Search

Purpose This paper aims to describe a service evaluation study of “Balance” – a National Health Service Tier 2 pilot weight management course delivered in a primary care mental health service. The 12 weekly sessions included dietetic, psychological and behavioural elements underpinned by cognitive behavioural theory and “third-wave” approaches, including acceptance and commitment therapy, compassion-focused therapy and mindfulness. Design/methodology/approach A mixed-methods design was used in this service evaluation study that included analysis of outcome measures (weight, eating choices, weight-related self-efficacy and mental health) and focus group data (n = 6) analysed using thematic analysis. Eleven clients with a body mass index of 25–40 kg/m2 enrolled, and nine clients completed the course. Outcome data were collected weekly with follow-up at three and six months. Findings Quantitative data analysis using non-parametric Wilcoxon signed-rank tests showed that the group mean weight decreased significantly (p = 0.030) by the end of Balance, but the group mean weight loss was not statistically significant at the three-month (p = 0.345) or six-month (p = 0.086) follow-up. The qualitative results showed that participants valued the course ethos of choice and also welcomed learning new tools and techniques. Balance was very well-received by participants who reported benefitting from improved well-being, group support and developing new weight management skills. Research limitations/implications Only one client attended all sessions of the group, and it is possible that missed sessions impacted effectiveness. Some of the weight change data collected at the six-month follow-up was self-reported (n = 4), which could reduce data reliability. Focus group participants were aware that Balance was a pilot with a risk that the group would not be continued. As the group wanted the pilot to be extended, the feedback may have been positively skewed. A small sample size limits interpretation of the results. A group weight management intervention, including dietetic, psychological and behavioural elements, underpinned by cognitive behavioural theory was well-received by service users and effective for some. Commissioners and service users may have different definitions of successful outcomes in weight management interventions. Practical implications Longer-term support and follow-up after Tier 2 weight management interventions may benefit service users and improve outcomes. Originality/value The paper contributes to a small but growing evidence base concerned with the design and delivery of weight management interventions. Areas of particular interest include: a gap analysis between the course content and National Institute for Health and Care Excellence clinical guidelines, participants’ views on the most impactful course features and recommendations for course development. The results also show a disconnect between evidence-based guidelines (mandatory weight monitoring), participants’ preferences and clinicians' experience. The difference between client and commissioner priorities is also discussed.

Purpose The purpose of the paper is to examine the likely impact of the COVID-19 pandemic on health with particular attention to the mental health of children, adolescents, and adults in the most populous country in Africa – Nigeria. Presently, the Coronavirus Disease-2019 (COVID-19) is well-established in Nigeria with increasing community transmission. While a significant response has been initiated by the Federal Government of Nigeria through a multidisciplinary task force, there are challenges for the country’s already weak health sector and invariably the mental health systems. For example, the testing capacity is inadequate because of limited technical, infrastructural, financial and logistical capacity to rapidly scale-up testing which could be a reflection of the health system. Design/methodology/approach In this paper, the authors examined and explored the impact of the COVID-19 pandemic on the prevalent public mental health challenges in Nigeria, the most populous country in sub-Saharan Africa. Findings The authors argued for sustained investments in digitally enhanced health-care delivery and medical surveillance system that incorporate public mental health in a way that accommodates equity in Nigeria. Originality/value The authors have examined the likely impact of the COVID-19 pandemic on health with particular attention to the mental health of children, adolescents and adults in the most populous country in Africa – Nigeria. Furthermore, they discussed emerging frameworks and strategies to build a clinical practice and research capacities for these populations

Purpose User involvement in research is entering the mainstream of traditional mental health research. In practice, there are diverse ways in which the process of involvement is experienced by mental health service user researchers. This paper aims to explore two diverse experiences of involvement by the researcher. Design/methodology/approach Auto-ethnography is the research methodology used in this study; it combines a process of reflective writing and critical analysis which enables the author to explore experiences of being both a service user and academic researcher. Two accounts of the author’s involvement in mental health research are presented: one which builds on a consultation model and the other based on co-production principles. Findings Experiences of power-sharing and collaborative decision-making, alongside disempowerment, are discussed, leading to exploration of the theoretical and practical processes for promoting participation of users in research. Research limitations/implications The research is limited because it is undertaken by one individual in a local setting, and is therefore is not generalisable; however, it provides useful insights into the diverse processes of involvement that many service users experience. Practical implications Recommendations are presented to support the involvement of service users in research, with final remarks offered considering the possible future implementation of this still emerging tradition. Originality/value This paper reflects on the experiences of one service user academic involved in research and highlights diverse experiences of both empowering and disempowering involvement, providing recommendations for best practice.

Purpose Studies show that experiences of repeated or complex trauma are very common in patients with severe mental health problems. Unfortunately, many professionals do not routinely ask about abuse, due to concerns about how to ask and respond. There is also a need for frontline staff to be trained in trauma-informed care. The purpose of this paper is to identify the needs of inpatient staff and developed a tailor-made training package. Design/methodology/approach A training programme was developed from focus-group discussion and delivered to the team. Questionnaires were administered pre-, post-training and at three-month follow-up, to assess changes in knowledge, confidence and worries in the assessment and treatment of complex trauma. Findings There was an increase in self-reported staff confidence (p=0.001) and knowledge (p=0.028) about working with complex trauma and their worries decreased (p=0.026) between pre- and post-training. Practical implications In order to sustain the benefits of training for longer, recommendations were made to the service for on-going training, supervision and evaluation. Originality/value Given the recent interest in complex trauma within the literature (Diagnostic and Statistical Manual of Mental Disorders – Fifth Version (DSM-V); International Statistical Classification of Diseases – 11th Version (ICD-11)), the piloting and development of complex trauma training packages is timely. To the author’s knowledge, this is the first published account of complex trauma training for inpatient staff. This paper offers clinical and research implications to services who may want to develop as trauma-informed services within the NHS.

