Alan Rosen

Assessing the value of existing recovery measures for routine use in Australian mental health services

Object: The concept of recovery has been recognized as important in the treatment of mental illness. A number of specific instruments exist which are designed to: (i) measure recovery at an individual level; and (ii) assess the recovery orientation of services. The current review aimed to identify these and evaluate their potential for routine use in Australian public sector mental health services. Method: We identified potential instruments by drawing on existing reviews, searching MEDLINE and PsycINFO, and consulting with experts. We used a hierarchical criterion-based approach to assess whether given instruments might be candidates for measuring recovery in the Australian context. Results: We identified 33 instruments: 22 designed to measure individuals’ recovery and 11 designed to assess the recovery orientation of services (or providers). Four of the former (Recovery Assessment Scale; Illness Management and Recovery Scales; Stages of Recovery Instrument; Recovery Process Inventory) and four of the latter (Recovery Oriented Systems Indicators Measure; Recovery Self Assessment; Recovery Oriented Practices Index; Recovery Promotion Fidelity Scale) were identified as promising candidates for routine use in Australian public sector mental health services. Conclusions: Further work is required, however, to determine which, if any, might best be used for this purpose; the possibility that modifications to existing instruments or the development of new instruments might be required should not be ruled out. It might be desirable to invest in two instruments: one designed to measure individuals’ recovery and one designed to measure the recovery orientation of services. If Australia were to go down this path, it would make sense to align indicators in each as far as possible, and to ensure that they were consistent with existing endeavours aimed at monitoring and improving recovery-focused aspects of service quality.

The lived experience of involuntary community treatment: a qualitative study of mental health consumers and carers

Objective: To describe the lived experiences of people subject to community treatment orders (CTOs) and their carers. Method: We recruited 11 participants (five mental health consumers and six carers) through consumer and carer networks in NSW, Australia, to take part in interviews about their experiences. We analysed the interview data set using established qualitative methodologies. Results: The lived experiences were characterised by ‘access’ concerns, ‘isolation’, ‘loss and trauma’, ‘resistance and resignation’ and ‘vulnerability and distress’. The extent and impact of these experiences related to the severity of mental illness, the support available for people with mental illnesses and their carers, the social compromises associated with living with mental illness, and the challenges of managing the relationships necessitated by these processes. Conclusions: The lived experience of CTOs is complex: it is one of distress and profound ambivalence. The distress is an intrinsic aspect of the experience of severe mental illness, but it also emerges from communication gaps, difficulty obtaining optimal care and accessing mental health services. The ambivalence arises from an acknowledgement that while CTOs are coercive and constrain autonomy, they may also be beneficial. These findings can inform improvements to the implementation of CTOs and the consequent experiences.

It’s raining mental health commissions: prospects and pitfalls in driving mental health reform

Objective: Partly in response to ongoing concerns about the state of mental health care, several jurisdictions across Australia, including the federal government, are hoping to drive change via the establishment of a mental health commission. This is the first of two articles in a series which aims to describe the background to this new trend. The commissions are being established with different powers and structures. This variety is explored and considered against a typology of commissions. Some consistent themes and goals emerge. The paper then provides a contemporary assessment of the ‘state of play’ of the nascent commissions and describes important emerging issues and differences between the models. Conclusion: There are significant differences not only in the construct of the respective commissions but also in the political circumstances in which each must work. At the same time, the problems facing mental health in Australia are ubiquitous and profound. For commissions to be successful they will require not only astute leadership but also durable, bipartisan political support and an enduring capacity to generate new resources for the mental health sector.

Psychiatrically impaired medical practitioners: better care to reduce harm and life impact, with special reference to impaired psychiatrists.

Objective: The aims are to briefly review treatment outcomes for impaired practitioners, and to explore how preventive and early intervention, and the accessing of and retention within treatment systems for impaired medical practitioners, and particularly psychiatrists, could be improved to maximize the doctors’ chances of full recovery and to minimize danger to self and others. Methods: The literature on the treatment and care of medical practitioner impairment due to mental illness, and substance use, with special reference to impaired psychiatrists is briefly reviewed. The implications of deficiencies of usual clinical management of doctors impaired by mental illness and opportunities for improvement in services for them are explored, including the impact of the experience of being an impaired medical practitioner under psychiatric treatment. The roles of medical boards and advisory services are examined. Results: Medical practitioner impairment due to mental illness has a severe impact on doctors’ lives and the lives of their families due to both the effects of the disorder and the experience of communal, professional and self stigma and discrimination. Deficiencies in usual practice in the treatment and rehabilitation of such individuals are identified, and alternatives explored. Conclusions: Prevention, early detection, intervention, and treatment programs that are more continuous more sensitive to the needs of impaired practitioners, that are more continuous, better structured, and rehabilitation and recovery focused, may be more likely to produce a positive outcome.

Psychiatrically Impaired Medical Practitioners: An Overview with Special Reference to Impaired Psychiatrists

Objective: This paper will define and describe impairment in medical practitioners due to mental illness, with special reference to the specialty of psychiatry, and then review the prevalence and identification of impaired practitioners. Methods: The quantitative and qualitative evidence regarding the incidence and impact of medical practitioner impairment due to mental illness (and, to some extent, substance use), with special reference to impaired psychiatrists, is reviewed. Results: Medical practitioner impairment due to mental illness has a severe impact on their lives and their families due to both the effects of the disorder and the experience of communal, professional and self stigma. Conclusions: The consequences of impairment among medical practitioners and specialist psychiatrists as well as the under-reporting of impaired practitioners is a significant problem.

