceptions to, 133 diabetes mellitus, co-occurring, 114
conscious awareness, in MSE, 56–57 diagnosis of mental illness, risk factors for,
consciousness, level of, 56 105b
constipation, as side effect, 93t Diagnostic and Statistical Manual of Mental
consultation-liaison psychiatry, 144 Health Disorder, 5th edition (DSM-5),
co-occurring medical problems, 113–119 29–30
diabetes mellitus, 114 diagnostic classification, 29–30
extent of the problem, 113–114 dialectical behaviour therapy, 83
management of, 115 diazepam, 85–86
mental illness, risk for, 3 disenfranchised loss, 124
metabolic syndrome, 114–115, 115b diversity, in framework for recovery, 12t
physical illness, risk for, 3–4 donepezil, 99
poor physical health and, 116 dos and don’ts
prevention of, 115 for breaking bad news, 126b
strategies for improving physical health, 117 for dealing with acute trauma, 72–73, 73b
coordination of care, 139 for dealing with aggression and violence,
counsellor, registered, 151 76b
creative therapies, 84 for dealing with alcohol or drug intoxication,
criteria for diagnosis 78b
of delirium, 42 for dealing with panic attacks, 78b
of intellectual disability, 39 for dealing with personality disorders, 72b
cultural awareness, 106–107, 106t for dealing with psychotic people, 77b
cultural competence, 107, 107b for self-harming behaviour assessment,
cultural diversity, 104 71b
cultural issues, 49 for suicidal behaviour assessment, 70b
cultural safety, 103, 106–107 dose forms, abbreviations for, 153t
practice, 106–107, 106t dose frequency, abbreviations for, 152t
Cultural Safety Training Program, Aboriginal dose timing, abbreviations for, 152t
Health Council of Western Australia, drowsiness, as side effect, 93t
106 drug intoxication, 78–79, 78b
cultural sensitivity, 106–107, 106t drug-induced psychosis, 34
culturally and linguistically diverse (CALD) dry mouth, as side effect, 93t
backgrounds, 104, 107–108 duty of care, defined, 133–134
culturally inclusive environment, 107, 108b dynamic risk factors, 62–63
culture, 103 dystonia, 91t–92t
mental health and, 103–112
risk of mental illness and, 104, 105b
social groups and, 103, 104b E
working with interpreters and, 108, 109b eating disorders, 37–38
echolalia, 55
Edinburgh Postnatal Depression Scale, 35–36
D elderly, see older people
debriefing, after violence of aggression, 75 environment
de-escalation, 74–75 culturally inclusive, 107, 108b
delirium, 40–42, 42t safe, 25
delusions, 54 EPSEs, see extrapyramidal side effects
dementia, 42–43, 42t escitalopram, 88
drugs for, 98–99 ethical practice and professional development
depersonalisation, 55 responsibilities (national practice
depot antipsychotic medication, 95 standard), 20t
168 Index
ethics, 130–137 health professionals

