Treating first episode psychosis--the service users' perspective: a focus group evaluation

Early intervention in psychosis for first episode psychotic mania: the experience of people diagnosed with bipolar disorder

BACKGROUND

Early intervention for people diagnosed with bipolar disorder has been identified as a priority, but little is known about how existing early intervention services are experienced by this group or could be tailored to their needs.

AIMS

This study examined the experience of early intervention in psychosis (EIP) services for people diagnosed with bipolar disorder, following first episode psychotic mania.

METHOD

Semi-structured interviews were conducted with 11 adults in EIP services and analysed using Interpretative Phenomenological Analysis.

RESULTS

One superordinate theme was formed, Rebuilding within EIP service, consisting of five subthemes: (i) Piecing together episode through talking to staff; (ii) Exploring other perspectives during CBT; (iii) Empowered through shared decision-making; (iv) Reconsidering future and purpose; (v) Service as safety-net. EIP provision was pivotal in helping participants understand their episode, adjust their perspective, build confidence and progress.

CONCLUSIONS

Aspects of the service that were valued, including person-centred relationships with staff, shared decision-making and the development of motivation and opportunities, reflect key principles of mental health care for young people following first episode psychosis. Furthermore, findings point to elements that may be particularly relevant to early intervention following first episode psychotic mania including managing mood escalation and individualised approaches to goals.

Time for You: A process evaluation of the rapid implementation of a multi-level mental health support intervention for frontline workers during the COVID-19 pandemic

The coronavirus (COVID-19) pandemic had wide-ranging negative impacts on mental health. The pandemic also placed extraordinary strain on frontline workers who were required to continue working and putting themselves at risk to provide essential services at a time when their normal support mechanisms may not have been available. This paper presents an evaluation of the Time for You service, a rapidly developed and implemented intervention aimed at providing frontline workers with quick access to flexible online mental health support. Time for You provided service users with three service options: self-guided online cognitive behavioural therapy (CBT) resources; guided engagement with online CBT resources; 1-1 psychological therapy with trainee sport and exercise psychologists and trainee health psychologists. A process evaluation informed by the Consolidated Framework for Implementation Research considered service fidelity, adaptations, perceived impact, reach, barriers, and facilitators. Interviews with project managers (n = 5), delivery staff (n = 10), and service users (n = 14) explored perceptions of the service implementation and outcomes, supported by data regarding engagement with the online CBT platform (n = 217). Findings indicated that service users valued the flexibility of the service and the speed with which they were able to access support. The support offered by Trainee Psychologists was perceived to be of high quality, and the service was perceived by service users to have improved mental health and wellbeing. The rapid implementation contributed to issues regarding appropriate service user screening that led to trainee psychologists being unable to provide the service users with the support they needed as the presenting issues were outside of trainees' competencies. Overall, the findings suggest that interventions offering flexible, online psychological support to frontline workers can be an effective model for future interventions. Trainee psychologists are also able to play an important role in delivering such services when clear screening processes are in place.

Initial adaptation of the OnTrack coordinated specialty care model in Chile: An application of the Dynamic Adaptation Process

Background

In 2005, Chile became the first country in Latin America to guarantee universal free access for the diagnosis and treatment of schizophrenia. A cluster randomized control trial utilizing the Dynamic Adaptation Process framework is underway to adapt and test the OnTrack coordinated specialty care model to provide recovery-oriented, person-centered care by a multidisciplinary team for individuals with first episode psychosis (FEP) in Chile.

Methods

A qualitative formative research study was conducted to inform the initial adaptation of the OnTrack Chile (OTCH) program. We conducted key informant interviews (n = 17) with various stakeholders (policymakers; directors/managers of community mental health centers; mental health professionals) and focus group discussions (n = 6) with individuals with FEP and caregivers (n = 35 focus group participants total). Data was analyzed using thematic analysis, organized by participants' perspectives on the benefits, barriers, and recommendations for the key principles, multidisciplinary team, psychosocial components, and the training and supervision model of OnTrack.

Results

Participants expressed enthusiasm and support for OnTrack's recovery-oriented and person-centered principles of care. While many participants lauded the emphasis on shared decision-making and family involvement, some reported reticence, citing that it is culturally normative for patients and families to adopt a passive role in treatment. Peer specialists, and the family psychoeducation and support and supported education and employment components were perceived as aspects that could encourage the promotion of personhood and autonomy development. However, implementation challenges, including the prevailing biomedical approach, professional hierarchy, and the lack of infrastructure, human, and financial resources necessitate some modifications to these aspects. Some mental health professionals further conveyed reservations regarding the perceived hierarchical structure of the supervision model.

Conclusion

OnTrack represents a shift from a biomedical model to a valued, aspirational, person-centered and culturally responsive model that focuses on recovery, shared decision-making and psychosocial care. With the appropriate governmental and agency-level provision of resources and modifications to some of the program components, particularly regarding the shared decision-making framework, peer specialist, family engagement, and the training supervision model, OTCH could be a transformative program for a more comprehensive, evidence-based care for individuals with FEP in Chile.

The lived experience of psychosis: a bottom-up review co-written by experts by experience and academics

Psychosis is the most ineffable experience of mental disorder. We provide here the first co-written bottom-up review of the lived experience of psychosis, whereby experts by experience primarily selected the subjective themes, that were subsequently enriched by phenomenologically-informed perspectives. First-person accounts within and outside the medical field were screened and discussed in collaborative workshops involving numerous individuals with lived experience of psychosis as well as family members and carers, representing a global network of organizations. The material was complemented by semantic analyses and shared across all collaborators in a cloud-based system. The early phases of psychosis (i.e., premorbid and prodromal stages) were found to be characterized by core existential themes including loss of common sense, perplexity and lack of immersion in the world with compromised vital contact with reality, heightened salience and a feeling that something important is about to happen, perturbation of the sense of self, and need to hide the tumultuous inner experiences. The first episode stage was found to be denoted by some transitory relief associated with the onset of delusions, intense self-referentiality and permeated self-world boundaries, tumultuous internal noise, and dissolution of the sense of self with social withdrawal. Core lived experiences of the later stages (i.e., relapsing and chronic) involved grieving personal losses, feeling split, and struggling to accept the constant inner chaos, the new self, the diagnosis and an uncertain future. The experience of receiving psychiatric treatments, such as inpatient and outpatient care, social interventions, psychological treatments and medications, included both positive and negative aspects, and was determined by the hope of achieving recovery, understood as an enduring journey of reconstructing the sense of personhood and re-establishing the lost bonds with others towards meaningful goals. These findings can inform clinical practice, research and education. Psychosis is one of the most painful and upsetting existential experiences, so dizzyingly alien to our usual patterns of life and so unspeakably enigmatic and human.