The Many Faces of Risk: A Qualitative Study of Risk in Outpatient Involuntary Treatment.

OBJECTIVEnThis study aimed to derive a conceptualized model of risk in outpatient involuntary psychiatric treatment that has utility and meaning for stakeholders.nnnMETHODSnThirty-eight participants-patients, caregivers, clinicians, and legal decision makers-participated in qualitative interviews about their experiences of outpatient involuntary psychiatric treatment. Interview data were analyzed by using a general inductive method.nnnRESULTSnSix types of risk were identified: actual harm, social adversity, therapeutic outcome or compromised treatment, the system, interpersonal distress, and epistemic issues. There were overlaps between discourses on risk but variation in how different aspects of risk were emphasized by participant groups.nnnCONCLUSIONSnA comprehensive model of risk contextualized to outpatient involuntary treatment is proposed. It incorporates domains of risk of harm to self or others, risk of social adversity, risk of excess distress, and risk of compromised treatment. This model may have instrumental value in the implementation and the scrutiny of risk-based mental health laws.

Developing the living in the community questionnaire: reporting the social outcomes of mental health care

Abstract This paper examines an Australian approach to the measurement of social inclusion for consumers of public-funded mental health services. The former Australian Government Department of Health and Ageing commissioned the new measure, called the Living in the Community Questionnaire (LCQ), needed to be brief, able to be completed by consumers with minimal support (if any), quantifiable, allow normative comparison as available and demonstrate the social outcomes of care so the measure could be used to support recovery-orientated therapeutic practice. This paper describes the early development and initial psychometric testing of the LCQ.

How shortcomings in the mental health system affect the use of involuntary community treatment orders

Objective The aim of the present study was to examine stakeholder perspectives on how the operation of the mental health system affects the use of involuntary community treatment orders (CTOs). Methods A qualitative study was performed, consisting of semi-structured interviews about CTO experiences with 38 purposively selected participants in New South Wales (NSW), Australia. Participants included mental health consumers (n=5), carers (n=6), clinicians (n=15) and members of the Mental Health Review Tribunal of NSW (n=12). Data were analysed using established qualitative methodologies. Results Analysis of participant accounts about CTOs and their role within the mental health system identified two key themes, namely that: (1) CTOs are used to increase access to services; and (2) CTOs cannot remedy non-existent or inadequate services. Conclusion The findings of the present study indicate that deficiencies in health service structures and resourcing are a significant factor in CTO use. This raises questions about policy accountability for mental health services (both voluntary and involuntary), as well as about the usefulness of CTOs, justifications for CTO use and the legal criteria regulating CTO implementation. What is known about this topic? Following the deinstitutionalisation of psychiatric services over recent decades, community settings are increasingly the focus for the delivery of mental health services to people living with severe and persistent mental illnesses. The rates of use of involuntary treatment in Australian community settings (under CTOs) vary between state and territory jurisdictions and are high by world standards; however, the reasons for variation in rates of CTO use are not well understood. What does this paper add? This paper provides an empirical basis for a link between the politics of mental health and the uptake and usefulness of CTOs. What are the implications for practitioners? This paper makes explicit the real-world demands on the mental health system and how service deficiencies are a significant determinant in the use of CTOs. Practitioners and policy makers need to be candid about system limitations and how they factor in clinical and legal justifications for using involuntary treatment. The results of the present study provide data to support advocacy to improve policy accountability and resourcing of community mental health services.

Mental health commissions of different sub-species: can they effectively propagate mental health service reform? Provisional taxonomy and trajectories

Purpose – The aim is to provide a brief overview of a series of articles tracing the emergence of several Mental Health Commissions (MHCs) in developed countries over recent years, sometimes to enhance mental health law administration, but often in connection with mental health reform strategies. The paper seeks to review the functions of, and elicit a framework for, Mental Health Commissions (MHCs) as effective vehicles for effective operation and reform of a mental health service system.Design/methodology/approach – The approach of the paper is to identify the functions and limitations of Mental Health Commissions and then cluster them to form a typology of commissions.Findings – There are broadly three types of MHCs: the first is more inspectorial and focussed on issues, concerns and complaints affecting the care of individuals, and is more restricted investigating the mental health service and the workings of mental health laws mainly to these ends; the second type is focussed on the entire mental hea...

Reconceptualizing involuntary outpatient psychiatric treatment: From "Capacity" to "Capability"

Justifying involuntary psychiatric treatment on the basis of a judgment that a person lacks capacity is controversial because there are questions about the meaning and utility of the concept in this context. There are complexities to using capacity in this way, which are further amplified in the community outpatient setting compared with acute inpatient care. A richer account of capacity, its meanings, and practical applications in context, is required. This qualitative study sought to build inductively a model of capacity in the context of involuntary outpatient psychiatric treatment, based on 38 interviews with stakeholders from New South Wales, Australia. The emergent model incorporates multiple “capacities”: to manage illness, for self-care, and to maintain social roles. It identifies core values that correspond with the “capabilities approach,” elaborating the justifications and processes of involuntary outpatient psychiatric treatment. This proposed model of “capability” may have a range of benefits to sound and ethical practice and scrutiny of systems of involuntary outpatient treatment.