Working with People with Mental Health Issues

Supporting clients to work towards and achieve their goals is an important part of working with people who have mental health issues. This process should be facilitated using a team approach applying collaboration between the client, their support network, and all professionals involved.

It is important to focus on making the best use of the client’s strengths and resources when facilitating their progress towards goals. When planning actions with the client you should consider:

• Their goals.
• Their current strengths and resources.
• Activities/strategies that can be implemented to help them meet their needs.
• Supports they might require implementing activities/strategies.
• How the activities/strategies will be monitored.

When working with clients with mental health issues, the above considerations are useful, however, the National Standards for Mental Health Services 2010 also highlight a range of additional considerations for mental health professionals to keep in mind when working with people with a mental health issue. These are outlined in the following extract. While, as a helping professional you may not be working directly to treat clients with mental health issues, it is still useful for you to be aware of the standards that all mental health professionals should comply with.

To meet the needs, goals and aspirations of people and their families and carers, mental health practitioners deliver quality, evidence-informed health and social interventions.

The mental health practitioner:

1. Advises the person and their family or carer of their right to informed consent for treatment and of their right to refuse treatment
2. Discusses the range of treatment, care and support options available with the person and, where appropriate, their families and carers, identifying potential benefits and risks pertaining to experimental or controversial treatment and care, or treatment and care with an undeveloped evidence base
3. Plans, implements and monitors a range of engaging, evidence-informed, safe and effective intervention strategies chosen with the person and family or carers, and consistent with experience, professional background and roles within the interdisciplinary team
4. Identifies a range of culturally and developmentally appropriate interventions that may derive from but not be limited to the following approaches
   • cognitive
   • behavioural
   • interpersonal
   • attachment-based
   • motivational
   • systemic
   • psychoeducation
   • psychodynamic
   • psychopharmacological
5. Articulates an understanding of common interventions, including medications, commensurate with role and experience
6. Delivers treatments and interventions using a recovery and family-focused approach, along the spectrum from prevention through to tertiary treatment
7. Recognises when to ask senior practitioners or peers for assistance in working with people and families; operates within their own scope of practice; and refers on when needed
8. Delivers treatments, interventions and support work in the most appropriate formats, which may include
   • sessions with individuals
   • group work
   • family or systems interventions
9. Enquires about, recognises, works with and develops the person’s and family or carer’s strengths and experience of what works and what does not work
10. Works flexibly at the person’s pace and with their priorities and schema, facilitating engagement throughout the course of intervention
11. Assists people and families or carers to see things from the other’s perspective, and to develop shared understandings
12. Supports the person in parenting or caring roles where relevant, promoting effective parenting or care strategies relevant to the needs of dependents
13. Monitors people for evidence of appropriate and sufficient response to treatment interventions including medication, and for symptoms of possible side-effects, then communicates the results to the team or medical practitioner as appropriate
14. Observes the dynamics of transference and countertransference processes and uses these to guide practice, seeking supervision and support if required to facilitate positive outcomes
15. Provides or facilitates management, including self-management, of the person’s physical healthcare needs including detrimental use of licit or illicit substances
16. Reviews the person’s status and updates their individual care plan with the person and family or carers as appropriate, consistent with progress and changing needs

^{(National Standards for Mental Health Services 2010)}

While these standards are written for mental health professionals, the theme of these standards can be applied in any work with clients with mental health issues. For example, these standards highlight the importance of adopting a holistic approach to care when working with clients with mental health issues. Such clients will typically be working towards multiple goals that address all of their needs, not just the needs related to mental health issues. This means that the client’s care network is interested in meeting the client’s physical, emotional, psychological, social, economic, environmental, and spiritual needs. Therefore, as a helping professional, you should not solely focus on the client’s mental illness but look at the aspirations and goals of the individual and work towards supporting them to achieve these. The holistic approach to mental health care includes recognising that people have experiences and issues that are not necessarily related to their mental illness. These are issues that can affect anyone regardless of their mental health problems and need to be addressed in a way that might not refer to the person’s mental health problems.

Other key aspects of working with clients with mental health issues are facilitating social justice and social inclusion.