The role of key workers in improving physical health in first episode psychosis: A scoping review

AIM

Studies have demonstrated that a majority of the decline in health status and functioning emerges during the first few years following the onset of psychosis. This knowledge led to the development of specialized early intervention services (EIS) targeting patients experiencing their first episode of psychosis (FEP). The central component of EIS is often assertive case management delivered by a multidisciplinary team, where an appointed key worker is responsible for coordinating treatment and delivering various psychosocial interventions to service users. The aim of this scoping review was to examine how key workers can enhance the physical health outcomes in people with FEP by addressing the factors associated with increased mortality in this population.

METHODS

The scoping review framework comprised a five-stage process developed by Arksey and O'Malley. The search process was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS

A total of 27 studies conducted across 10 countries were analysed. These studies discussed the various ways in which key workers can mediate enhancements in the various factors contributing to the increased mortality rates in FEP patients.

CONCLUSIONS

A broad range of key worker-mediated outcomes was identified, which were broadly classified into three themes: influences on lifestyle, influences on effects of psychosis and influences on organizational barriers. Our findings suggest that key workers primarily mediated the amelioration of psychosis-induced effects and the reduction of organizational barriers. Further trials of key worker interventions to enhance physical health outcomes in this cohort are warranted.

Emergency workers' experiences of the use of section 136 of the Mental Health Act 1983: interpretative phenomenological investigation

AIMS AND METHOD

To explore the experiences of emergency workers dealing with incidents in which section 136 of the Mental Health Act 1983 is invoked by the police. Data from interviews with police officers and ambulance workers in a London locality were subject to interpretative phenomenological analysis.

RESULTS

Participants felt they were the first port of call and that training should be improved to help them deal with those experiencing mental health crises in the community. Police participants noted time pressures trying to gain individuals' trust and described section 136 detention as sometimes feeling like a betrayal of the individual. Most participants had negative experiences of admissions to the 136 suite; several suggested ways of improving the admissions system. Several went beyond their expected duties to ensure that distressed individuals were supported before accessing mental healthcare services.

CLINICAL IMPLICATIONS

Improving training of emergency workers in dealing with mental health crises would also help with aftercare decision-making. Learning identified from the participants' experiences lends support to collaboration between emergency and mental health services, an important step towards improving the section 136 process so that detainees can access help without unnecessary delay.

Service users' and carers' experiences of engaging with early intervention services: A meta-synthesis review

AIM

The provision and implementation of early intervention for psychosis services (early intervention services [EIS]) has received increasing attention over recent years. Maximizing engagement with EIS is of clinical and economic importance, and exploring the experiences of those who access EIS is vital. Although research has been conducted exploring the experiences of engaging with EIS from both a service user and carer/family member point of view, these data have not been systematically collated to generate new understanding. The primary aim of this study is to review, critically appraise and synthesize qualitative findings relating to the experiences of service users and/or carers and family members engaging with EIS.

METHODS

Four databases were systematically searched. Studies were analysed using an inductive thematic analysis approach, within a critical realist epistemological framework. Studies were critically appraised using the critical appraisal skills programme tool.

RESULTS

Fourteen papers were identified for inclusion. Three main themes were identified: the importance of a personal relationship with an EIS staff member, the impact of this relationship and consideration of life after EIS. The importance of a strong relationship with EIS staff was the most prominent theme throughout the papers reviewed.

CONCLUSIONS

The quality of the therapeutic relationship with at least one EIS staff member was the single most important factor in determining whether the experience of accessing EIS was a positive or negative one. The majority of the studies reviewed were conducted in the United Kingdom or Australia. Therefore, more research across countries is needed to understand transferability of findings.

'Something wasn't quite right': a novel phenomenological analysis of internet discussion posts detailing initial awareness of psychosis

INTRODUCTION

A significant number of psychosis studies have focussed on and have attempted to model and frame the earliest psychosis experiences. Using a wide array of methodologies and targeting a variety of 'at risk' groups, researchers have offered much to inform our treatment responses, and understanding of psychosis onset and development.

OBJECTIVES

Due to the nature of scientific investigation however and investigator led exploration, those who experience psychosis are rarely afforded ultimate free rein to dictate and direct the exchange of information or to impose their unique narrative on that which is being explored. In an attempt to address this, the current study opportunistically harvested rich self-report data from replies to the question, "People that have been diagnosed with schizophrenia, what was the first time you noticed something wasn't quite right?" on the internet discussion forum Reddit.com.

METHODS

User data was analysed using Interpretive Phenomenological Analysis to identify key themes in participants' first experiences and initial awareness of psychosis.

RESULTS

While respondents varied widely in their recounted experiences and chose to describe these experiences in a variety of ways, analysis showed that (i) respondent distress was associated with psychosis onset timeframe, negative-voice auditory hallucinations, visual hallucinations, paranoid delusions, and insight (ii) early childhood psychosis experience resulted in novel explanatory schemas and psychosis/distress progression with contributory factors in adolescence and (iii) 41.3% of the sample reported self-realisation in gaining insight and greater insight was associated with help-seeking behaviour.

CONCLUSIONS

This novel use of publicly shared experiential data might enrich our existing qualitative literature concerning early psychosis.