Purpose The purpose of this paper is to address a knowledge gap on advocacy outcomes from mental health service users’ perspective, and the implications for evaluating advocacy impact. The studies discussed highlight challenges for measuring the outcomes of advocacy, but underline the importance of doing so, and of involving service users alongside other stakeholders in co-designing evaluation systems. Design/methodology/approach The paper uses findings from three qualitative studies of independent advocacy involving focus groups and interviews with: 30 African and African Caribbean men who were mental health service users; 90 “qualifying patients” in a study of Independent Mental Health Advocate services; and nine young women in children and adolescent mental health services (CAMHS). Findings A comparative analysis and synthesis of findings from three studies identifies four common dimensions: how mental health advocacy is conceptualised and understood; how service users define advocacy outcomes; wider impacts; and, user involvement in evaluating advocacy outcomes. Advocacy outcomes were conceptualised as increasing involvement, changing care and treatment and supporting personal development. There was evidence of advocacy acting to empower mental health service users, and of broader impacts on service regimes and policies. However, there was limited evidence of transformational impact. Evaluating advocacy outcomes is increasingly seen as important. Originality/value Few researchers have focused primarily on the perspectives of people using independent mental health advocacy, or on the experience of “advocacy as empowerment”, and none have done so across diverse groups. This analysis adds insight into the impact of independent advocacy. Data from empirical studies attest to the important role independent advocacy plays in modern mental health systems.

Purpose The spread of novel coronavirus 2019 (COVID-19) has infected millions of people worldwide. Public health emergencies caused by COVID-19 affect not only people’s physical health but also mental health. This paper aims to summarize recent research findings on the mental health impact of COVID-19 experienced by the general adult population. Design/methodology/approach This paper used a systematic approach and aimed to review the literature on mental health problems faced by general adults during the COVID-19 pandemic. The PubMed database has been selected randomly from the Google Scholar, Cochrane Library, Embase and PubMed databases. Ten journal articles published between January and July 2020 were selected from the PubMed database for the final review. Findings There is growing evidence that COVID-19 may be an objective risk factor for mental distress among the general adult population. More psychological and social support should be provided to protect adult people’s mental health. Practical implications This review will help policymakers develop mental health interventions for the general adult population vulnerable to psychological distress because of COVID-19 pandemic. Originality/value This paper is original and contributes to the existing knowledge that the mental health challenges of COVID-19 are widespread. There is, therefore, a need for more psychological interventions for adults, older adults, in particular, to promote mental health and reduce the distress associated with public health emergencies caused by COVID-19.

Purpose The purpose of this paper is to critique Spandler and McKeown’s recent advocacy of a truth and reconciliation (T&R) process in psychiatry. Design/methodology/approach A critique of a recent paper in Mental Health Review Journal. Findings That Spandler and McKeown’s advocacy of a T&R process in psychiatry can be criticised from a number of inter-related practical, political and ethical perspectives. Originality/value The present critique contributes to the ongoing debate about the desirability of a T&R process in psychiatry.

Purpose The purpose of this paper is to identify and describe, in a systematic way, the various academic discourses on the rationale for shared decision making (SDM) in mental health care, and so provide a comprehensive account of the ways in which this emerging field is being conceptualised in the research literature. Design/methodology/approach This study is a systematic review of peer-reviewed papers presenting a rationale for SDM in mental health. Relevant databases were searched from inception to July 2016. Data were analysed using a thematic analysis which aimed to identify and describe different discourses on the rationale for SDM in mental health care. Data were extracted into a standardised data extraction form which contained fields representing the developing thematic framework, study information and research methodology. Findings An initial search returned returned 1,616 papers, of which 175 were eligible for inclusion in this review. The authors developed ten distinct but interrelated themes which capture the various academic discourses on the rationale for SDM and represent some compelling arguments for SDM from a range of different perspectives including ethical, clinical, “user” focussed, economic and political. Dominant narratives in the literature linked SDM to the recovery moment and person-centred care, and adherence and engagement with mental health services. Research limitations/implications The authors are unable to make any conclusions about the strength of evidence for these rationales. The review was restricted to peer-reviewed publications, published in English. Practical implications The findings could be a useful framework to support the selection of outcome measures for SDM evaluations. Originality/value There have been no systematic reviews published in this area previously.

Purpose The purpose of this paper is to consider the role of shared decision making (SDM) as one component of recovery-oriented care. Design/methodology/approach This paper is conceptual and reviews the literature relevant to recovery-oriented care, person-centered recovery planning (PCRP), and SDM. Findings To the degree to which SDM offers tools for sharing useful information about treatment options with service users and family members or other loved ones, it can be considered a valuable addition to the recovery-oriented armamentarium. It is important to emphasize, though, that recovery-oriented practice has a broader focus on the person’s overall life in the community and is not limited to formal treatments or other professionally delivered interventions. Within the more holistic context of recovery, SDM regarding such interventions is only one tool among many, which needs to be integrated within an overall PCRP process. More emphasis is given within the recovery-oriented care to activating and equipping persons for exercising self-care and for pursuing a life they have reason to value, and the nature of the relationships required to promote such processes will be identified. In describing the nature of these relationships, it will become evident that decision making is only one of many processes that need to be shared between persons in recovery and those who accept responsibility for promoting and supporting that person’s recovery. Originality/value By viewing SDM within the context of recovery, this paper provides a framework that can assist in the implementation of SDM in routine mental health care.

