Fiona Foley

Relationship between aggression, interpersonal style, and therapeutic alliance during short‐term psychiatric hospitalization

Aggression during psychiatric hospitalization is frequent, problematic, and a major challenge for nurses and mental health services more generally. The strength of the therapeutic alliance between nursing staff and patients has been posited as an important protective factor that can limit the likelihood of aggression. This study examined the relationship between interpersonal style, perceived coercion, and psychiatric symptoms on the therapeutic alliance between patients and staff, and how each, in turn, is related to aggression. Participants in this study were 79 patients admitted to an acute psychiatric hospital. Each participant was interviewed to determine perceived coercion, symptoms of psychiatric illness, interpersonal style, and therapeutic alliance. Incidents of aggression were recorded at discharge through a review of incident forms, file review, and interviews with unit nursing staff. The results showed that a hostile-dominant interpersonal style and symptoms of paranoia predicted poor therapeutic alliance, contributing 14% of the variance in therapeutic alliance scores. A dominant interpersonal style predicted aggression towards staff. Therapeutic alliance, perceived coercion, and symptoms of psychiatric illness did not predict aggression. Implications for engagement in treatment and the prevention of aggression are discussed.

Are people with severe mental illness ready for online interventions? Access and use of the Internet in Australian mental health service users

Objectives: The Internet is increasingly used in mental health service delivery, but there are significant potential barriers to Internet access for persons with severe mental illness (SMI). There is a need to understand this group’s access to, and confidence with using, the Internet, and current views on using online resources as part of mental healthcare. Method: A survey was conducted of 100 consumers attending a specialist mental health service in Melbourne, Australia. Results: Approximately three-quarters of participants had regular access to the Internet, and two-thirds used the Internet weekly or more. Half of the sample used email at least weekly, and a third were regular users of social networking sites. Internet access was often via mobile devices. Only a minority of participants used the Internet for mental health information, with video streaming and general websites accessed more often than peer forums for mental health content. Most participants were positive about their mental health worker using tablet computers with them in appointments for delivery of mental health materials. Conclusion: Most people with SMI are active Internet users and, therefore, able to use interventions online.

Predictors of Perceived Coercion in Patients Admitted for Psychiatric Hospitalization and the Stability of these Perceptions over Time

The origins of patients’ perceptions of coercion during short-term psychiatric hospitalization are varied. The purpose of this study was to elucidate the characteristics of patients that are associated with higher levels of perceived coercion and to determine whether these perceptions remain stable one year after admission. One hundred and twenty-five patients were recruited within three days of admission to the acute units at the Alfred Hospital Inpatient Psychiatry Department, Melbourne, Australia. In the initial recruitment phase, patients’ perceptions of coercion, psychiatric symptoms and interpersonal style were assessed using the Macarthur Admission Experience Scale, the Brief Psychiatric Rating Scale-18 and the Impact Message Inventory–Circumplex. Admission status (voluntary versus involuntary) and demographic characteristics were also assessed. Follow-up assessments were conducted approximately one year later. Results suggest that a significant but small positive correlation existed between perceived coercion and a Hostile–Dominant interpersonal style at initial recruitment. Females reported significantly higher perceptions of coercion than males, but admission status and severity of psychiatric symptoms were unrelated to perceived coercion. Despite perceptions of coercion appearing to lessen over time, there is a need for specific interventions for these patients during their admission to hospital. There was a statistically significant decrease in perceived coercion over time.

Promoting Personal Recovery in People with Persisting Psychotic Disorders: Development and Pilot Study of a Novel Digital Intervention