Essential ingredients of engagement when working alongside people after their first episode of psychosis: A qualitative meta-synthesis

AIM

Early intervention services (EISs) for first-episode psychosis (FEP) have been established internationally, however, service disengagement is a recurrent concern resulting in unplanned treatment cessation. The implications of this are far-reaching due to the financial and personal costs associated with untreated symptoms. The aim of this meta-synthesis was to collect, interpret and synthesize qualitative research about how engagement is experienced within EISs for FEP.

METHODS

A systematic search was conducted in PsycINFO, Ovid MEDLINE and Ovid Emcare from date of conception to November 2016. Following initial screening, 91 abstracts and 13 full texts were reviewed for eligibility. Nine studies were then critically appraised using the CASP tool for qualitative studies, data were systematically extracted and results were synthesized using constant comparison and reciprocal translational analysis.

RESULTS

Nine qualitative studies explored engagement with EISs, from the perspectives of service users and their caregivers. No studies were found from the perspectives of clinicians or services. All 9 studies employed an inductive methodology, within an interpretivist epistemology. Five main themes were identified: experiences of finding help; factors promoting engagement; the therapeutic relationship; the role of caregivers in supporting engagement; and factors impacting ongoing engagement.

CONCLUSIONS

There is a critical need to stimulate discussion around this multifaceted phenomenon, including a continued focus on the roles of key stakeholders and clinical models that may further facilitate collaboration in treatment plans and recovery.

Using a structured model to promote mental health

Purpose

A Promoting Mental Health and Well-Being Working Model (subsequently “the model”) was developed in response to recognition through teaching undergraduate nursing students that interventions aimed at enhancing mental health and well-being are often hidden or cloaked in traditional professional specific working interventions. The model was developed with the purpose of making the elements of mental health and well-being promotion visible and structuring them into a framework to aid working practice and personal development. The purpose of this paper is to evaluate the effectiveness from the participant perspective of using the model to enhance clients’ mental health and well-being in community settings (Keeling and McQuarrie, 2014).

Design/methodology/approach

A total of 14 participants were interviewed within two focus groups. Five questions were posed to the participants structured around their experiences of using the model when working with clients in the community. The responses were recorded and transcribed and then categorised using a thematic analysis approach.

Findings

Three key themes were derived from the analysis in equal measure: “Reconciling a Non-traditional approach”, “Promoting a holistic approach” and “Developing creativity and sense of empowerment to promote mental health and well-being”. The findings suggest that using the model enabled participants to engage with clients in meaningful ways that in turn developed their self-confidence in helping clients develop creative strategies to promote their own mental health and well-being.

Originality/value

This paper shows that using a structured model to promote well-being and mental health has benefits in enhancing creativity, therapeutic relationships and knowledge base. Further research is needed in terms of the utility of the model from the client’s perspective.

Factors affecting mental health nurses working with clients with first-episode psychosis: A qualitative study

WHAT IS KNOWN ABOUT THE SUBJECT?: First-episode psychosis (FEP) usually occurs in adolescence, a time of great change and upheaval and the effect on the sufferer and their family can be immense The nurse's role is to alleviate this suffering, aid recovery and minimize the risk of relapse. They manage this onerous task ideally through the therapeutic relationship, and use the skills of assessment and risk identification in order to maximize patient outcomes. WHAT DOES THE STUDY ADD TO EXISTING KNOWLEDGE?: The study adds knowledge about the challenges that mental health nurses experience specifically in the presentation of first-episode psychosis The findings of this study reinforce the idea that pathways to care need to be clearly identified with a community-wide educational led experience This study illuminates the fact that additional training and formalized clinical supervision are necessary for mental health nurses to improve quality of care and reduce stress levels, both of which lead to better clinical outcomes. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental Health nurses should engage with additional training, formalized clinical supervision and avail of peer support in order to improve confidence, skills and quality of care. Dialogue among mental healthcare colleagues is important not only about caring for people presenting with a first-episode psychosis but in relation to the wider community and family. This demonstrates the need for family-centred care within the mental health profession. There should be more recognition of the social impact on the individual during untreated psychosis with regard to isolation and withdrawal as well as factors which also affect help-seeking behaviours.

ABSTRACT

Introduction Although there is much research on mental health nurses working with individuals presenting with psychosis, there is a lack of knowledge about the factors that impact the experience of nurses in the presentation specifically of first-time psychosis. Aim This study aimed to explore the factors that impact on the experience of mental health nurses working with individuals and their families who present with a first-time psychosis. Method This qualitative study was conducted through individual semi-structured interviews with eight mental health nurses recruited from community mental health settings with a minimum of 2 years post-qualification experience. Data were then subjected to a thematic content analysis. Results This study identified the importance of therapeutic engagement, as well as the need to have clear pathways to care and building capacity through clinical supervision and training when working with this population. Implications for practice Mental Health nurses should engage with additional training, formalized clinical supervision and avail of peer support in order to improve confidence, skills and quality of care, leading to better therapeutic engagement. Pathways to care should be embedded within the wider community to ensure ease of access for individuals and their families. There should be more recognition of the social impact on the individual during untreated psychosis with regard to isolation and withdrawal as well as factors which also affect help-seeking behaviours.

Carers' and service users' experiences of early intervention in psychosis services: implications for care partnerships

AIM

To explore carers' and service users' experiences of UK Early Intervention Services following referral for first-episode psychosis.

METHODS

Thirty-two semi-structured interviews (16 interviews with service users and 16 corresponding interviews with their carers) were completed and analysed.

RESULTS

Carers spoke retrospectively and prospectively by framing their accounts into the periods before and since their engagement with Early Intervention Services. Desperation was evident as emotive experiences were recalled prior to referral. Relief then emerged as carers described support and engagement with key workers. Hope and optimism for the service user's prognosis and life trajectory were also expressed.Service users described similar positive experiences of Early Intervention Services and the support and insight they had gained through their relationships with key workers. They were however less focused on accounts of desperation and relief and more immersed in their current understanding and attempts to normalize their experiences of first-episode psychosis. Prognosis and future trajectories were only discussed tentatively.