case study, 135b breaking bad news, 125
in health care, 133 grief and, 126–127, 127b–128b
terms in, 134b mental health promotion and, 12–13
individual and professional views in, 135, mental illness and, 62
136t people with mental health problems and, 116b
of restraint, 133–135 personality disorders and, 70–72
exercise physiologist, accredited, 149 risk assessment and, 61
explanatory models, of mental illness, suicidal person and, 69
105–106 support for people with mental illness from,
extrapyramidal side effects (EPSEs), 90, 154
91t–92t health promotion and prevention (national
practice standard), 20t
history, of MSE, 50b
F holistic mental health assessment, 24
families hope, promoting, framework for recovery, 12t
family therapy, 83 hospital settings, 142
MSA and talking to, 49
working with, 14
feelings, in psychodynamic psychotherapy, I
81 illusions, 55
flight of ideas, 55 immediate past recall, 57
flunitrazepam, 86 indigenous people
fluoxetine, 87t, 88 Australian, 111b
flupenthixol, 95 loss for, 125
fluphenazine, 95 strategies for responding to, 126t
fluvoxamine, 88 working with, 107–108
Framework for recovery-oriented practice, Aboriginal and Torres Strait Islander
10–11, 12t people, families and communities
friends, MSA and talking to, 49 (national practice standard), 20t
individual planning (national practice
standard), 20t
G influence, delusions of, 54
galantamine, 99 informed consent, defined, 134b
general health care, for mental illness, 4, 4b inpatient therapy, goals of, 143
general practitioners, 140 insight, in MSE, 57
and people with mental health problems, integration and partnership (national practice
116b standard), 20t
generalised anxiety disorder, 30–31 intellectual disability, 39
symptoms of, 31 treatment of, 39
grandiose delusions, 54 intermediate care centres, 143
grief, 120–129, 121t International Statistical Classification of
complicated, 122–123 Diseases and Related Health Problems
health professionals for, 126–127, (ICS-11), 29–30
127b–128b interpreters, working with, 108, 109b
self-care in, 128 guidelines for conducting an interview with,
supportive strategies for, 122b 109b–110b
uncomplicated, 122 involuntary detention, 130
understanding, 120–121
unhelpful strategies for, 123b
Guardianship and Administration Board, 131 J
gustatory hallucinations, 55 judgment, in MSE, 57
justice, individual and professional views of, 136t
H
hallucinations, 55 K
haloperidol, 90t Kübler-Ross, 121
Index 169
L medications
lamotrigine, 96–97 administration, abbreviations for, 152–153
Largactil, 90t categories, 85–96
law, 130–137 concordance, 99, 101b
case study, 135b dementia, 98–99
mental health, 130–133 general management issues, 99–100
learning, in framework for recovery, 12t managing, 85–102, 100b
life span, loss across, 124 side effects of, tools for assessing, 99
listening, and therapeutic relationship, 80 special populations and, 101–102
literacy, mental health, 23 meeting diverse needs (national practice
lithium, 96–97 standard), 20t
toxicity, 97, 98b memory, in MSE, 57
Liverpool University Neuroleptic Side Effect mental health
Rating Scale (LUNSERS), 99 contexts, risk in, 61–62
logical thought, 55 definition of, 1
loose associations, 55 health professional and, 1–7
lorazepam, 86 multidisciplinary teams in, 149–150
loss, 120–129, 121t risk assessment and management plan,
across life span, 124 65t–67t
for indigenous peoples, 125, 126t who does what in, 149–151
models and theories of, 121 Mental Health Act, New Zealand, 131,
for people living with mental illness, 134–135
123–124 mental health assessment, 47–60, 48f
in special circumstances, 123–125 additional information required for,
self-care in, 128 58–60
suicide and, 125 case study, 58b
trauma and, 124–125 mental health care, 4–5, 138
understanding, 120–121 care coordination in, 139
LUNSERS, see Liverpool University for chronic physical illness, 4–5
Neuroleptic Side Effect Rating Scale compulsory, 132
ethical issues in, 133–135
settings for, 138–146
M mental health law, 130–133
mainstreaming, of mental health services, 138 mental health nurse, 149
major depressive disorder, 34 mental health nurse incentive program, 22,
management 140–141
of co-occurring medical problems, 115 mental health practice, 19–28
of medications, 85–102, 100b assessment and, 24
of panic attacks, 75–78 guiding principles in, 21–22
plan, 64 scope of, 23
of self-harming behaviour, 69–70 settings and models for care, 22
of suicidal behaviour, 69 mental health problems, 29–46
manic depression, 34–35 aetiology of, 30
MAOIs, see monoamine oxidase inhibitors diagnostic classification for, 29–30
measurement, units of, abbreviations for, mental health professionals
153t competent, 14–16
medical history, 59 National practice standards for the mental
medical problems, co-occurring, 113–119 health workforce 2013, 21
diabetes mellitus, 114 recovery competencies for, 14–16
extent of the problem, 113–114 Recovery competencies for New Zealand
management of, 115 mental health workers, 21–22
mental illness, risk for, 3 Mental Health Review Tribunal, 131
metabolic syndrome, 114–115, 115b mental health services
physical illness, risk for, 3–4 community, 138–139
poor physical health and, 116 contemporary, 138
prevention of, 115 mainstreaming of, 138
strategies for improving physical health, 117 mental health support worker, 149
170 Index
mental health triage, 144 national practice standards, 19, 20t