Background For people with persisting psychotic disorders, personal recovery has become an important target of mental health services worldwide. Strongly influenced by mental health service consumer perspectives, personal recovery refers to being able to live a satisfying and contributing life irrespective of ongoing symptoms and disability. Contact with peers with shared lived experience is often cited as facilitative of recovery. We aimed to develop and pilot a novel recovery-based digitally supported intervention for people with a psychotic illness. Methods We developed a website to be used on a tablet computer by mental health workers to structure therapeutic discussions about personal recovery. Central to the site was a series of video interviews of people with lived experience of psychosis discussing how they had navigated issues within their own recovery based on the Connectedness–Hope–Identity–Meaning–Empowerment model of recovery. We examined the feasibility and acceptability of an 8-session low intensity intervention using this site in 10 participants with persisting psychotic disorders and conducted a proof-of-concept analysis of outcomes. Results All 10 participants completed the full course of sessions, and it was possible to integrate use of the website into nearly all sessions. Participant feedback confirmed that use of the website was a feasible and acceptable way of working. All participants stated that they would recommend the intervention to others. Post-intervention, personal recovery measured by the Questionnaire for the Process of Recovery had improved by an average standardized effect of d = 0.46, 95% CI [0.07, 0.84], and 8 of the 10 participants reported that their mental health had improved since taking part in the intervention. Conclusion In-session use of digital resources featuring peer accounts of recovery is feasible and acceptable and shows promising outcomes. A randomized controlled trial is the next step in evaluating the efficacy of this low intensity intervention when delivered in conjunction with routine mental health care.

The effects of utilizing a near-patient e-learning tool on medical student learning

Abstract Context: This study aimed to develop a near-patient, e-learning tool and explore student views on how utilization of such a tool influenced their learning. Methods: Third year medical students from Monash University in Melbourne, Australia were invited to trial a novel, near-patient, e-learning tool in two separate pilots within the ward environment. All participating students were invited to contribute to focus groups which were audio-recorded, transcribed verbatim and thematically analyzed. Results: Four focus groups were conducted with a total of 17 participants. The emerging themes revealed influences on the students’ learning both prior to and during a clinical encounter, as well as following completion of an e-learning module. The unifying concept which linked all six themes and formed the central feature of the experience was patient-centered learning. This occurred through the acquisition of contextualized knowledge and the facilitation of workplace integration. Conclusions: Utilization of a near-patient e-learning tool influences medical student learning in a number of complex, inter-related ways. Clinical e-learning tools are poised to become more commonplace and provide many potential benefits to student learning. However, incorporation of technology into clinical encounters requires specific skills which should form an integral part of primary medical training.

What do GPs want from a psychiatrist's letter?

Objective: The aim of this study was to investigate the preferences of general practitioners (GPs) in reply letters for patients referred for a one-off psychiatric assessment. Method: A sample of GPs referring to a primary mental health team service were mailed a questionnaire inquiring into the usefulness of 21 different letter items. Results: The response rate was 51%. Many of the items in our routine reply letters were rated highly, but others such as developmental history, supplementary information and a comprehensive report were not. Sending a copy of the letter to the patient was rated as useful by only 42.5%. Conclusions: The Royal Australian and New Zealand College of Psychiatrists’ guidelines for reply letters are endorsed. There are, however, some additional items that GPs may find useful.

Designing a referral form.

The results highlighted the need for a comprehensive and thorough orientation program with eight (57%) participants identifying a strong theme of inadequate information. Suggestions on improving orientation included staggering orientation, a cross-cultural focus, explanation of case management, overview of the Australian legal system, introductions to senior staff, restricting driving requirements and debriefing after the commencement of clinical work.