Purpose While shared decision making (SDM) in general health has proven effectiveness, it has received far less attention within mental health practice with a disconnection between policy and ideals. The purpose of this paper to review existing developments, contemporary challenges, and evidence regarding SDM in mental health with a particular focus on the perspectives of service users. Design/methodology/approach This is a review of international papers analysed using narrative synthesis of relevant data bases. Findings The review shows significant barriers to the utilisation of SDM including ethical and legal frameworks, accountability and risk. The medical model of psychiatry and diagnostic stigma also contributes to a lack of professional acknowledgement of service user expertise. Service users experience an imbalance of power and feel they lack choices, being “done to” rather than “worked with”. Practical implications The paper also presents perspectives about how barriers can be overcome, and service users enabled to take back power and acknowledge their own expertise. Originality/value This review is the first with a particular focus on the perspectives of service users and SDM.

Purpose The purpose of this paper is to explore the case for a truth and reconciliation (T&R) process in the context of mental health services. Design/methodology/approach The approach is a conceptual review of T&R approaches; a consideration of why they are important; and how they might be applied in the context of mental health services and psychiatry. First, the paper sets out a case for T&R in psychiatry, giving some recent examples of how this might work in practice. Then it outlines potential objections which complicate any simplistic adoption of T&R in this context. Findings In the absence of an officially sanctioned T&R process a grassroots reparative initiative in mental health services may be an innovative bottom-up approach to transitional justice. This would bring together service users, survivors and refusers of services, with staff who work/ed in them, to begin the work of healing the hurtful effects of experiences in the system. Originality/value This is the first paper in a peer-reviewed journal to explore the case for T&R in mental health services. The authors describe an innovative T&R process as an important transitional step towards accomplishing reparation and justice by acknowledging the breadth and depth of service user and survivor grievances. This may be a precondition for effective alliances between workers and service users/survivors. As a result, new forms of dialogic communication and horizontal democracy might emerge that could sustain future alliances and prefigure the social relations necessary for more humane mental health services.

Purpose: To conduct a systematic search of the peer-reviewed qualitative literature investigating the lived experience of seclusion for adults with mental health difficulties, to appraise the quality of the existing literature and synthesise findings.\ud \ud Background: Seclusion is a controversial intervention for the short-term management of unsafe behaviours in inpatient mental health services. There has been some sporadic interest in the service-users' experiences of this.\ud \ud Design: Systematic literature review and meta-synthesis.\ud \ud Data Sources: Databases MEDLINE, EMBASE, CINAHL and PSYCHINFO were searched in July 2015.\ud \ud Review Methods: The JBI QARI tools for critical appraisal and data extraction were used to review papers and synthesise findings.\ud \ud Findings: A small number of papers was found, which were of mixed quality.\ud \ud Value: The existing research is limited in both quantity and quality. Although most participants from the existing research described seclusion as mostly negative with the potential for causing iatrogenic harm, some described more positive experiences, often in the context of compassionate interactions with staff.\ud \ud Summary Statement: \ud \ud Why is this research or review needed? \ud • The use of seclusion is common within mental health services but there is an absence of evidence for the purported theoretical rationale for its use. \ud • Studies of the experiences of individuals placed in seclusion are small in number, of mixed quality and with mixed findings. \ud • A systematic literature review and meta-synthesis of the existing qualitative literature investigating the lived experience of seclusion for adults with mental health difficulties was conducted, to synthesize the existing evidence base and make suggestions for future developments in research and practice. \ud \ud What are the key findings? \ud • The existing research is limited both in quantity and quality.\ud • Despite the limitations of existing research, the evidence does not support the purported theoretical rationale for the therapeutic use of seclusion. This poses a significant challenge to a common practice within mental health settings. \ud • Seclusion has the potential to cause iatrogenic harm, particularly where interactions with nursing staff are not experienced as compassionate.\ud • The actions of nursing staff in implementing seclusion procedures may mitigate iatrogenic harm. \ud • Individuals who have experienced seclusion have suggestions for how to improve its use.\ud \ud How should the findings be used to influence policy/practice/research/education? \ud • There is clearly scope for further, high quality research into people’s experiences of seclusion, particularly within the UK.\ud • The findings include concrete ways in which the practice of seclusion can be improved.\ud • Action research methods may offer a useful way of implementing and evaluating changes in practice.

Purpose – Multidisciplinary team (MDT) clinical supervision is being used in many mental health services but at present has not received adequate attention by researchers in order to generate evidence-based approaches. The purpose of this paper is to explore the utility and staff perspectives of an MDT model of clinical supervision in the form of a “Clinical Discussion Group” (CDG) on an acute inpatient mental health ward within the context of the current literature on the components of effective supervision in order to make recommendations for practice. Design/methodology/approach – In total, 12 members of staff working on the ward were interviewed to gather their perspective on attendance, helpful aspects, outcomes, unhelpful aspects, and changes. Interview transcripts were analysed using thematic analysis. Findings – In total, 11 themes were identified, three within “The Group and how it operates” (attendance, discussion topics and facilitation), five within “Impact and Usefulness” (valued by staff, understanding a case, emotional benefit, learning and working together as a team) and three within “Changes to the Group” (organisation, discussion topic and group outcomes). Originality/value – This paper explores the benefits and challenges of a CDG from the perspective of the staff who attend. It presents some recommendations for good practice which should be of use to managers and supervisors who wish to use team supervision to improve patient outcomes and also makes suggestions for future research in this field.