CONCLUSION

Communication and 'partnerships' with service users and carers are essential for effective service engagement, delivery of care and the reduction in relapse following first-episode psychosis. This study highlights how key workers from Early Intervention Services are appropriately valued and situated to develop such relationships. Findings also reveal that service users' and carers' focus and expectations of recovery vary during the early stages of engagement with services. How key workers manage awareness and communication around such differing expectations is a crucial consideration for maintaining the 'partnerships' necessary for effective service provision.

How Do People Experience Early Intervention Services for Psychosis? A Meta-Synthesis

We conducted a study to explore how people diagnosed with first-episode psychosis experienced their contact with early intervention services for psychosis and the way these experiences relate to their recovery processes. Our aim was to integrate and describe the service users' experiences in a rigorous and comprehensive way. A broad literature search was performed in June and July 2016. After screening, 17 qualitative studies were included. We analyzed the findings in two main steps: (a) translating studies into one another and (b) synthesizing the findings from the studies. Through these interpretative processes, we found five new and overarching themes: (a) something is wrong, (b) do for myself, (c) it's about people, (d) a price to pay, and (e) ongoing vulnerability. We describe these themes as a process that service users' maneuver through in their contact with the services. Our findings are discussed in light of relevant research.

The Common Elements of treatment engagement for clinically high-risk youth and youth with first-episode psychosis

AIM

Without treatment, clinically high-risk (CHR) youth or youth with first-episode psychosis (FEP) have increased risk for significant complications from their illness; yet, treatment engagement among these youth is critically low. The purpose of this study was to examine engagement efforts with CHR/FEP youth to stimulate new ideas that might facilitate participation in services for this population.

METHODS

A literature review using distillation methods identified engagement practices reported in two bodies of literature. The first body of literature (i.e. 'CHR/FEP engagement') included 13 studies employing qualitative designs to explore consumer perspectives about treatment engagement practices in samples of CHR/FEP youth and their families. The second body of research (i.e. 'CHR/FEP RCTs') included 18 randomized controlled trials (RCTs) testing treatments for CHR/FEP youth and their families. Engagement practice frequencies were compared with the frequency of these practices within effective engagement interventions, as tested in 40 RCTs within the broader child and adolescent mental health literature (i.e. 'CAMH engagement').

RESULTS

Treatment attrition and attendance were the most frequent engagement outcomes measured in the CHR/FEP RCTs. There were notable efforts described in the CHR/FEP RCTs towards engaging youth and families, yet CHR/FEP RCTs reportedly included only a small proportion of engagement practices described in either the CHR/FEP or CAMH engagement literatures.

CONCLUSION

Results suggest there might be practices available to complement current efforts at engaging CHR/FEP youth in treatment, and that increased attention to the measurement of engagement outcomes could provide important information regarding engagement in a population with low treatment engagement rates.

A qualitative study of online mental health information seeking behaviour by those with psychosis

BACKGROUND

The Internet and mobile technology are changing the way people learn about and manage their illnesses. Little is known about online mental health information seeking behaviour by people with psychosis. This paper explores the nature, extent and consequences of online mental health information seeking behaviour by people with psychosis and investigates the acceptability of a mobile mental health application (app).

METHODS

Semi-structured interviews were carried out with people with psychosis (n = 22). Participants were purposively recruited through secondary care settings in London. The main topics discussed were participants' current and historical use of online mental health information and technology. Interviews were audio-recorded, transcribed and analysed by a team of researchers using thematic analysis.

RESULTS

Mental health related Internet use was widespread. Eighteen people described searching the Internet to help them make sense of their psychotic experiences, and to read more information about their diagnosis, their prescribed psychiatric medication and its side-effects. Whilst some participants sought 'expert' online information from mental health clinicians and research journals, others described actively seeking first person perspectives. Eight participants used this information collaboratively with clinicians and spoke of the empowerment and independence the Internet offered them. However nine participants did not discuss their use of online mental health information with their clinicians for a number of reasons, including fear of undermining their clinician's authority. For some of these people concerns over what they had read led them to discontinue their antipsychotic medication without discussion with their mental health team.

CONCLUSIONS

People with psychosis use the Internet to acquire mental health related information. This can be a helpful source of supplementary information particularly for those who use it collaboratively with clinicians. When this information is not shared with their mental health team, it can affect patients' health care decisions. A partnership approach to online health-information seeking is needed, with mental health clinicians encouraging patients to discuss information they have found online as part of a shared decision-making process. Our research suggests that those with psychosis have active digital lives and that the introduction of a mental health app into services would potentially be well received.

The relevance of professionals' attachment style, expectations and job attitudes for therapeutic relationships with young people who experience psychosis

BACKGROUND

Therapeutic relationships are a central component of community treatment for psychosis and thought to influence clinical and social outcomes, yet there is limited research regarding the potential influence of professional characteristics on positive therapeutic relationships in community care. It was hypothesised that professionals' relating style and attitudes toward their work might be important, and thus this exploratory study modelled associations between these characteristics and therapeutic relationships developed in community psychosis treatment.

METHODS

Dyads of professionals and young patients with psychosis rated their therapeutic relationships with each other. Professionals also completed measures of attachment style, therapeutic optimism, outcome expectancy, and job attitudes regarding working with psychosis.

RESULTS

Professionals' anxious attachment predicted less positive professional therapeutic relationship ratings. In exploratory directed path analysis, data also supported indirect effects, whereby anxious professional attachment predicts less positive therapeutic relationships through reduced professional therapeutic optimism and less positive job attitudes.

CONCLUSIONS

Professional anxious attachment style is directly associated with the therapeutic relationship in psychosis, and indirectly associated through therapeutic optimism and job attitudes. Thus, intervening in professional characteristics could offer an opportunity to limit the impact of insecure attachment on therapeutic relationships in psychosis.