F208. COGNITION, POSITIVE SYMPTOMS, AND INTERNET USE FOR MENTAL HEALTH IN PEOPLE WITH PSYCHOSIS

Abstract Background People with severe mental illness are increasingly using digital resources for mental health, including social media and online interventions. However, individuals’ ability to engage with or benefit from such resources may be impaired by deficits in cognition and insight, and experiences of psychotic symptoms, including paranoia about cyber-security or motives of others in online social interactions. This study aimed to explore the association between cognition, positive symptoms, and internet use for mental health information in adults with psychosis. Methods This study used baseline data collected as part of a broader research program investigating a digital recovery-focused intervention for psychosis. Participants completed a questionnaire on their existing internet use, both in general and for mental health information, and a range of cognitive and functioning measures. Cognitive variables included premorbid IQ, estimated using the Wechsler Test of Adult Reading, and composite scores for processing speed, working memory, and executive functioning. The Positive and Negative Syndrome Scale was also administered, with five items used to examine the relationship between mental health-related internet use and psychopathology: Delusions, Grandiosity, Suspiciousness & Persecution, Unusual Thought Content, and Lack of Judgment & Insight. Logistic regressions were used to identify unique predictors of internet use for mental health information, controlling for age and frequency of general internet use. Results 179 adults with psychosis (mean age = 39.82 years; range = 18–65; SD = 11.0) took part in this study, of whom 157 (87.7%) were regular internet users. Of these, 107 (68.2%) reported regularly using the internet for mental health information, with 33 (20.9%) doing so daily, 28 (17.7%) weekly, and 46 (29.3%) monthly or less. General websites were most commonly used for this purpose (n = 92; 58.6%), followed by video streaming sites (n = 62; 39.5%), social networking sites (n = 52; 33.2%), and forums (n = 34; 21.7%). When age and frequency of general internet use were controlled for, use of any type of website for mental health information was predicted by lower scores on Grandiosity (Exp(B) = .675, 95% CI = .513, .886, p = .005); mental health-related social media use was significantly predicted by lower estimated premorbid IQ (Exp(B) = .964, 95% CI = .937, .991, p = .010); lower scores on Unusual Thought Content predicted use of both video networking sites (Exp(B) = .629, 95% CI = .403, .981, p = 041) and forums (Exp(B) = .576, 95% CI = .379, .876, p = .010) for mental health information; while use of general websites for mental health information was not uniquely predicted by any cognitive or symptom variables. Discussion While internet use for mental health information is now common among people with severe mental illness, the presence of psychotic symptoms may inhibit such information-seeking behaviour, particularly when using interactive websites such as video streaming sites and forums. Cognitive functioning may also affect how online sources of mental health information are selected. However, using general websites for mental health information is common regardless of cognition and symptom severity, with implications for how such resources should be designed.

Going Online Together: The Potential for Mental Health Workers to Integrate Recovery Oriented E-Mental Health Resources Into Their Practice

Background: The Internet offers a growing range of e-mental health resources for people experiencing severe mental illness. How these resources may be used in face-to-face interactions with consumers in mental health practice is not well understood. Aim: This article explores mental health workers’ current use of online resources and their views about integrating e-mental health resources for promoting self-management and recovery into community-based practice. Method: A total of 37 mental health workers from six services attended focus groups to discuss their views about using online and e-mental health resources in face-to-face interactions with consumers. Data were analyzed using qualitative content analysis. Results: Participants described accessing Internet information but having little opportunity to use online resources with consumers. Limited access to mobile technology and perceptions that consumers lacked technological experience constrained current use. Three approaches to using e-mental health resources were perceived: directing, collaborating, and empowering. Access to mobile technology within worker–consumer interactions was identified as a potential catalyst for creating recovery-oriented therapeutic relationships. Conclusion: Mental health workers are ready to grasp opportunities to use e-mental health resources with consumers. This has the potential to develop and strengthen collaborative, partnership-based relationships if mental health services support workers and consumers to use online resources together.

Web-Based Self-Management Programs for Bipolar Disorder: Insights From the Online, Recovery-Oriented Bipolar Individualised Tool Project

Background Bipolar disorder (BD) is a complex, relapsing mood disorder characterized by considerable morbidity and mortality. Web-based self-management interventions provide marked opportunities for several chronic mental health conditions. However, Web-based self-management programs targeting BD are underrepresented compared with programs targeting other psychiatric conditions. Objective This paper aims at facilitating future research in the area of self-management of BD and draws insights from the development of one such intervention—the Online, Recovery-Oriented Bipolar Individualised Tool (ORBIT)—that is aimed at improving the quality of life of people with BD. Methods We have discussed the opportunities and challenges in developing an engaging, evidence-based, safe intervention within the context of the following three nested domains: (1) intervention development; (2) scientific testing of the intervention; and (3) ethical framework including risk management. Results We gained the following insights across the three abovementioned overlapping domains: Web-based interventions can be optimized through (1) codesign with consumers with lived experience to ensure relevance and appropriateness to the target audience; (2) novel content development processes that iteratively combine evidence-based information with lived experience perspectives, capitalizing on multimedia (eg, videos) that the digital health space provides; and (3) incorporating Web-based communities to connect end users and promote constructive engagement by access to a Web-based coach. Conclusions Self-management is effective in BD, even for those on the more severe end of the spectrum. While there are challenges to be aware of, guided self-management programs, such as those offered by the ORBIT project, which are specifically developed for Web-based delivery provide highly accessible, engaging, and potentially provocative treatments for chronically ill populations who may otherwise have never engaged with treatment. Key questions about engagement, effectiveness, and cost-effectiveness will be answered by the ORBIT project over the next 18 months.