Purpose – Co-production is becoming a more widely used term in mental health care in England, but it is not always clear what this means nor what the evidence base is behind particular uses of the concept. The purpose of this paper is to set some of this discussion into a historical context and examine some of the relevant evidence base to begin to highlight the challenges with operationalising more co-production. This is by way of setting the scene for the other articles in this special edition of the journal. The paper then provides an overview of the other articles on co-production in this edition. Design/methodology/approach – The paper is a short review and discussion of some key issues and evidence relevant to co-production in mental health. Findings – Some key historical insights from other moves to transform mental health care are discussed, recognising that these developments can take a long time to reach maturity in services and practice across the whole country. The discussion of some pertinent research and of the other articles in this special edition helps to highlight what foundations the author have in place for greater co-production in mental health care, and what remains as some of the challenges and gaps in the knowledge. Originality/value – The paper provides a historical overview of some key issues, evidence and lessons pertaining to moves to develop more co-production in mental health.

Purpose– The purpose of this paper is to provide a brief overview of the literature to date which has focused on co-production within mental healthcare in the UK, including service user and carer involvement and collaboration.Design/methodology/approach– The paper presents key outcomes from studies which have explicitly attempted to introduce co-produced care in addition to specific tools designed to encourage co-production within mental health services. The paper debates the cultural and ideological shift required for staff, service users and family members to undertake co-produced care and outlines challenges ahead with respect to service redesign and new roles in practice.Findings– Informal carers (family and friends) are recognised as a fundamental resource for mental health service provision, as well as a rich source of expertise through experience, yet their views are rarely solicited by mental health professionals or taken into account during decision making. This issue is considered alongside new policy recommendations which advocate the development of co-produced services and care.Research limitations/implications– Despite the launch of a number of initiatives designed to build on peer experience and support, there has been a lack of attention on the differing dynamic which remains evident between healthcare professionals and people using mental health services. Co-production sheds a light on the blurring of roles, trust and shared endeavour (Slay and Stephens, 2013) but, despite an increase in peer recovery workers across England, there has been little research or service development designed to focus explicitly on this particular dynamic.Practical implications– Despite these challenges, coproduction in mental healthcare represents a real opportunity for the skills and experience of family members to be taken into account and could provide a mechanism to achieve the “triangle of care” with input, recognition and respect given to all (service users, carers, professionals) whose lives are touched by mental distress. However, lack of attention in relation to carer perspectives, expertise and potential involvement could undermine the potential for coproduction to act as a vehicle to encourage person-centred care which accounts for social in addition to clinical factors.Social implications– The families of people with severe and enduring mental illness assume a major responsibility for the provision of care and support to their relatives over extended time periods (Roseet al., 2004). Involving carers in discussions about care planning could help to provide a wider picture about the impact of mental health difficulties, beyond symptom reduction. The “co-production of care” reflects a desire to work meaningfully and fully with service users and carers. However, to date, little work has been undertaken in order to coproduce services through the “triangle of care” with carers bringing their own skills, resources and expertise.Originality/value– This paper debates the current involvement of carers across mental healthcare and debates whether co-production could be a vehicle to utilise carer expertise, enhance quality and satisfaction with mental healthcare. The critique of current work highlights the danger of increasing expectations on service providers to undertake work aligned to key initiatives (shared decision-making, person-centred care, co-production), that have common underpinning principles but, in the absence of practical guidance, could be addressed in isolation rather than as an integrated approach within a “triangle of care”.

Purpose – The purpose of this paper is to explore the issues surrounding a long planned expansion of Payment by Results (PbR) into mental health services and to highlight the factors responsible for the delay. Design/methodology/approach – PbR relies upon “standardisation” of conditions and treatments. This depends upon a scheme of classification that can realistically predict resources required to execute treatment of any one case. Plans to fund NHS mental health services on the basis of tariffs derived in this way have been delayed, and a key reason is the lack of high-quality data. This would require effective “standardisation-to the-average” of both a system of classification and a repertoire of costed treatment pathways. This paper investigated the delay implementation by exploring the difficulties in applying standardisation principles to service provision and tariff calculation. Findings – The paper identified the fundamental difficulty with PbR’s implementation in applying “standardisation” to practice. This is defining the mental disorder that the patient is suffering and designing care pathways at clinical level considering the balance between practical applicability and conceptual/constructional validity. This is necessary to enable the calculation of a national tariff. The conceptual flaws of the Health of the Nation Outcome Scale led to the constructional shortcomings which compromised the credibility and validity of Mental Health Clustering Tool regarding making accurate classification in a standardised way. The validity and credibility of calculating a national tariff thus became contentious on the basis of this inaccurate clinical classification system. Originality/value – This paper explored the driving factors of delay in implementing PbR in mental health through connecting the recent reform with the fundamental assumptions of “standardisation-to the-average”, which provided another perspective to illustrate the current obstacles.