Mental Health Tribunal, 131 National practice standards for the mental
mental illness health workforce 2013, 20t, 21
in community, extent of, 1–2 National standards for mental health services
definition of, 1 2010, 21
explanatory models of, 105–106 nausea, as side effect, 93t
health care for, 4, 4b–5b NDIS, see National Disability Support
loss for people living with, 123–124 Scheme
prevention of, 19 neuroleptic malignant syndrome, 95
rights of people with, 132–133 New Zealand Māori, 105, 110b
risk of, culture and, 104, 105b cultural safety and, 106
supporting people taking medications for, nitrazepam, 86
154 non-government organisations, 141
mental state assessment (MSA), 47 nonmaleficence
cultural issues in, 49 defined, 134b
talking to family, friends and, 49 individual and professional views of, 136t
mental state examination (MSE), 47 nurse, mental health, 149
basics and purpose of, 50–51
case study, 58b
components of, 51–57, 51f O
essential skills for, 49–50 obesity, co-occurring medical problems and,
setting for, 49 114
mental wellness, 13–14 obsessions, 54
metabolic syndrome, 3–4 obsessive-compulsive disorder, 32
co-occurring, 114–115 common themes of, 32t
diagnostic criteria for, 115b occupational therapist, 150
methamphetamine intoxication, 79 olanzapine, 90t, 114
mindfulness, 82 older people
mirtazapine, 89, 114 disorders in, 40–43
mobile assertive care teams, 140 medications for, 101–102
models for care, 22 olfactory hallucinations, 55
monoamine oxidase inhibitors (MAOIs), 87, ongoing physical monitoring, for co-occurring
89–90 medical problems, 115
mood, in MSE, 53 organisation, in clinical placement, 147
mood disorders, 34–36 orientation, 56
childbirth and, 35 outreach teams, 140
mood stabilisers, 85, 96–98, 97b oxazepam, 86
motivational interviewing, 82–83
mourning, 121t
understanding, 120–121 P
MSA, see mental state assessment panic attacks
MSE, see mental state examination dos and don’ts for, 78b
multidisciplinary team, 22–23, 25 managing, 75–78
in mental health, 149–150 paramedics, role of, 132
mutual support/self-help/information/advocacy parkinsonism, 91t–92t
groups, 142 paroxetine, 87t, 88
past experiences, in psychodynamic
psychotherapy, 81
N paternalism, defined, 134b
narrative practices, 83–84 patterns of behaviour, in behavioural
narrative therapy, 83–84 psychotherapy, 81
National Disability Support Scheme (NDIS), PD, see personality disorders
142 peer consumer workers, 150
National Mental Health Promotion and Peplau, Hildegard, 11
Prevention Working Party, 10–11 perceptions, in MSE, 55–56
National Perinatal Depression Initiative, persecutory delusions, 54
35–36 perseveration, 55
Index 171
persistent complex bereavement-related psychiatric history, in mental health

disorder, 123 assessment, 59
personal values, of practitioner, 24–25 psychiatrist, 150
personality disorders, 39–40, 70–72 psychodynamic psychotherapy, 81
borderline, 71–72 psychoeducation, 23
dos and don’ts for, 72b psychologist, 151
groups, 40, 41t psychotherapies, 81
person-centred approach, 24 psychotherapist, 151
Pharmaceutical Society of Australia, 141 psychotic people
pharmacist, 141, 150 dealing with, 75
phenomenon, 8–9 dos and don’ts for, 77b
phobias, 31
physical health
factors affecting poor, 116 Q
mental health problems and, 116b quality improvement (national practice
strategies for improving, 117 standard), 20t
physical illness quetiapine, 90t
co-occurring, risk for, 3–4
mental health care for chronic, 4–5
physiotherapist, 151 R
positive risk taking, 16 rapport, developing, 26b
postnatal depression, 35–36 reboxetine, 87t
postpartum psychosis, 35 recent past recall, 57
post-traumatic stress disorder, 32–33 recovery, definition of, 8–9
prevalence of, 32 Recovery competencies for New Zealand
symptoms of, 33 mental health workers, 15, 21–22
treatment of, 33 recovery framework, 8–18
postural hypotension, as side effect, 93t competencies for mental health workers,
practising dietician, accredited, 149 14–16
practitioners mental health and, 16
essentials of, 24–27 person-centred, 8–9
general, 140 protective factors and, 9–10
personal and professional values of, 24–25 risk and, 16
private, 140 risk factors and, 9–10
self-awareness of, 25 working with families and, 14
working alliance and, 26 working with individuals and, 13–14
pregnancy, medications during, 101 recovery-focused understandings, biomedical
prenatal depression, 35–36 approach vs, 9t
prevention, of co-occurring medical problems, recovery-oriented mental health services, 10–11
115 delivery of, 10
primary care focus, 117 providing, 11–13
primary care setting Tidal model and, 13
general health care for mental illness in, 4, reference, delusions of, 54
4b–5b reflection, in framework for recovery, 12t
mental health care for chronic physical reform policy, 138
illness in, 4–5 registered counsellor, 151
privacy, defined, 134b religious delusions, 54
private practitioners, 140 remote past recall, 57
PRN medication, 95–96, 96b resilience, developing, 27b
professional behaviour, in clinical placement, 148 respect, 24
professional values, of practitioner, 24–25 responding, 27b
promotion of mental health, 12–13, 19 restraint, ethics of, 133–135
protective factors Rethink model, 14
community, 10, 11b rights
family and peers, 11b of people with mental illness, 132–133
individual, 11b responsibilities, safety, privacy and (national
recovery and, 9–10 practice standard), 20t
172 Index
risk serotonin syndrome, 88b