An exploration of what service users value about early intervention in psychosis services

OBJECTIVE

Given the potential severity of developing chronic mental health problems, particular attention has been paid to the first emergence of psychosis. Earlier detection is expected to lead to quicker access to the effective treatment that is necessary during the 'critical period' and is one of the main incentives for setting up early intervention in psychosis (EIP) services. EIP services have demonstrated good clinical outcomes since inception, but little is understood yet as to which specific element of EIP leads to these good outcomes. The aim of this research was to conduct an exploratory investigation of the elements that people experiencing a first episode of psychosis find most valuable about EIP treatment.

DESIGN

The study employed a single group design and utilized Q-methodology.

METHOD

20 people with first-episode psychosis aged between 18 and 35 were recruited and asked what they valued most about EIP.

RESULTS

Four separate factors were identified, which were interpreted and named as 'therapeutic relationship', 'medical care', 'psychological interventions', and 'support, coping and recovery'. Three of the factors were consistent with a biopsychosocial approach of EIP that is recommended by expert professionals working in EIP services and Government guidance on service delivery.

CONCLUSIONS

The factor that accounted for the most variance is 'therapeutic relationship', highlighting the importance of non-specific factors in mental health care and recovery from a first episode of psychosis.

PRACTITIONER POINTS

Service users reported that four main components of Early Intervention in Psychosis Services were helpful to them. These included a strong and effective therapeutic relationship, as well as medication, psychological therapies, and practical help and support. Services are valued both for the quality of the therapeutic relationship but also for their ability to deliver meaningful and valued treatments in this context.

Hope-inspiring therapeutic relationships, professional expectations and social inclusion for young people with psychosis

OBJECTIVE

Personal recovery accounts suggest that a positive therapeutic relationship with an optimistic mental health professional may facilitate social inclusion. However, little empirical research has investigated the role of the therapeutic relationship in social outcomes or explored potential mechanisms of change within community psychosis care. This study investigated the direct predictive associations of the therapeutic relationship and professional expectancies for social inclusion and vocational activity for young people with psychosis, and indirect associations through hopefulness.

METHOD

Young people with psychosis and their main mental health professional (n=51 dyads) participated across two time points. Measures of therapeutic relationships, professional expectancies, and vocational activity were obtained at baseline. Measures of hopefulness, social inclusion and vocational activity were obtained at follow-up. Direct and indirect associations between variables were analysed using path modelling.

RESULTS

Directed path models were consistent with a positive therapeutic relationship and positive professional expectancies predicting social inclusion and vocational activity through mediation by increased patient domain-specific hopefulness. The professional-rated therapeutic relationship more directly predicts change in vocational activity status. Change in vocational activity status predicts increased patient hopefulness.

CONCLUSION

The therapeutic relationship between professionals and young people with psychosis appears hope-inspiring and important to patients' social inclusion and vocational outcomes. Vocational activity may produce reciprocal gains in hopefulness.

Subjective experiences of illness recovery in individuals treated for first-episode psychosis

PURPOSE

Individuals with psychotic disorders identify several parallel dimensions of recovery as being important, including illness related, personal and social domains. Learning how patients deal with the experience of psychosis and recovery early in the course of illness may provide insights for improvement of early intervention services. The primary aim of the present research is to explore experiences related to recovery for individuals receiving services following a first episode of psychosis (FEP) in a specialized early intervention (SEI) program and to examine key turning points that shape such recovery.

METHODS

Semi-structured interviews were carried out with 30 individuals in early recovery following an FEP. Interpretative phenomenological analysis (IPA) was used to examine the subjectively identified important processes and turning points in relation to the illness domain of recovery.

RESULTS

Participants described several early recovery processes including symptom recovery; reconciling the meaning of the illness experience; regaining control over the experience; and negotiation and acceptance of treatment. Of particular relevance were the various turning points associated with the recovery processes that were described.

CONCLUSIONS

Differences in illness acceptance trajectories and the turning points within such trajectories have important implications for understanding psychological adjustment to the experience of psychosis, its diagnosis and treatment. These findings underline the importance of assisting individuals with the construction of meaning following the initial illness experience.

Participant views on involvement in a trial of social recovery cognitive-behavioural therapy

BACKGROUND

The PRODIGY trial (Prevention of long term social disability amongst young people with emerging psychological difficulties, ISRCTN47998710) is a pilot trial of social recovery cognitive-behavioural therapy (SRCBT).

AIMS

The PRODIGY qualitative substudy aimed to (a) explore individual experiences of participating in the pilot randomised, controlled trial (recruitment, randomisation, assessment) and initial views of therapy, and (b) to explore perceived benefits of taking part in research v. ethical concerns and potential risks.

METHOD

Qualitative investigation using semi-structured interviews with thematic analysis.

RESULTS

Analysis revealed participant experiences around the key themes of acceptability, disclosure, practicalities, altruism and engagement.

CONCLUSIONS

Participants in both trial arms perceived themselves as gaining benefits from being involved in the study, above and beyond the intervention. This has implications for the design of future research and services for this client group, highlighting the importance of being flexible and an individualised approach as key engagement tools.

The experiential impact of hospitalisation in early psychosis: service-user accounts of inpatient environments

Early Intervention in Psychosis services aim to keep young people out of hospital, but this is not always possible. This research used in-depth interviews to explore the experience of hospitalisation amongst young people with psychosis. Findings describe fear and confusion at admission, conflicting experiences of the inpatient unit as both safe and containing, and unsafe and chaotic, and the difficult process of maintaining identity in light of the admission. We discuss the need to move from construing psychiatric hospitals as places for 'passive seclusion', to developing more permeable and welcoming environments that can play an active role in recovery.

Young people at risk of psychosis: their subjective experiences of monitoring and cognitive behaviour therapy in the early detection and intervention evaluation 2 trial

OBJECTIVES

To explore participants' experiences of 'enhanced monitoring' and cognitive behaviour therapy (CBT) within a randomized controlled trial evaluating early detection and prevention of psychosis ('early detection and intervention evaluation [EDIE] 2').

DESIGN

Semi-structured qualitative interviews were conducted with a sample of participants at the end of their involvement with the trial.