Purpose – The purpose of this paper is to systematically appraise the effect of use of interpreters for mental health problems in old age. The primary objective of the review is to assess the impact of a language barrier for assessment and management in relation to mental health problems in the old age. The secondary objectives are to assess the effect of the use of interpreters on patient satisfaction and quality of care, identify good practice and make recommendations for research and practice in the old age mental health. Design/methodology/approach – The following data sources were searched for publications between 1966 and 2011: PubMed, PsycINFO, CINAHL and Cochrane Library. The authors found in previous reviews that a substantial number of papers from developing and non-English speaking countries are published in journals not indexed in mainstream databases, and devised a search strategy using Google which identified a number of papers, which could not be found when the search was limited to scientific data bases only (Farooq et al., 2009). The strategy was considered especially important for this review which focuses on communication across many different languages. Thus, the authors conducted a search of the World Wide Web using Google Scholar, employing the search term Medical Interpreters and Mental Health. The search included literature in all languages. The authors also searched the reference lists of included and excluded studies for additional relevant papers. Bibliographies of systematic review articles published in the last five years were also examined to identify pertinent studies. Findings – Only four publications related specifically to “old age” and 33 addressed “interpreting” and “psychiatry” generally. Four articles presented original research (Parnes and Westfall, 2003; Hasset and George, 2002; Sadavoy et al., 2004; Van de Mieroop et al., 2012). One article (Shah, 1997) reports an “anecdotal descriptive account” of interviewing elderly people from ethnic backgrounds in a psychogeriatric service in Melbourne and does not report any data. Therefore, only four papers met the inclusion and exclusion criteria and present original research in the field of “old age”, “psychiatry” and “interpreting”. None of these papers present UK-based research. One is a quantitative study from Australia (Hasset and George, 2002), the second is a qualitative study from Canada (Sadavoy et al., 2004), in the third paper Van de Mieroop et al. (2012) describe community interpreting in a Belgian old home and the final paper is an American case study (Parnes and Westfall, 2003). Practical implications – Interviewing older patients for constructs like cognitive function and decision-making capacity through interpreters can pose significant clinical and legal problems. There is urgent need for training mental health professionals for developing skills to overcome the language barrier and for interpreters to be trained for work in psychogeriatrics. Social implications – The literature on working through interpreters is limited to a few empirical studies. This has serious consequences for service users such as lack of trust in services, clinical errors and neglect of human rights. Further studies are needed to understand the extent of problem and how effective interpreting and translating services can be provided in the routine clinical practice. It is also essential to develop a standard of translation services in mental health that can be measured for their quality and also efficiency. At present such a quality standard is not available in the UK, unlike Sweden (see www.regeringen.se/sb/d/3288/a/19564). This omission is disturbing – especially when decisions on human rights are being considered as part of the Mental Health Act. Such a standard can best be achieved by collaboration between medical profession and linguists’ professional associations (Cambridge et al., 2012). Originality/value – Whilst translation/interpretation has been addressed more generally in mental health: specific considerations related to old age psychiatry are almost absent. This needs urgent rectification given that a large proportion of older people from BME communities will require translation and interpretation services.

Purpose – The concept of recovery is well accepted internationally as a guiding vision for mental health services. The purpose of this paper is to highlight the challenges faced by in-home psychiatric support workers in implementing this vision in their work with clients with severe psychiatric disability. Design/methodology/approach – The findings reported here are based on interviews with 27 support workers and ten managers of organisations providing support services. These were collected as part of evaluations of two supported housing programmes carried out between 2010 and 2011. Findings – Challenges faced by support workers coalesced around two areas: first, balancing the need to provide care with the need to promote autonomy and second, developing an effective working relationship while working mainly within a clients’ home. Practical implications – These challenges for support workers highlight tensions within the recovery vision that are not easily resolved. To ensure high quality, recovery-oriented care services are provided, support workers need access to training courses that focus on challenging areas of this work and should be provided with regular professional supervision. Originality/value – Existing literature on support workers has generally focused on the nature of the role and support worker interactions with other health workers. In this paper, the authors highlight difficulties faced by support workers in implementing the vision of recovery in their work. The paper provides important information for policy makers and managers who are designing service delivery systems that aim to promote recovery.

Purpose – This paper adds to growing research of psychiatric intensive care units (PICU) by recounting descriptions of psychiatric intensive care settings and discusses the perceptions held by nurses of the organisational interfaces, arrangements and provisions of care in these settings. Design/methodology/approach – Data gathered from focus groups held with nurses from two PICUs was used to establish terminology, defining attributes, related concepts, antecedents, values, processes and concepts related to current practices. A literature search was conducted to permit a review of the conceptual arrangements and contemporary understanding of intensive care for people experiencing acute psychiatric illness based on the perspectives held by the nurses from the focus groups. Findings – Dissonance between service needs and the needs and management of individual patients overshadow strategies to implement comprehensive recovery-oriented approaches. Three factors are reported in this paper that influence standards and procedural practice in PICU; organisational structures; physical structures; and subtype nomenclature. Practical implications – Acute inpatient care is an important part of a comprehensive approach to mental health services. Commonly intensive acute care is delivered in specialised wards or units co-located with acute mental health inpatient units mostly known as PICU. Evidence of the most effective treatment and approaches in intensive care settings that support comprehensive recovery for improved outcomes is nascent. Originality/value – Current descriptions from nurses substantiate wide variations in the provisions, design and classifications of psychiatric intensive care. Idiosyncratic and localised conceptions of psychiatric intensive care are not adequately entailing effective treatment and methods in support of recovery principles for improved and comprehensive outcomes. The authors suggest that more concrete descriptions, guidelines, training and policies for provision of intensive psychiatric health care encompassing the perspective of nursing professionals, would reinforce conceptual construction and thus optimum treatments within a comprehensive, recovery-oriented approach to mental health services.

Purpose This paper aims to explore inpatient staff experiences of seeking to meet the religious and cultural needs of Black, Asian and Minority Ethnic (BAME) inpatients on mental health wards. Design/methodology/approach Nine semi-structured interviews were undertaken with inpatient staff in one NHS Trust in England to explore their views and experiences of supporting BAME inpatients to meet their religious and cultural needs. Anonymised transcripts were analysed thematically. Findings Inpatient staff reported lacking the confidence and knowledge to identify and meet BAME inpatients’ religious and cultural needs, especially inpatients from smaller ethnic groups and newly emerging communities. There was no specific assessment used to identify religious and cultural needs and not all inpatient staff received training on meeting these needs. Concerns were raised about difficulties for staff in differentiating whether unusual beliefs and practices were expressions of religiosity or delusions. Staff identified the potential role of inpatients’ family members in identifying and meeting needs, explaining religious and cultural beliefs and practices, and psychoeducation to encourage treatment or medication adherence. Practical implications Potential ways to address this gap in the knowledge and confidence of inpatient staff to meet the religious and cultural needs of BAME patients include training for inpatient staff; the production and updating of a directory of common religious and cultural practices and needs; local resources which can help to support those needs; and religious and cultural practices and needs being documented by mental health practitioners in community teams such that this information is readily available for inpatient staff if a service user is admitted. Originality/value This is the first study to consider inpatient staff views on meeting the religious and cultural needs of BAME informal patients and patients detained under the Mental Health Act 1983.

