Richard Lakeman

The impact of recovery-oriented day clinic treatment on internalized stigma: preliminary report.

Internalized stigma is a complicating feature in the treatment of schizophrenia spectrum disorders and considerably hinders the recovery process. The empowerment and recovery-oriented program of our day clinic might contribute to a reduction in internalized stigma. The aim of the study was to explore the influence of this day clinic program on internalized stigma and other subjectively important outcome measures such as quality of life and psychopathology. Data from two groups of patients had been collected twice, at baseline and after 5 weeks. The experimental group attended the day clinic treatment (N=40) and the control group waited for the day clinic treatment (N=40). The following significant differences between the two groups were found: Patients in day clinic treatment showed a reduction in internalized stigma while the control group showed a minimal increase (Cohens d=0.446). The experimental group as compared with the control group also showed a greater improvement in the quality of life domain psychological health (Cohens d=0.6) and in overall psychopathology (Cohens d=0.452). Interestingly, changes in internalized stigma and psychological quality of life were not associated with changes in psychopathology. Results are encouraging but have to be confirmed in a randomized design.

Talking science and wishing for miracles: Understanding cultures of mental health practice

Science can only offer a limited account of, and prescription for, mental health care. Yet the language of science and faith in the universal applicability of particular scientific methods to the craft of mental health care has come to permeate mental health practice communities. In this paper, the argument that many beliefs held by mental health professionals might be considered to be based on faith rather than science is presented, and the view that culture provides a useful lens for understanding mental health services and these paradoxes is proposed. Clearly there is a grand mental health narrative or colonizing influence of biological psychiatry that in various ways affects all mainstream mental health services. Local health services and professional communities might be considered subcultures. Understanding how mental health professions and practice are embedded in culture might be useful in considering how practice changes and why. Culture and caring practices are mutually embedded in localized subcultures. Therefore, a rich description of context and history is necessary in publication, presentation, or other communications to enable genuine understanding by a global audience. Viewing mental health practice in a cultural context highlights the importance of values and differences, and encourages humility in the face of ambiguity.

'That was helpful ... no one has talked to me about that before': research participation as a therapeutic activity

There is considerable interest in the various ethical problems associated with undertaking health and social science research. Participants in such research are often considered vulnerable because of their health status, social position, or dependence on others for health and welfare services. Researchers and ethics committees pay scrupulous attention to the identification and amelioration of risks to participants. Rarely are the benefits to participants of engaging in research highlighted or drawn to the attention of potential participants. Such potential benefits need to be considered by researchers and reviewers when considering the balance of benefits and harms associated with research projects. In this paper, we particularly consider the psychotherapeutic benefits of participation in research.

Becoming a Psychiatric/Mental Health Nurse in the UK: A Qualitative Study Exploring Processes of Identity Formation

Identity studies are well established across the social science literature with mental health nursing beginning to offer evidenced insights into what may, or may not, constitute key identity performances. For mental health nursing these performances remain contested, both from within the profession and from international contexts that favour generic constructions of mental health. This paper offers findings from a qualitative study that focused upon the process of how mental health nursing identity development is influenced, rather than what that identity may or may not be. These findings highlight that mental health nurses (MHNs) not only form their identity around service user centred education and training, but that many also use the education as a means to leave the profession. Through highlighting the impact of informal education (i.e., through work), formal education, and training upon the formation of mental health nursing identity, nurses are potentially alerted to the importance of clinically focussed mental health being prominent within curricula, rewarding mental health nursing skills specialisation, and the importance of the role of the service user in mental health nurse education and, hence, identity formation.

Released potential: a qualitative study of the Mental Health Nurse Incentive Program in Australia

The Mental Health Nurse Incentive Program (MHNIP) is a Commonwealth Government funded scheme that supports people living with a mental illness. Despite its significance, the program has received little attention from researchers nor critical discussion within the published work. This paper first critically examines the MHNIP from the contexts of identities, autonomy, and capabilities of mental health nurses (MHN) and then reports on findings from a qualitative study that explored the experiences of staff working in the MHNIP. Key findings from this qualitative study include four main themes indicating that both the program and the nurses working within it are addressing the unmet needs of people living with a mental illness. They achieve these ends by adopting holistic and consumer-centred approaches and by providing a wide range of therapeutic interventions. As well, the MHN in this study valued the freedom and autonomy of their practice outside public health services and the respect received from colleagues working in other disciplines. Findings suggest that MHN within the study were experienced as having autonomous identities and roles that may be in contrast to the restrictive understandings of MHN capability within the programs funding rules.

What is Good Mental Health Nursing? A Survey of Irish Nurses

The practice, theory, and preparation associated with nursing people with mental health issues has changed in profound ways in recent decades. This has in part been reflected by a shift in nurses identifying as being mental health rather than psychiatric nurses. Context, theory, and values shape what it means to be a mental health nurse. Thirty experienced mental health nurses in Ireland completed a survey on what good mental health nursing is and a definition induced from their responses. Mental health nursing is a professional, client-centered, goal-directed activity based on sound evidence, focused on the growth, development, and recovery of people with complex mental health needs. It involves caring, empathic, insightful, and respectful nurses using interpersonal skills to draw upon and develop the personal resources of individuals and to facilitate change in partnership with the individual and in collaboration with friends, family, and the health care team. This appears to encapsulate the best of what it meant to be a psychiatric nurse, but challenges remain regarding how to reconcile or whether to discard coercive practices incompatible with mental health nursing.