METHODS

Ten young people were interviewed; six males and four females, with a mean age of 27.5. Nine participants identified themselves as White British and one Black British. All participants had received 'enhanced monitoring' during the trial, and 8 of 10 also received CBT. Interviews were transcribed verbatim and analysed using thematic analysis to identify central themes within and among participants' accounts.

RESULTS

Three super-ordinate thematic areas were identified: 'a chance to talk', monitoring-specific themes, and CBT-specific themes. The central theme ('a chance to talk') was drawn from across all participants' accounts and represents the most consistently valued attribute of participants' experiences of the EDIE 2 trial. Sub-themes of this topic were identified as follows: interpersonal engagement, informality and normalization, and 'opening up'. Sub-themes related to monitoring include the following: clarity and reassurance, 'a therapeutic process', and challenges. CBT experience was most consistently conceptualized as 'rethinking things', and two additional CBT-specific sub-themes were identified: hard work and moving forward.

CONCLUSIONS

Our findings suggest that for young people at risk of psychosis, a normalizing psychosocially oriented assessment and monitoring process may have benefits for many, while CBT may help to reduce the negative impact of unusual psychological experiences for both the short- and long term.

PRACTITIONER POINTS

Young people considered at risk of psychosis highly value normalizing, collaborative, and flexible approaches when engaging with research or clinical staff. All of our participants highlighted the primary value of their engagement with staff members as having a 'chance to talk' about their experiences and difficulties. CBT seems to be widely acceptable among 'at-risk' participants, though further research is required to establish the 'key ingredients' of effective CBT for 'at-risk' individuals. Valued CBT-related outcomes highlighted by participants included improved psychosocial understanding of their difficulties, improved coping ability, and greater optimism for the future.

Young people's views of UK mental health services

AIMS AND METHOD

Adolescence is the period of highest risk for the development of mental illness, but also the age group least likely to seek help from mental health services. We undertook a systematic review of the published literature on the views of young people of mental health services in the UK and a thematic analysis of the findings to explore the reasons behind this to guide those developing services for young people.

RESULTS

Thirty-one studies were identified, which captured the views of 13 605 young people including 625 young people who had experience of mental health services. Positive views to emerge were of qualities of mental health workers and encouraging self-reliance. Negative views were of stigma, lack of information, medicalization of their problems and a lack of continuity of care.

CONCLUSIONS

Young people have consistent views of the positive and negative aspects of mental health services, which could be helpfully incorporated in the design of services. The views of some groups of young people have not been well represented, however, and the views of minority ethnic groups and those who have disengaged from services in particular need to be actively sought.

A qualitative analysis of influences on recovery following a first episode of psychosis

BACKGROUND

Understanding perceived influences on recovery following a first episode of psychosis could help improve services.

MATERIAL

Thematic analysis was used to examine important influences on early recovery identified by 30 individuals receiving services in an early intervention programme.

DISCUSSION

Social support, medication, meaningful activities and lifestyle modification were identified as helpful, and stigma, substance abuse and medication side effects as harmful. Perceptions of benefits of social support and the negative effects of stigma were particularly prominent.

CONCLUSIONS

Results suggest the importance of assistance with engagement in valued activities and relationships, and provision of messages of worth and hope for recovery.

'A different world' individuals' experience of an integrated family intervention for psychosis and its contribution to recovery

OBJECTIVES

The aim of this study is to explore the meaning and significance of family interventions (FI) for the individual who experiences psychosis, and its significance for recovery.

DESIGN

A qualitative in-depth interview design was used to explore individuals' experience of FI and its meaning to them.

METHODS

Seven individuals recovering from psychosis attending integrated FI sessions were interviewed using a semi-structured interview schedule developed with service user input. Interviews were recorded, transcribed verbatim, and explored using Interpretative Phenomenological Analysis.

RESULTS

Three central themes highlighted the participants' experience: (1) They welcomed the shared experience with their families and felt contained and valued by the therapists; (2) They felt the sessions contributed to changed patterns of relating within the family and the creation of new meaning through the validation of multiple perspectives; and (3) They described how the family sessions supported a new positioning in the world, a sense of their own empowerment and personal responsibility, greater self-acceptance, an increased ability to manage emotions, and hope for the future.

CONCLUSIONS

Conditions in the family sessions provided an environment for changes in patterns of relating, personal meaning, and emotions to take place. Recovery, for these individuals, appeared to be about repositioning themselves in the world. The shared experience of sessions and the recognition of multiple perspectives within a containing environment may be related to recovery via the development of new perspectives and a more robust sense of self. This has clinical implications for the focus of FI sessions.

Service-users' experiences of an early intervention in psychosis service: an interpretative phenomenological analysis

OBJECTIVES

Previous research regarding Early Intervention in Psychosis (EIP) services has mainly adopted quantitative methodologies, in order to study the effectiveness of EIP services. Research studies that have explored service-users' experiences of EIP services are small in number. This research aimed to explore service-users' experiences of being in contact with an EIP service, its impact of their experience of psychosis and current life situation.

DESIGN

Interpretative Phenomenological Analysis (IPA) was used to conduct an in-depth qualitative study of a small sample of EIP service-users, in order to explore their experiences of being in contact with the service.

METHOD

Flexibly guided interviews were conducted with eight service-users who had been receiving a service from an EIP team for more than 2 years and were recruited using a purposive sampling method. Verbatim interview transcripts were analysed using IPA.

RESULTS

Five super-ordinate themes, developed from the analysis, are discussed in sections: Stigma, Relationships, Understanding the experiences, Sense of agency, and Impact on sense of self. Sub-themes of these super-ordinate themes are also discussed.

CONCLUSIONS

The themes developed from the analysis were envisioned as representing an overarching theme of 'A personal journey of recovery', which was influenced by participants' involvement with the EIP service. Clinical implications include the need for EIP services, as with other mental health services, to find ways to promote recovery and create opportunities for agency and control. Future research directions are also discussed.

Experience of recovery from a first-episode psychosis

AIM

To understand the subjective factors involved in the recovery process following a first-episode psychosis.

