The evolution of in-patient mental health care

Some people say that more has happened within mental health care in the last century than ever before in history. As we evolve as human beings, hopefully everything else grows with us, from technologies to ideologies, for better or for worse.

Similarly, in-patient mental health care is also ‘changing’, but people within the sector – both staff and service users – often feel that mental health gets the short end of the stick regarding being a government or even societal priority. This is despite the fact that the chances are, every single reader of this article will experience a mental health issue at some point in their lives, or will at least know somebody who is close to them that will.

In our never-ending aim to reach parity of esteem between mental and physical healthcare, it is intriguing that we remain in a situation where mental health is so ‘behind’ developments in physical healthcare.

A recent conversation with a former service user who has spent over 25 years in secure mental health services reminded me that stigma plays a significant part in why mental health care is under-resourced or forgotten. He said: “The government does things in response to what the media and people want. Until recently, I don’t think anybody cared about mental health. I have spent my life on psychiatric wards and I am only seeing a change in the way things are done to us now.”

While the history of mental health, and society’s response to it, can arguably date back to prehistoric times, it is useful to explore the foundations of in-patient mental health care to get some answers.

Historically, the first documented ‘hospital’ dedicated to people experiencing mental distress was in Baghdad in the 8th century. A further two ‘hospitals’ were then established within the Islamic world shortly after.

In Britain, the first dedicated psychiatric institution was the Bethlem Hospital back in 1247. The roots of the Bethlem – as a building – were initially monastic. Indeed, religion has historically close links to mental health as people experiencing mental distress were often thought to be undergoing a spiritual encounter as opposed to a medical condition.

In the non-western world, religious and spiritual ways of interpreting mental ill health are still commonplace. This results in alternative models of care, for example ‘healing centres’ which can be considered as commonplace in some cultures with many existing today in Africa, for example.

Within the western world, in-patient mental health care was focused on confinement within institutions or asylums. However, the pharmacological revolution of the 1950s shifted psychiatry from solely relying on institutionalisation to focusing on a medical model, reliant on medication as well as institutional care. The was an eventual move towards psychologically-informed care, such as psychological therapies.

During this period, the discovery of antipsychotic medication was described as being comparable to a form of ‘psychiatric penicillin’. This period within psychiatry seemed to identify mental illness as an organic disease process, which could be alleviated through the use of medication.

Historically, people experiencing mental distress have been discriminated against and segregated from society. This is in line with the historical pattern of people experiencing mental distress being institutionalised.

The traditional approach, as demonstrated by psychiatric practice, can be particularly symptom-focused. As a result, the approach primarily materialises itself in the form of medical prescribing and mental health nursing within institutions, such as asylums and more recently, in-patient hospitals. This has remained the case for over a century.

Emil Kraepelin, considered a leading figure in psychiatry, was the first to suggest that people experiencing mental distress was the result of an organic dysfunctional issue. He believed that sufficient symptomology and frequency could result in a diagnosis of a disease.

In recent years, we have seen a paradigm shift within in-patient mental health care, through the growing belief in a ‘recovery model’ which directly challenges, but can arguably work alongside, the traditional medical model of in-patient mental health care.

There is some confusion on the definition and concept of ‘recovery’. For the purpose of brevity and to provide a working definition, the recovery approach is defined as one that primarily focuses on ‘personal recovery’ as well as other forms of recovery, such as ‘functional’ and ‘social’ recovery. This could mean focusing on improvements in social relations, connectedness and employment, people’s assets, abilities, building confidence and self-esteem without an expectation on living symptom-free.

Most of the different perceptions on recovery tend to agree on fundamental principles, as outlined within the acronym of the CHIME model, which are; connectedness, hope, identity, meaning and empowerment.

Similarly, there is also some confusion regarding its history. One school of thought states that the concept of recovery stemmed from the physical disability movement in the 1960s. Another perspective is that recovery, within the context of mental health, has its roots in the 1980s, following a study on people with lived experience of mental distress.

In any event, there seems to have been a clear shift following the deinstitutionalisation of people experiencing mental distress in the 1960s and 1970s. In any event, all perspectives on the roots of recovery agree that as a concept, it stemmed from people with direct lived experience of mental health difficulties.

There are a number of different models and services which fall under the recovery approach. Sometimes they are referred to as ‘alternative services’ and often focus on the direct involvement of people with lived experience (i.e. service users and family carers) in service delivery which includes social inclusion, hope and co-production.
One of the ways the recovery approach can operate within in-patient mental health settings is through the use of tools such as the ‘Recovery Star’. Recovery Star is a tool that follows an individual’s progress and journey through services through the use of a visual 10-pronged star and a ladder of change in which an individual’s progress may fluctuate.

The Recovery Star centres on areas such as hope, self-esteem, social networks and employment and core values that identify with the recovery approach, similar to the principles outlined within the aforementioned CHIME model.

Research demonstrates that this model is an effective tool for following an individual’s progress and for measuring outcomes. There is also a separate Recovery Star for secure in-patient services demonstrating the diversity of settings in which the model and similar tools may be used.

One of the more recent innovations that have become a ‘hot topic’ within the recovery movement of mental health care has been the rise of ‘Recovery Colleges’, based on the idea that people can develop the skills to engage in recovery, thereby producing a paradigm shift.

Recovery Colleges are described as learning centres, designed specifically for people who are experiencing mental distress, to help them develop meaningful skills relevant to their individual recovery journey.

Attention is paid to personal recovery, co-production and building on strengths and assets as opposed to focusing on individuals’ deficits. Recovery colleges are an increasingly growing phenomenon within mental health services – nationally and international – and within community and in-patient settings.

While these colleges are becoming embedded, the resonances of the ‘medical gaze’ still exist as remnants from the past, as psychiatrists continue to be taught that mental health is an illness drawing from Kraepelin’s typology.

We seem to have come a long way from thinking of mental health as simply being a spiritual phenomenon. Through the various phases over time, it is clear that the in-patient care has evolved to a degree where service users have more choice and options with regards to their treatment.

I believe the future of in-patient mental health care will be led by a workforce where the majority of staff have themselves used, or cared for someone who has used services as experts by experience. A system in which service users have more say in how and where they receive care.

This will create more options for people and greater competition among service providers, leading to better quality of care.


About the Author

Rafik Hamaizia is the expert by experience lead for Cygnet Healthcare. Rafik, aged 25, has been a service user in a variety of mental health settings. His role within the Cygnet Healthcare is to work alongside the Executive Board of Directors to shape and improve service user involvement, co-production and patient experience structures on both strategic and local levels. In 2017 he was given the Cygnet Healthcare Special Recognition Award by Universal Health Services. He has participated in over 100 Care Quality Commission inspections and develops guidance with the National Institute for Health and Care Excellence (NICE). He is currently studying for an MSc in Mental Health Recovery and Social Inclusion at the University of Hertfordshire. Rafik is also the founding member of the Joint Thinking Initiative, a not-for-profit, service user led organisation, focusing on improving mental health care through co-production.
You can follow Rafik and his work on Twitter: @Raf_Hamaizia.