formulation, 64, 65t sertraline, 88
for mental health contexts, 61–62 settings, 22
recovery and, 16 community, 138–139
working with, core principles for, 62, 62b hospital, 142
risk assessment, 59 for mental health care, 138–146
case study, 64 for MSE, 49
core issue with, 61 primary care, 4, 4b–5b
definition of, 61 side effects
making formulation and management plan of anticonvulsants, 98b
in, 64, 65t–67t of antipsychotics, 90, 91t–92t
questions, 61, 62b of anxiolytics, 86b
undertaking, 64 extrapyramidal (EPSEs), 90, 91t–92t
what is in, 64 LUNSERS (Liverpool University Neuroleptic
when to do, 63 Side Effect Rating Scale), 99
risk factors of mood stabilisers, 97b
in aggression/violence, 63, 63b tools for assessing, 99
for diagnosis of mental illness, 105b Skylight Australia, 142
recovery framework and, 9–10 SNRIs, see serotonin and noradrenaline
for suicide, 63, 63b reuptake inhibitors
types of, 62–63 social groups, culture and, 103, 104b
dynamic, 62–63 social history, in mental health assessment,
static, 62–63 59–60
risk management, 61 social worker, 151
Risperdal, 90t sodium valproate, 96–97
risperidone, 90t, 95 Solian, 90t
rivastigmine, 99 solution-focused therapy, 82
routes of administration, abbreviations for, 152t South Australian Civil and Administrative
Tribunal, 131
special populations
S medications for, 101–102
safe environment, 25 mental health care settings and, 144
Safewards model, 143 speech, in MSE, 52–53
schizoaffective disorder, 33 SSRI discontinuation syndrome, 88–89
schizophrenia, 33–34 SSRIs, see selective serotonin reuptake
co-occurring medical problems and, 114 inhibitors
negative symptoms of, 33 Statement on ethical issues concerning
positive symptoms of, 33 patients with mental illness, 130
schizophreniform disorder, 33 static risk factors, 62–63
scope of practice, 23 Stelazine, 90t
secure/extended care inpatient facilities, 143 Stolen Generations, 125
selective serotonin reuptake inhibitors (SSRIs), strengths, in framework for recovery, 12t
87–88 substance misuse disorders, 43–44
self-awareness, of practitioners, 25 suicidal person, 69
self-care, 25 dos and don’ts for, 70b
in clinical placement, 148 suicide
in loss and bereavement, 128 loss following, 125
self-determination, promoting, framework for risk factors for, 63, 63b
recovery, 12t assessment and management plan of,
self-harm, definition of, 69–70 65t–67t
self-harming person, 69–70 support worker, mental health, 149
dos and don’ts for, 71b Supporting Families in Mental Illness New
sensitivity, to sunburn, as side effect, 93t Zealand, 142
Serenace, 90t surviving clinical placement, 147–148
Seroquel, 90t communication in, 147–148
serotonin and noradrenaline reuptake organisation in, 147
inhibitors (SNRIs), 87–89 professional behaviour in, 148
Index 173
self-care in, 148 trifluoperazine, 90t