Social justice is about the way in which wealth, opportunity, and privilege is distributed in society. The principle of social justice requires that everyone has equal access to social resources regardless of whether they have a mental illness. In a similar vein, the principle of social inclusion involves working with the client to find ways to enable them to feel connected to the community and participate at any point within the recovery process.

Social exclusion occurs when people experience discrimination, unemployment, poverty and family breakdowns, which leads to their inability to participate in community life. People with a mental illness who experience significant barriers to accessing social and recreational activities or obtaining resources that people need to engage with the community (such as transport) are socially excluded. It is important to develop an understanding of this principle in order to work with people with mental health issues who are commonly isolated from the mainstream community. Indeed, part of your role may involve providing clients with specific support to facilitate their social inclusion.

It is also important to ensure that all work conducted with your clients fulfills your legal and ethical responsibilities. Upholding a client’s rights involves ensuring that the client is aware of their rights at all junctures during service provision. Reminding the client that they have choices and encouraging them to express their thoughts and opinions on a regular basis is an integral part of working effectively with people with mental health issues. Clients should feel that their views are going to be heard from a non-judgmental stance and that their opinions and decisions are valued at all times. Other steps you can take to ensure that you are upholding client rights include:

• Checking-in with the client regularly to ensure that they are satisfied with the service(s) they are being provided.
• Providing the client with access to information and resources required to uphold their rights.
• Ensuring that the client has decision-making powers.
• Encouraging the client to be assertive about their rights.
• Facilitating social inclusion.

There are also a number of programs within the mental health sector in which clients are encouraged to become involved in the managerial and review aspects of mental health organisations. This includes being part of interview panels for mental health jobs, developing and reviewing policies and procedures, advocating for other people with mental health issues, and being part of education and mental health promotion activities. There are also research projects that look into issues such as improvement of services and access and equity. By encouraging client participation in such activities you would not only be protecting their rights but also empowering them to take an active involvement in the sector.

Upholding a client’s rights sometimes also involves you making necessary adaptations to your service in order to meet the client’s needs. Mental health legislation and organisational policies and procedures call for the need for flexible service delivery. When working with clients with mental health issues you should always consider whether any adaptations are needed to your approach to better meet the client’s needs. This might involve making amendments such as adapting your approach, including members of the client’s support network in the counselling process, working more closely with other service providers, or maximising support services. Of course, when adapting your service delivery, it is always important for you to consider your organisation’s policies and procedures and work within them. If you are ever in doubt as to what adjustments are suitable then it would be important for you to seek the advice of your workplace supervisor.

Throughout your practice, it is vital that you comply with all relevant organisational policies/procedures and legislative requirements. While most of these requirements are the same regardless of your client, there are a few additional legislative considerations that are particularly important when working with clients with mental health issues – we will explore these below.

Mental Health Laws

Each State and Territory has a Mental Health Act that governs how mental health is assessed and treated and safeguards the rights of people with mental health needs. In addition to the state-based Mental Health Acts, as you learned in the first section of this module, the Commonwealth Government has implemented the National Standards for Mental Health Services 2010 (NSMHS). This document outlines standards that aim to improve the quality of mental health care in Australia.

The National Standards for Mental Health Services are standards that apply to all mental health services across Australia, including clinical services, in-patient units, and community mental health services provided by the public, private and non-government sectors. There are ten standards that deal with a range of issues which include rights and responsibilities, safety, consumer and carer participation, diversity responsiveness, and delivery of care. The Standards include recommendations about how to put the standards into effect and monitor whether or not mental health services are meeting the standards.

^{(Mental Health Coordinating Council, 2015)}

When working with clients with mental health issues it is vital that you comply with this legislation. Reading F outlines specific implementation standards that can be used to ensure compliance.

Workplace Health and Safety

The workplace health and safety issues associated with working with clients with mental health issues can be complex. It is important to understand the issues associated with workplace health and safety in order to protect your own safety as a worker, the safety of your coworkers, and the safety of your clients.

Employers and workers at allied health services, counselling services, community services, and mental health services have a legal obligation to take reasonable steps to keep themselves and other people who are accessing the service safe. This includes:

• Clients of the service.
• Families and carers of the clients.
• Visitors (including children).
• Co-workers in the service.