Mental health nurses in primary care: Qualitative outcomes of the Mental Health Nurse Incentive Program

The Mental Health Nurse Incentive Program (MHNIP) is a government-funded programme, which, since 2007, has enabled mental health nurses to work in primary care settings in Australia in collaboration with general practitioners (GPs) or private psychiatrists. To date, small-scale qualitative studies have explored outcomes of the programme from the point of view of nurses, consumers, and the perceptions of GPs. This study reports on an on-line survey of credentialed mental health nurses perceptions of outcomes of the MHNIP. Two hundred and twenty five nurses who worked in MHNIP provided detailed narrative responses that were examined using thematic content analysis. The most commonly-cited outcomes were reductions in symptoms or improved coping, improved relationships, and enhanced community participation. Other reported outcomes included reduced hospitalization or use of state-funded mental health services, better use of health services, the continuation or establishment of meaningful occupation, improved physical health and medication management, less use of coercive interventions, and greater independence.

Values and valuing mental health nursing in primary care: what is wrong with the ‘before and on behalf of’ model?

Accessible summary The present model of employment specified in the Mental Health Nurse Incentive Program (MHNIP) is closely aligned to a traditional practice nurse model whereby the nurse is employed to assist and extend medical practice. Mental health nurses working within MHNIP typically possess post graduate qualifications and a breadth of experience characteristic of a specialist and advanced practitioner in mental health. Mental health nurses ought to enjoy the same status, level of remuneration, professional esteem and accountability of other health professionals. Abstract The Mental Health Nurse Incentive Programme (MHNIP) provides funding to organizations to enable mental health nurses (MHNs) to provide care to people with complex needs in primary care settings in Australia. The programme is based on a ‘for and on-behalf of’ practice nursing model whereby the MHN is presumed to have no specialist knowledge, skills or professional autonomy, and rather extends the reach of medicine. This paper provides a profile of MHNs working in the MHNIP derived from an online survey. A content analysis of responses establishes that nurses who work within MHNIP are highly experienced, and have extensive postgraduate qualifications particularly in psychotherapy. Nurses have negotiated a range of complex employment and contractual arrangements with organizations and pushed the boundaries of the programme to realize good outcomes. The ‘practice nurse model’ of employment and the underpinning assumptions about MHNs and their skill set relative to other professions is critically examined. Changes to the programme funding mechanism and programme specifications are recommended.

Mental health nurses in primary care: quantitative outcomes of the mental health nurse incentive program

The Mental Health Nurse Incentive Program (MHNIP) is a funding scheme in Australia that enables mental health nurses to work in primary care settings with people with complex mental health problems for as long as necessary. This study examined the outcomes of the programme as reported by nurses. Nurses provided profiles of 64 people with whom they worked, including measures of symptoms and problems on admission to the programme and at a second point in time. The findings showed that people had high levels of symptom severity and distress on admission, and they experienced significant improvements in all problem areas except physical health over their time working with the nurse. The MHNIP appears to be addressing the needs of people with highly complex needs, but more sensitive measures of outcome ought to be routinely collected. The Mental Health Nurse Incentive Program (MHNIP) provides a funding mechanism for credentialed mental health nurses to work in primary care settings in Australia with people with complex and serious psychosocial and mental health problems. This project explored the extent to which the programme contributed to positive outcomes. Sixty-four service user profiles were provided by nurses working within the programme, including the Health of the Nation Outcome Scales (HoNOS), on admission and at the last review point. Mean total HoNOS scores on admission were higher than those typically seen on admission to inpatient care in Australia. Significant reductions in all problem areas except physical health problems were found at the last review point for this sample. These findings support the viewpoint that MHNIP is addressing the needs of people with the most complex needs in primary care and is achieving clinically significant outcomes.

Unknowing: A potential common factor in successful engagement and psychotherapy with people who have complex psychosocial needs

Mental health nurses have a demonstrated capacity to work with people who have complex mental health and social problems in a respectful and non-coercive way for lengthy periods of time. Despite contributing to positive outcomes, nurses are rarely described as possessing psychotherapeutic skills or having advanced knowledge. More often, they are described as being instrumental to medicine, and nurses are socialized into not overstepping their subordinate position relative to medicine by claiming to know too much. Paradoxically, this position of unknowing, when employed mindfully, could be a critical ingredient in fostering therapeutic relationships with otherwise difficult-to-engage people. The concept of unknowing is explored with reference to different schools of psychotherapy. Adopting an unknowing stance, that is, not prematurely assuming to know what the persons problem is, nor the best way to help, might enable a deeper and more authentic understanding of the persons experience to emerge over time.