Purpose Individuals living in areas of higher deprivation are more likely to have requested mental health treatment but are less likely to have received treatment or benefitted from it. Less is known about the extent of access equality and treatment outcomes for individuals with a long-term health condition who experience mental health difficulties. The purpose of this paper is to evaluate the extent to which the neighbourhood Index of Multiple Deprivation predicted access to treatment, appointment attendance, treatment completion and clinical outcomes in a British health psychology clinic. Design/methodology/approach Retrospective data were used from 479 individuals referred to a health psychology clinic over 12 months. Clinical outcomes were measured using the Clinical Outcomes in Routine Evaluation – Outcome Measure. Patient data were linked with their neighbourhood Index of Multiple Deprivation decile. Data were analysed using correlation, linear regression and Fisher’s exact test. Findings There were no significant associations between deprivation and whether an individual attended assessment, attended treatment or completed treatment or between deprivation and patients’ clinical outcomes. Exploratory evidence indicated that individuals from higher deprivation neighbourhoods may be over-represented in clinic referrals, and individuals from lower deprivation neighbourhoods may be under-represented, compared with local population distribution estimates. Originality/value This evaluation provides insights into treatment outcomes and deprivation in those with physical health difficulties. Further evaluation using a larger sample and comparing referrals with local prevalence estimates of comorbid mental and physical health problems would enable greater confidence in the conclusion that no evidence of inequality on the basis of neighbourhood deprivation was found.

PurposeThe term “Mental health literacy” is defined as knowledge and beliefs about mental disorders which aid their recognition, management or prevention. The importance of health literacy for physical health is widely studied; however, the area of mental health literacy in Pakistan has been comparatively neglected. The purpose of this paper is to address the knowledge about mental health in people living in Pakistan.Design/methodology/approachRelevant literature relating to mental health literacy was identified through various database searches. The databases searched included: PubMed, Cochrane database of Systemic Reviews, PsycINFO using the terms mental health, mental health literacy, mental health education, Pakistan.FindingsLiterature suggests that there is dearth of knowledge about mental illnesses and their treatment among public. This review also highlights the importance of mental health literacy among professionals working in the field of health care. In Pakistan, due to low literacy rate, a high percentage of poverty and dearth of trained professionals warrants an emendation in approaches established for attaining the goal of public health and psychiatric care.Practical implicationsFindings have implications for practitioners in the field of mental health care as well as designing targeted interventions for enhancing mental health literacy and help-seeking behavior in the future.Originality/valueA limited understanding and lack of improvement in mental health literacy may interfere with society’s acceptance of evidence-based mental health care which may hamper the delivery of adequate mental health services to the needy.

PurposeInterventions that promote both mental and physical wellbeing have been advocated for people with mental health difficulties, as they have been found to engage less in healthy behaviours and have lower levels of physical fitness. However, no optimal approach to facilitate this undertaking has been identified. The purpose of this paper is to explore the experiences of people with psychological distress who accessed a social enterprise that fosters the building of positive social networks in the community, as part of a personalised recovery programme. The intention was to gain an insight into its therapeutic effect in relation to mental and physical health.Design/methodology/approachAn exploratory survey design was undertaken with a purposive sample of 50 individuals who had attended the enterprise. Descriptive statistics and thematic analysis were employed to analyse the data from both closed and open-ended questions.FindingsThe wellbeing service appeared to provide a supportive environment that offered people access to social networks through their participation in local services and activities. Fostering participants’ active participation, connection building and the ability to make meaningful contributions helped to facilitate health behaviours that had a positive impact on their health and wellbeing.Originality/valueThis study highlights the potential role of a social enterprise in optimising the social context for promoting the health and wellbeing of people with mental health difficulties.

Purpose Nurses working in acute mental-health services are vulnerable to occupational stress. One stressor identified is the challenging behaviour of some service users (Jenkins and Elliott, 2004). The purpose of this paper is to discuss the discourses drawn on by nurses to understand challenging behaviour and talk about its management. Design/methodology/approach Nurses working on acute and psychiatric intensive care unit (PICU) wards were interviewed, and data were analysed using discourse analysis. Findings Biomedical and systemic discourses were found to be dominant. Alternative psychosocial and emotional discourses were drawn on by some participants but marginalised by the dominant biomedical construction of challenging behaviour. Originality/value Existing studies have not considered how discourses socially construct challenging behaviour and its management in inpatient mental-health services.

Purpose Facilitation of genuine occupational engagement rather than a more superficial level of participation that has minimal therapeutic benefit is a challenge within secure mental health settings. The purpose of this paper is to develop, pilot and evaluate therapeutic tools based on a framework of occupational engagement. Design/methodology/approach The study used action research with occupational therapists from two secure residential units. Focus group discussions gathered participants’ views of how the occupational engagement framework could be used to inform a therapeutic tool. Following the development and piloting of the subsequent tools, focus groups were again used to review their usefulness in practice. Discussions were audio recorded and thematically analysed. Findings Three tools were designed and piloted. Evaluation revealed a number of benefits and different ways in which the tools could be used in practice. Research limitations/implications This research has indicated that the occupational engagement framework has potential for increasing understanding of the relationship between the value and consequences of participating in occupations. The limited timescale of the research restricted the opportunity to fully explore the tools’ potential effectiveness as outcome measures. Practical implications The clinical tools developed within this research have provided some information to the clinical teams which has contributed to their understanding of how service users experience participating in occupations. Originality/value The occupational engagement framework and resulting tools have the potential to enhance understanding of occupational engagement within secure settings.