work/life balance in, 148 type 2 diabetes, 114
T U
tactile hallucinations, 55 uncomplicated grief, 122
talking-based therapies, for mental health, understandings, in psychodynamic
80–84 psychotherapy, 81
acceptance and commitment therapy, 82
cognitive therapy, 81–82
context for, 80–81 V
creative therapies, 84 valproate, 97–98
dialectical behaviour therapy, 83 vascular dementia, 42
essential skills in, 80 venlafaxine, 87t
family therapy, 83 veracity, defined, 134b
motivational interviewing, 82–83 Victorian Department of Health, 10–11, 16
narrative therapy/narrative practices, 83–84 violence, risk factors for, 63, 63b
psychotherapies, 81 assessment and management plan of,
solution-focused therapy, 82 65t–67t
Tarasoff rule, 133 violent situation, 74–75
tardive dyskinesia, 91t–92t dos and don’ts for, 76b
teamwork, 22–23 potentially, determining, 74
temazepam, 86 visual hallucinations, 55
therapeutic milieu, 22 vulnerable populations, 2–5
therapeutic relationship, 11
thinking patterns, in cognitive therapy, 81–82
thought broadcasting, 54 W
thought content, in MSE, 54 weight gain, as side effect, 93t
thought form, in MSE, 53 Western medicine, 105
thought insertion, 54 WHO, see World Health Organization
thought process, in MSE, 54–55 word salad, 55
thought withdrawal, 54 Worden, William, 121
Tidal model, 13 working alliance, 24, 26
topiramate, 97–98 building strengths in, 27b
Torres Strait Islander people, 105, see also developing and maintaining, 27b
indigenous people initiating, 26b
working with Aboriginal and Torres Strait working with Aboriginal and Torres Strait
Islander people, families and Islander people, families and
communities (national practice communities (national practice
standard), 20t standard), 20t
transitions in care (national practice standard), working with people, families and carers in
20t recovery-focused ways (national
trauma practice standard), 20t
acute, 72–73 work/life balance, in clinical placement, 148
after crisis has passed, 73 World Health Organization (WHO), 1
dos and don’ts for, 73b World Medical Association, 130
loss and, 124–125
traumatic event
definition of, 72–73 Y
example of, 73 young people
treatment and support (national practice disorders in, 36–37
standard), 20t medications for, 101
Treaty of Waitangi, 106, 131
triage, mental health, 144
triazolam, 86 Z
tricyclic antidepressants, 87, 89 zuclopenthixol, 95
overdose of, 89b Zyprexa, 90t

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3RD EDITION

POCKETBOOK OF MENTAL HEALTH

This edition © 2018 Elsevier Australia.

2nd edition 2014; 1st edition 2010

National Library of Australia Cataloguing-in-Publication Data

Content Strategist: Tamsin Curtis

Chris Burns CSC

Foreword v 11 Co-occurring Medical

Approximately 450 million people worldwide have a mental health

Eimear Muir-Cochrane BSc(Hons), RN, CMHN, GradDip—Adult Ed, MNS,

Paula Duffy RN, MPET, ACMHN, ACN

… a state of well-being in which every individual realizes his or her

Mental illness, however, is defined as the presence of cognitive,

A clinically diagnosable disorder that significantly interferes with an

Mental health is integral to health and wellbeing, yet throughout the

THE EXTENT OF MENTAL ILLNESS IN THE COMMUNITY

proportion of the population who are experiencing mental health problems,

VULNERABLE POPULATIONS AND INDIVIDUALS

Risk for Co-occurring Mental Illness

Risk for Co-occurring Physical Illness

Adapted from Gibson et al 2011 and Mitchell et al 2013

cardiovascular disease (Mitchell et al 2013, Vancampfort et al 2013).

Providing General Health Care for People With Mental Illness in

Providing Mental Health Care for People With a Chronic

Adapted from World Federation for Mental Health 2010

Australian Government, Department of Health and Ageing. http://www.health.gov.au/internet/main/

… a deeply personal, unique process of changing one’s attitudes,

throughout the 20th century the focus shifted from a person-centred

PROTECTIVE AND RISK FACTORS

RECOVERY-ORIENTED MENTAL HEALTH SERVICES

for delivering recovery-oriented mental health care. They are summarised

PROVIDING RECOVERY-ORIENTED MENTAL HEALTH CARE

• encourage the person to define their problems and perceptions of their

The role of health professionals in mental health promotion is to:

• support people to access employment services, housing, education and

The Tidal Model

WORKING WITH INDIVIDUALS

• creates an environment that supports personal recovery and values

WORKING WITH FAMILIES

RECOVERY COMPETENCIES FOR MENTAL HEALTH WORKERS

Understands recovery principles and experiences, supports service

health issues, has self-awareness and respectful communication skills,

This is exemplified in the ‘Recovery competencies for New Zealand

culturally safe and trauma informed’ (New Zealand Ministry of Health

Recovery and Risk

Settings and Models for Care

skill sets among mental health professionals, so frequent meetings are

MENTAL HEALTH LITERACY AND PSYCHOEDUCATION

• A ‘safe’ environment. Mental health care is best delivered in

Self-Awareness and Self-Care

The Working Alliance

Organization, provides a listing of clinical diagnoses that are coded and is

AETIOLOGY OF MENTAL ILLNESS

Generalised Anxiety Disorder

OBSESSIVE-COMPULSIVE AND RELATED DISORDERS

POST-TRAUMATIC STRESS DISORDER

Treatment for Anxiety Disorders

Brief Psychotic Disorder

Major Depressive Disorder