METHOD

Sixteen individuals from a First Episode Program in São Paulo, Brazil were evaluated by a semistructured interview designed to elicit an in-depth narrative of participants' subjective experience of recovery after a first-episode psychosis. Eligibility was established by using the Structured Clinical Interview for DSM-IV Axis I Disorders. The interviews were recorded, the transcripts were coded and themes were grouped together to form conceptual categories.

RESULTS

The participants described the recovery course as a slow and gradual process. Improvement was perceived as based on a decrease or absence of psychotic symptoms, changes in social relationships, renewed autonomy and independence, and restoration of self-reliance and trust in others.

CONCLUSIONS

Recovering after a first-episode psychosis can be considered a complex process correlated with treatment, social support, and individual experiences and characteristics. These are important areas to be addressed in first psychotic psychosis interventions, and gains can probably only be obtained in specialized first-episode psychosis programmes.

Patient satisfaction with treatment in first-episode psychosis

PURPOSE

To examine first-episode psychotic patients' satisfaction with elements of a comprehensive 2-year treatment program.

SUBJECTS AND METHOD

The TIPS (Early Treatment and Intervention in Psychosis) project provided a 2-year treatment program consisting of milieu therapy (inpatient), individual psychotherapy, family intervention and medication. Of 140 patients at baseline, 112 were included at 2-year follow-up. Eighty-four participants were interviewed using a questionnaire eliciting levels of satisfaction with different treatment elements at two of the four sites.

RESULTS

Participants and non-participants did not differ on demographic or clinical data at baseline. Of those participating, 75% were satisfied with treatment in general. Individual and milieu therapy received higher rating than medication or family intervention. No predictors of general satisfaction with treatment were found, but continuously psychotic patients were the least satisfied with medication treatment.

DISCUSSION

As in most patient satisfaction studies within mental health treatment networks, there was high level of general satisfaction with the total package of treatment but considerable variation in satisfaction for specific interventions. In this sample of first-episode psychosis patients, there was general satisfaction with treatments based on one-to-one relationships while multi-family group intervention was consistently valued less enthusiastically.

Service user perspectives on the impact of a mental illness diagnosis

Aim – to provide a conceptual and practical analysis of the impacts of mental health diagnoses on consumers and to consider how service users might contribute to the new psychiatric classifications currently being drawn up. Methods – A search was carried out revealing a very sparse literature on this topic. Consultations with service users were conducted and the views of experts sought. Results – Diagnosis is important as it marks the formal status of psychiatric patient being conferred. Consumers react differently, and often, negatively to this. Stigma can follow from a diagnosis. The process of giving a diagnosis can range from one of negotiation and taking the person's strengths into account to the blunt allocation of an unwanted label. Consumers can be reduced to their diagnosis so it becomes their whole personhood and this can have an effect on their sense of self. However, consumers are not passive victims and have their own strategies for dealing with these issues. Conclusion – Consumers can use these experiences to make contributions to the new diagnostic classification systems and to future research.

Mental health nursing and first episode psychosis

The purpose of this literature review is to identify mental health nursing's contribution to the care and treatment of patients with a first episode of psychosis; A systematic literature review was undertaken, with 27 articles selected for study. Five domains were identified: development of therapeutic relation, relapse prevention, enhancement of social functioning, stimulation of medication adherence, and support of family members. The level of evidence of mental health nursing's contribution to the care and treatment of those undergoing their first episode of psychosis was low. Our review suggests that mental health nurses should reflect upon their own daily practices within the five domains.

A descriptive review of qualitative studies in first episode psychosis

AIM

The aim of this paper is to provide a descriptive review of published qualitative research studies on first episode psychosis (FEP).

METHODS

A review was undertaken to describe the findings of qualitative studies in early psychosis. Keyword searches in Medline, CINAHL, ASSIA, PsychINFO databases, as well as manual searches of other relevant journals and reference lists of primary papers, were conducted.

RESULTS

Thirty-one qualitative papers (representing 27 discrete studies) were identified. The majority reported research concerning young people based in community settings. The research studies were organized according to the following generic social processes: (i) achieving identity; (ii) acquiring perspectives; (iii) doing activity; and, (iv) experiencing relationships. The papers reviewed are based on first-person accounts obtained from individuals who have experienced FEP, their family members and service providers.

CONCLUSION

This descriptive review contributes to our understanding of the complex social processes of achieving identity, acquiring perspectives, doing activities and developing relationships as experienced by young people and the significant others in their world. The cumulative findings highlight the contextually rich and detailed information made possible through qualitative studies of FEP. They begin to account for the active engagement of individuals affected by psychosis in making sense of their experience and suggest that this experience should be understood from within young people's own framework of meaning.

The place and promotion of well-being in mental health services: a qualitative investigation

The study investigated the place and promotion of well-being from the perspectives of services users and mental health professionals. * Data from focus groups and interviews were analysed and found that well-being promotion was available, for example weight management groups in mental health services. However, they also found that there were some contradictions between the groups of people interviewed about what was available and what to promote in the future. * The study concludes suggesting partnerships with local communities to further develop well-being services, such as opportunities for physical activity, for people with mental health problems. Abstract This study explored service users' and mental health professionals' understandings, experiences and opinions of well-being and its promotion within mental health services. A qualitative case study methodology included nine participants (five adult service users, three mental health professionals, one senior manager) who were purposively sampled from a Mental Health Trust in England. Service users participated in a focus group, while individual semi-structured interviews were held with the mental health professionals and senior manager. Interpretative phenomenological analysis of the data revealed five main themes including well-being as a holistic concept; well-being promotion; the place, promotion and position of well-being; role of mental health services in well-being promotion; and areas for further improvement. Findings revealed evidence of well-being promotion; however, there were contradictions regarding what was known between the groups of participants and what could be provided in the future. Implications for practice include the need to establish more effective partnership working between mental health services and local communities, especially in light of financial constraints within health services at large. This could assist the increased provision of therapeutic services for well-being promotion.

Families' experience with seeking treatment for recent-onset psychosis

OBJECTIVE

Qualitative research methods were used to understand the experiences of families seeking treatment for young people with recent-onset psychosis; such knowledge can inform services design.