The term ‘safe’ refers to both physical and psychological (or emotional) safety, which means that steps should be taken to minimise the risk of individuals being exposed to unsafe, traumatic, or emotionally stressful events. The workplace health and safety procedures and regulations that apply to your State or Territory will provide you with instructions on how to deal with situations where harm does occur including procedures such as applying first aid, calling an ambulance, or providing support.

Working in a safe manner means that you need to assess the risks associated with the work. Assessing risk involves understanding the nature of the harm that could be caused by the risk, identifying how serious harm could be, and the likelihood of it happening. The level of risk is determined by asking yourself questions such as:

• What could go wrong?
• What is the likelihood of something going wrong?
• What are the consequences of something going wrong?

When you identify possible risks, it is important to use your organisation’s risk management procedures or discuss the matter with your supervisor.

One aspect of workplace health and safety that most organisations will have specific policies and procedures for is the presence of children in the workplace. These policies refer to the children of workers or clients who are present in the workplace because they are accompanying their parents, not children who are clients themselves (for which there will be other specific policies and procedures that must be followed). Essentially, community service organisations have these policies and procedures that help ensure the safety and wellbeing of children while they are in the workplace. These policies usually include the need for children to be supervised and details about areas of the workplace in which there are too many risks to allow children to be present. When working with a client who brings along their own children you will need to consider issues of risk. For example, children cannot be left unsupervised while you work with your client. In some instances you might need to arrange for specific supervision of children in which case you may need to arrange a parent or guardian consent for this to occur.

As in any aspect of your work, when working with clients with mental health issues it is important for you to comply with all relevant legislation. If you are ever in doubt as to how to act in a specific situation, then you will need to seek the advice of your supervisor.

As with all your work, it will be important for you to document your work clearly and accurately with clients with mental health issues as per your organisation’s policies and procedures. While each organisation will have their own expectations relating to note taking and record keeping, all documentation should be detailed, accurate, and professional. Some key considerations that you should keep in mind when documenting client contact include:

• Write the date, time, location and names of people present at the interaction.
• Record who said what and use inverted commas when indicating direct quotes.
• Ensure that your records are objective and accurate.
• Record facts rather than your opinions.
• Record the client’s actions and behaviours using objective terms.
• Make sure that you are writing facts not inference – identify what actually happened not what you thought might have happened.
• Record the reasons why you made certain decisions.
• Use short sentences and be concise.
• Use plain language.
• Use appropriate headings and set out the information in a logical manner.
• Make sure that you sign all of the notes you record.

In the mental health sector, many organisations use specific documentation standards called the SOAP principles, which are outlined in the following extract. If you are providing counselling as part of a larger case management plan in the allied health sector, then it might be appropriate to also use such an approach.

In general, progress notes in mental health services are documented using SOAP principles (Subjective, Objective, Assessment, and Plan). While this is not the only format used to document progress notes it is considered a helpful way of organising thoughts, identifying priorities for documentation and ensuring the various elements are documented.

• S: The subjective component of documentation describes a consumer's [client’s] view of their current condition in narrative form. Notes are taken about a consumer's thoughts, feelings, concerns, the intensity of the consumer's problems and impact they are having on others. It may include the consumer's goals or plans
• O: The objective component includes any observable, measurable and quantifiable data about a consumer such as their appearance and behaviour, their response to the therapeutic relationship, observable strengths, and any outside data or test results
• A: Assessment (also described as Analysis) involves a synthesis and analysis of the subjective and objective information gathered. It documents the practitioner's clinical reasoning and may include a summary of the consumer's main symptoms or issues to be addressed. Issues may be identified by a number which corresponds to actions under the next heading.
• P: The plan refers to the proposed action or interventions. Date of next expected contact should be noted. It may also include a prognosis.

An example from a clinical file at a Community Care Unit (CCU)

23/10/08 Case management review

S: F reports feeling “a bit down”. Concerned about tension in relationship with girlfriend since she moved out of CCU. Feels he is not making progress and wants to “get on with life, get a job”. Reports minimal auditory hallucinations and not bothered by these. Frustrated with medication side effects, nocturnal drooling and impotence. Mother has been ringing unit this week wanting update.

O: Well kept and highly engaged. Talked openly and developed a clearer plan for future. Mood euthymic and sadness/frustration expressed is appropriate. Mental state stable and responding well to current medications.