Purpose This study aims to determine depression, anxiety and stress levels of health-care students during coronavirus (COVID-19) pandemic according to various socio-demographic variables. Design/methodology/approach This cross-sectional study was conducted with 933 students. Data were collected with an information form on COVID- 19 and an electronic self-report questionnaire based on depression, anxiety and stress scale. Findings Findings revealed that 58% of the students experienced moderate-to-extremely severe depression, 39.8% experienced moderate-to-extremely severe anxiety and 38% experienced moderate-to-extremely severe stress. Practical implications Educational administrators can help reduce long-term negative effects on students’ education and mental health by enabling online guidance, psychological counseling and webinars for students. Originality/value This paper is original and adds to existing knowledge that health-care students’ depression, anxiety and stress levels were affected because of many factors that are not yet fully understood. Therefore, psychological counseling is recommended to reduce the long-term negative effects on the mental health of university students.

Purpose This paper aims to outline the process of supporting frontline inpatient mental health staff in developing ways of coping with COVID-19. Design/methodology/approach A whole system approach was used in formulating and developing support structures with particular focus on relationship-focused coping. Findings Interventions were developed to support staff in coping with problem-focused (e.g. systemic changes) and emotion-focused challenges (e.g. deaths of colleagues). These included psychoeducation, mindfulness-based meditation and rituals to mark the deaths of colleagues. Staff SPACE (Stopping to Process and Consider Events) sessions were used to support staff in managing the many emotions they were experiencing. Positive psychology-based interventions were used to keep morale up and help people to stay motivated. The process of seeking feedback and making changes was introduced to support staff in feeling heard and having a voice. The maternal or master intervention within each of the above was the relational component. Practical implications This work aimed to boost the emotional and psychological literacy of the system. This will be important in the aftermath of the pandemic and could have many benefits thereafter. Social implications The post-COVID-19 health-care workforce will experience significant challenges in terms of readjustment and recovery. It is important that appropriate measures are put in place to ameliorate this. Originality/value An innovative systemic formulation of the impact of COVID-19 on frontline staff, and a coordinated way of dealing with this, is outlined.

Purpose The purpose of this paper is to present a qualitative analysis of the role of self-harm self-help groups from the perspective of group members. Design/methodology/approach A qualitative case study approach guided the research, which involved working with two self-harm self-help groups and all regularly attending members. Findings A thematic approach to the analysis of the findings indicates that self-harm self-help groups can provide a safe, non-judgemental space where those who self-harm can meet, listen and talk to others who share similar experiences for reciprocal peer support. Offering a different approach to that experienced in statutory services, the groups reduced members’ isolation and offered opportunities for learning and findings ways to lessen and better manage their self-harm. Research limitations/implications This was a small-scale qualitative study, hence it is not possible to generalise the findings to all self-harm self-help groups. Practical implications The value of peers supporting one another, as a means of aiding recovery and improving well-being, has gained credence in recent years, but remains limited for those who self-harm. The findings from this research highlight the value of self-help groups in providing opportunities for peer support and the facilitative role practitioners can play in the development of self-harm self-help groups. Originality/value Self-harm self-help groups remain an underexplored area, despite such groups being identified as a valuable source of support by its members. This research provides empirical evidence, at an individual and group level, into the unique role of self-harm self-help groups.

Purpose Occupational therapists working in mental health services in the UK are under increasing scrutiny to provide both clinically and cost-effective services. The profession has indicated that a stronger evidence base would help promote the unique contribution of occupational therapy when influencing service managers and government bodies. The paper aims to discuss these issues. Design/methodology/approach The Royal College of Occupational Therapists (RCOT) and its Specialist Section – Mental Health carried out a survey to gauge recent research capacity among occupational therapists working in mental health services in the UK and to seek their views about how to further increase research capacity and partnerships. Findings Of the 145 participants approximately half had been involved in research in the past five years, and most had involved research partnerships. A number had successfully applied for funding and about half of the research carried out had been disseminated. The participants felt that methods to increase research capacity and partnerships should continue to include improving research leadership and networks; promoting research skills through formal studies and increasing research dissemination. Originality/value A variety of methods will continue to be required to expand the evidence base. RCOT and its Specialist Sections continue to have an important role developing research capacity and partnerships.

Purpose Referrals to specialist eating disorder (ED) services from the South Asian (SA) community are under-represented, despite research suggesting that disordered eating attitudes and behaviours of SA people are similar to the population in general. The purpose of this paper is to identify the reasons for this and sought to inform ways to encourage help-seeking. Design/methodology/approach A qualitative methodology was used to investigate barriers to help-seeking for EDs among the SA community. A key informant focus group was conducted with clinicians working within the local specialist ED service (participants n=16, 12 female, 4 male). Six focus groups were conducted with members of the SA community in Leicester, UK (participants n=28, 23 female, 5 male), recruited from a local university, two charities and Children, Young People and Family Centres. Findings A number of themes emerged as possible factors for delaying early access to help: lack of knowledge about EDs and their potential seriousness, ideals regarding body shape, family living circumstances and the role of food in the community. Participants acknowledged stigma among their community associated with mental health issues, including EDs and concerns about confidentiality when approaching services, particularly primary care. Originality/value General practitioners and specialist services need to be aware of the potential barriers to help-seeking for EDs as early specialist help is recommended for effective treatment. An educational campaign around EDs specifically designed with the SA community in mind may improve awareness, reduce stigma and promote early help-seeking.

