Conflict, compromise and collusion: dilemmas for psychosocially-oriented practitioners in the mental health system

Examining Attitudes Towards Mental Health Diagnoses: A Q-Methodology Study

BACKGROUND

Debates exist regarding the validity and utility of functional psychiatric diagnoses. How mental health diagnoses are understood has real impacts for service users and service delivery.

AIMS

To investigate different attitudes about the utility of psychiatric diagnoses.

METHODS

Forty-one stakeholders sorted 57 statements related to the usefulness of psychiatric diagnoses. Using q-methodology, four viewpoints were identified and interpreted.

RESULTS

Viewpoint 1 (Pathologising human experience) regarded diagnoses as pseudo-scientific constructs that lacked validity and obscured the relationships between lived experience and distress. Viewpoint 2 (Illnesses like any other) held that labels reflected real disorders and diagnosis offered important benefits for service users and services. Viewpoint 3 (Stigmatised conditions) similarly regarded diagnoses as reflecting real disorders, but diagnostic criteria were viewed as biased and the impacts of applying labels seen as causing problems for service users. Conversely, Viewpoint 4 (Useful short-hands) viewed diagnostic processes as imperfect but necessary for supporting communication and structuring service delivery.

CONCLUSIONS

While not all viewpoints are in keeping with empirical evidence, we hope results will enable professionals and service users to take meta-positions in relation to their own and others' attitudes, and to reflect on the impacts of privileging certain viewpoints over others.

There is something about oppression: Allies' perspectives on challenges in relationships with experts by experience

The genuine and meaningful involvement of Experts by Experience in the education of health professionals has consistently demonstrated positive attitudinal change in students. These changes are essential if policy goals for recovery-oriented services and service user participation in mental health services are to be realized. To date academic roles for Experts by Experience have often relied on the support of allies. Despite the important role allies play, research investigating their experiences is limited. The aim of this research was to explore allies' views on supporting implementation of the academic positions for Experts by Experience. A qualitative exploratory study was undertaken involving in-depth interviews with 16 allies. Data were analysed thematically. Challenges that can exist between allies and Experts by Experience was one theme identified from the data. Allies described occasional difficulties in their relationships with Experts by Experience where they felt they were perceived as representative of members of their broader profession with whom Experts by Experience had negative experiences. The perspectives of allies are presented in four subthemes: relationships imbedded in history; consequences of interpersonal stigma; supportive, protective or paternalistic?; and the passion remains, which describes allies' ongoing commitment to supporting Expert by Experience involvement. Understanding the challenges can assist allies to respond appropriately in a non-judgemental and supportive manner. Trauma informed practice may provide a useful framework to address conflicts and facilitate more positive relationships between allies and Experts by Experience. These positive relationships are essential to maximize the positive benefits of Experts by Experience on future clinicians.

Diagnosis and dilemma: Clinician experiences of the use of 'borderline personality disorder' diagnosis in children and adolescents

Borderline personality disorder (BPD) diagnosis in adolescents is a relatively recent concept and a fast-emerging research area. Regarded by some as controversial, it is important for research to provide greater understanding of differing perspectives and their impact on the use of this diagnosis. Perspectives of 13 clinicians (therapists, psychiatrists and mental health nurses) were explored, to provide a contemporary understanding of perceptions and use of BPD diagnosis within child and adolescent mental health services in England. A particular focus was to explore dilemmas faced by clinicians and how these dilemmas were negotiated. This research took a qualitative, social constructionist approach to explore the in-depth views and experiences of each participant. Interviews were analysed using thematic analysis, to seek out patterns and commonalities across these clinical perspectives. Three overarching themes were generated: 'Who holds the power?', 'Dilemmas within the multidisciplinary team (MDT)' and 'The weightiness of making this decision'. Professional opinions of an adolescent BPD diagnosis are influenced by dominant and less dominant mental health discourses, including the impact of power, and availability of resources within the service context. The role of meaningful collaboration with young people, clinical implications and directions for future research are discussed.

A realist evaluation of weighted modalities as an alternative to pro re nata medication for mental health inpatients

Implementing psychosocial approaches into mental health inpatient settings continues to be challenging. This is despite mental health policies prioritizing trauma-informed and recovery-orientated care approaches. This study reports on an interdisciplinary project that implemented and examined the uptake of weighted modalities in a psychiatric inpatient rehabilitation setting. While over-reliance on pro re nata (PRN) medication in these settings has been reported, weighted modalities are a sensory approach that can be self-initiated by consumers as an alternative to use of PRN to manage distress and agitation. A mixed-methods realist approach was used to determine what works, for whom, and in what circumstances weighted modalities were offered by clinicians and used by consumers. Additionally, we were interested in determining whether there was an associated change in PRN use during the trial. Data included in-depth interviews with consumers (n = 12) and clinicians (n = 11), and extraction of PRN medication use preceding, throughout, and following implementation. Statistical analysis revealed a significant increase in PRN rates in the first 3 months of implementation (mean difference from baseline = 29.5, P = 0.047) but a significant decrease in the second three-month period following implementation (mean difference from baseline = -30.7, P = 0.036). Qualitative findings highlighted the key components of successful implementation as being environmental restructuring (availability/accessibility and visibility of weighted modalities) and social influences. Strategies to enhance these components are discussed.