A: Currently settled with improvement in mental state and motivation. Ready for more active goal setting and intervention re future goals. Side effects persist and frustrated by these. Willing to tolerate medications in the immediate future as can see benefits.

P:

• Review ISP with emphasis on reconsidering future goals – set some clear short-term goals that he is highly motivated about.
• Discuss side effects and medication with Dr A (24/10) – may need to review in medium term if unprepared to tolerate side effects
• Organise family meeting for 27/10. Include ISP development in this meeting.
• To be seen 24/10.

^{(Mental Health Professional Online Development)}

It is also important to ensure all notes and documentation about a client are treated with the highest levels of care and filed securely according to your organisation’s policies and procedures.

There may be times when you have to respond to a client with mental health issues who is in a state of distress or crisis. On these occasions it is important to respond in the best way to meet the immediate needs of the person experiencing distress and keep work health and safety considerations in mind. Some of the types of distress or crisis situations that you might come across include:

• Clients threatening to harm themselves.
• Clients being at risk of harm from others.
• Clients threatening to harm others.
• Significant/sudden changes to the client’s situation.

When a client expresses distress, regardless of the nature of the crisis, it is important to respond promptly and supportively. One commonly used approach that can support helping professionals and other community service workers respond appropriately in such situations is the ALGEE approach:

• A – approach, assess and assist with any crisis. This involves assessing any immediate risks of suicide or harm, signs of trauma, or high anxiety.
• L – Listen to the client’s full story and concerns in a non-judgmental manner.
• G – Give the client reassurance, support and information.
• E – Encourage the client to seek appropriate professional help.
• E – Encourage the client to seek other support strategies.

In such situations, as a helping professional, you have a duty of care to respond supportively to the client in crisis and ensure that their immediate needs are resolved (this might involve providing crisis counselling or making a referral to an appropriate support service to help meet the client’s immediate needs) as well as ensure that any appropriate amendments are made to their ongoing care plan.

When working with any client it is important to ensure that you work within the limits of your own knowledge, abilities, and work role, however, these considerations are particularly important when working with clients with mental health issues due to the complex nature of such work. Always remember to ensure that you have a realistic understanding of your limitations in terms of:

• Resources available to you.
• Your level of skills and knowledge.
• The formal roles and the associated responsibilities assigned to you.

There will be times when the client requires assistance that is beyond the limits of your skills, knowledge, or work role. This can include requiring the specialist knowledge/skills of GP’s, nurses, social workers, occupational therapists, psychiatrists, psychologists, drug and alcohol workers, and employment agencies. Depending upon the circumstances of the client’s care you may be required to make this referral yourself or discuss this need with the client’s case manager.

In situations in which you need to make the referral yourself, you will need to consider the client’s specific needs and make an appropriate referral based upon your organisation’s policies and procedures. When referring to a client with mental health issues, it is particularly important that the referral is completed effectively.

The table below outlines a few different types of referrals.

^{(Australian Government, Attorney-General’s Department, 2015)}

While you will need to comply with your organisation’s policies and procedures, in general, some form of ‘warm referral’ is usually most appropriate for clients with mental health issues. This ensures that the referral is most effectively made and that the client’s needs will be most effectively met.

When working with clients with mental health issues it is important to remember that, as a helping professional, you are essentially only completing one part of the client’s wider care plan. Be sure to complete your role effectively and work collaboratively with other service providers.

In this section of the module you learned about some of the critical considerations that you should keep in mind when working with clients with mental health issues. Specifically, you learned about the importance of engaging in collaborative, adaptive practice that promotes client rights while still conforming to your organisational and legislative requirements.

• Australian Government. (2010). National Standards for Mental Health Services 2010. Barton, ACT: Commonwealth of Australia.
• Australian Government Attorney – General’s Department. (2015). Referral Guidelines for Family Relationship Centers and the Family Relationship Advice Line. Retrieved from https://www.ag.gov.au/FamiliesAndMarriage/Families/FamilyRelationshipServices/Documents/Referral%20Guidelines.doc
• Bozhko, V. (2021). Remont construction beginning their work day. [Photograph]. Unsplash. https://unsplash.com/photos/lbO1iCnbTW0
• Mental Health Coordinating Council. (2015). Mental Health Rights Manual. Retrieved from http://mhrm.mhcc.org.au/chapter-2/2c.aspx