Purpose Peer support (PS) workers are being employed despite uncertain evidence for clinical and cost-effectiveness. Psychological theories have been proposed to explain the mechanisms of PS but these lack empirical validation and specificity to professional PS. The purpose of this paper is to develop a substantive interpretive grounded theory of service-users’ experience of professional PS work. Design/methodology/approach Constructivist grounded theory was used throughout. Semi-structured interviews were conducted with ten service-users who had engaged with a professional PS worker. Findings Three overarching themes were constructed. “The process of disclosure” describes how disclosure of mental health difficulties, experiences as a service-user and wider disclosure about life experiences, interests and values facilitate the development of a shared identity with the PS worker. “The product of disclosure” highlights the sense of being understood as a result of the disclosure and marks a deepening of the relationship. “Dual roles” describes the tenuous position of holding both a professional relationship and friendship. Research limitations/implications Future research should seek to refine the theory developed and compare the effects of therapist self-disclosure with that found within PS. There were limitations within the study, including limited diversity within the sample as well as difficulties with recruitment. Originality/value This study connects service-users’ accounts of receiving PS with existing psychological theory to move towards an understanding of the relationship between receivers and providers of professional PS.

Purpose Research demonstrates that non-attendance at healthcare appointments is a waste of scarce resources; leading to reduced productivity, increased costs, disadvantaged patients through increased waiting times and demoralised staff. The purpose of this paper is to investigate non-attendance and implemented interventions to improve practice. Design/methodology/approach A mixed methods service audit took place in a primary care psychological therapies service. Existing service guidelines and reporting systems were reviewed. A cross-sectional design was used to compare a year’s cohort of completers of cognitive behavioural therapy (CBT) (n=140) and drop-outs (n=61). Findings Findings suggested contrasting guidelines and clinically inaccurate reporting systems. The overall service did not attend (DNA) rate was 8.9 per cent; well below rates suggested in the literature. The drop-out rate from CBT was 17 per cent. The most influential factor associated with CBT drop-out was the level of depression. The level of anxiety, risk ratings and deprivation scores were also different between completers and drop-outs. The main reasons given for non-attendance were forgetting, being too unwell to attend, having other priorities, or dissatisfaction with the service; again these findings were consistent with prior research. Originality/value A range of recommendations for practice are made, many of which were implemented with an associated reduction in the DNA rate.

PurposeThe purpose of this paper is to reach beyond existing research into the mental health benefits of arts-based or educational opportunities, to discover the particular impact on members’ recovery processes of being part of a committed, long-term troupe or community – specifically focussing on specialist theatre companies.Design/methodology/approachFollowing a literature review investigating the growing number of theatre troupes for mental health service users, qualitative research was conducted into one such company. In-depth qualitative interviews were conducted with six company members. Thematic analysis of interview transcripts was then cross-checked and enriched through a group interview with six other members.FindingsTwo overarching themes emerged: the importance of “being known” within the company (key sub-themes included “intuitive democracy” and the “paradox of reliability”), and the ways in which individuals “branched out” from this secure basis into artistic, professional and voluntary roles, while remaining company members.Research limitations/implicationsThe findings from this small-scale study, while not necessarily generalisable to other long-term communities of care and learning with a “troupe” or “team” structure, would provide valuable starting points for a larger-scale investigation.Practical implicationsIf generalisable, institutions in the mental health and educational worlds should place more emphasis on developing and resourcing long-term models of support.Social implicationsThe specialist theatre company model contrasts with prevalent individualised, time-limited services for those experiencing mental ill health.Originality/valueThe study provides compelling narrative evidence to amplify understanding of how “connectedness” is experienced within a troupe, and may enable individuals with mental illnesses to progress further in their recovery journey.

Purpose – The purpose of this paper is to explore change within the commissioning of third sector mental health services in England. Design/methodology/approach – A case study methodology based on survey and interview data of a sample of third sector organisations and commissioners within an English conurbation. Findings – Normative commissioning models based on sequential cycles were not fully implemented with the main focus being on the procurement and contracting elements. There were examples of commissioning being an enabler of service improvement but overall it seems to have been limited in its ability to bring about whole system change. Barriers included commissioners’ capacity and competence, ineffectual systems within their organisations, and fragmentation in commissioning processes between user groups, organisations and sectors. Research limitations/implications – The case study conurbation may not represent practice in all urban areas of England and there may be particular issues of difference within rural localities. The view of private and public sector providers and those working in Commissioning Support Units were not sought. Practical implications – To lead whole system change the commissioning function needs to be adequately resourced and skilled with better integration across public sector functions and organisations. Greater emphasis needs to be placed on implementing the full commissioning cycle, including the engagement of relevant stakeholders throughout the process and the practical application of outcomes. Originality/value – This research adds to the limited body of empirical work regarding commissioning in mental health.

PurposeThe purpose of this paper is to investigate the operation of multidisciplinary team (MDT) meetings within a forensic hospital in England, UK.Design/methodology/approachMixed methods, including qualitative face to face interviews with professionals and service users, video observations of MDT meetings and documentary analysis. Data were collected from 142 staff and 30 service users who consented to take part in the research and analysed using the constant comparison technique of grounded theory and ethnography.FindingsDecisions taken within MDT meetings are unequally shaped by the professional and personal values and assumptions of those involved, as well as by the power dynamics linked to the knowledge and responsibility of each member of the team. Service users’ involvement is marginalised. This is linked to a longstanding tradition of psychiatric paternalism in mental health care.Research limitations/implicationsFuture research should explore the nuances of interactions between MDT professionals and service users during the meetings, the language used and the approach taken by professionals to enable/empower service user to be actively involved.Practical implicationsClear aims, responsibilities and implementation actions are a pre-requisite to effective MDT working. There is a need to give service users greater responsibility and power regarding their care.Originality/valueWhile direct (video) observations were very difficult to achieve in secure settings, they enabled unmediated access to how people conducted themselves rather than having to rely only on their subjective accounts (from the interviews).