METHODS

The authors conducted open-ended interviews in 1999 through 2002 with family members of 13 patients with recent-onset nonaffective psychotic disorders in the New York metropolitan area, focusing on their experience in seeking treatment and engaging with mental health services.

RESULTS

Family members described early lack of clarity of diagnosis and obstacles to obtaining treatment. Entry into the mental health system frequently occurred in the context of crisis, with African-American families specifically reporting police involvement. Inpatient hospitalization was depicted as traumatic yet offering relief. Aftercare was described as fragmented, and issues with third-party payers were paramount. Families expressed a desire for more education, information, and support and described their struggles with stigma. These data from families are presented in the context of more recent literature as to the efficacy of specialized treatment programs for early stages of psychotic disorder and their involvement of families.

CONCLUSIONS

These qualitative research data support the importance of involving and educating families about psychosis: its recognition, its treatment, and access to services. They also highlight the need to address stigma and implement structural changes in treatment that ensure continuity and coverage of care. Specialized first-episode psychosis services may address these issues, and they may minimize the traumatic experiences of involuntary hospitalization and police involvement early in treatment.

Families' experience with seeking treatment for recent-onset psychosis

OBJECTIVE

Qualitative research methods were used to understand the experiences of families seeking treatment for young people with recent-onset psychosis; such knowledge can inform services design.

METHODS

The authors conducted open-ended interviews in 1999 through 2002 with family members of 13 patients with recent-onset nonaffective psychotic disorders in the New York metropolitan area, focusing on their experience in seeking treatment and engaging with mental health services.

RESULTS

Family members described early lack of clarity of diagnosis and obstacles to obtaining treatment. Entry into the mental health system frequently occurred in the context of crisis, with African-American families specifically reporting police involvement. Inpatient hospitalization was depicted as traumatic yet offering relief. Aftercare was described as fragmented, and issues with third-party payers were paramount. Families expressed a desire for more education, information, and support and described their struggles with stigma. These data from families are presented in the context of more recent literature as to the efficacy of specialized treatment programs for early stages of psychotic disorder and their involvement of families.

CONCLUSIONS

These qualitative research data support the importance of involving and educating families about psychosis: its recognition, its treatment, and access to services. They also highlight the need to address stigma and implement structural changes in treatment that ensure continuity and coverage of care. Specialized first-episode psychosis services may address these issues, and they may minimize the traumatic experiences of involuntary hospitalization and police involvement early in treatment.

The Italian guidelines for early intervention in schizophrenia: development and conclusions

AIM

The effectiveness of early intervention in schizophrenia is still under discussion. The guidelines described in the present paper were aimed at contributing to the current debate by providing Italian practitioners, families, patients and health managers with evidence-based information on early intervention. They also examined the diagnostic tools that are currently available for assessing different stages of psychotic disorders.

METHODS

A multidisciplinary panel of experts (the Guidelines Development Group) used a set of key-questions to develop an explicit search strategy to conduct a systematic review of the literature published from January 2000 to June 2006. Trained personnel then selected papers from those yielded by the literature search. The Guidelines Development Group's final recommendations were scaled according to the Italian National Guidelines System grading system.

RESULTS

The evidence available up to the time of the literature search does not allow for recommendation of early intervention targeting prodromal or at-risk patients to prevent progression from the prodromal phase to acute, full-blown psychosis, nor to improve prognosis. Conversely, identification and timely treatment of first-episode psychotic patients through specific early intervention programmes are highly recommended.

CONCLUSIONS

The Italian Guidelines on early intervention in schizophrenia are based on a comprehensive assessment of an updated, large-scale body of literature. They draw specific, evidence-based conclusions to assist clinicians and stakeholders in the planning and implementation of appropriate intervention programmes. Further research is needed to ascertain the effectiveness of early intervention in delaying or preventing the conversion to psychosis and improving prognosis in prodromal or at-risk patients. Further investigation is also required for first-episode and critical period patients.

Early Psychosis: Treatment Issues and the Role of Occupational Therapy

Research has demonstrated that the establishment of early intervention services within mental health organisations is an effective method of reducing the impact of psychosis on a young person's life. The research literature and available clinical practice guidelines describe key intervention areas that have an impact on the effectiveness of the early intervention service. These include: comprehensive assessment, social functioning, weight control, substance misuse and vocational recovery. Early intervention services can develop effective programmes to address these areas.

The occupational therapist can have a defined role in this setting, primarily across the three domains of assessment, intervention and advocacy. Effective assessment by an occupational therapist provides information on the occupational role functioning of a young person. Intervention services provide consultative and direct treatment to assist the young person in engaging in developmentally and culturally appropriate occupational roles. Advocacy involves educating members of the multidisciplinary mental health team about the role and potential outcomes of occupational therapy. By assessing, intervening and advocating for young people with early psychosis, individual therapists can contribute to developing a central role for occupational therapy in the field of early psychosis.

First-episode psychosis: a literature review

This paper reports on a literature review of the impacts of first-episode psychosis on both the patient and their family and carers. The discussion focuses on the effects on the patient experiencing psychotic symptoms for the first time, including disruption to their environment, social connectedness, and future plans. Patients experiencing these symptoms can experience fear, distress, and isolation. Many of these patients are also at greater risk to themselves and others. The family and carers witnessing this psychosis may experience fear, guilt, and often carry the emotional and physical burden of care. Early intervention and treatment are crucial to potentially achieving better clinical outcomes, and to alleviating the psychological impact on patients and their families. The nurse's role in the treatment of the patient experiencing first-episode psychosis is to facilitate early intervention through recognition of symptoms and ongoing assessment, work to reduce a patient's risks, manage treatments, and work with the patient to reduce the risk of relapse.

Service user views and expectations of UK-registered mental health nurses: A systematic review of empirical research

OBJECTIVES

To review national (UK) literature in order to (i) examine service user and carer views of UK-registered mental health nurses; (ii) identify the diversity of populations from which these views have been collected; (iii) assess the methodological rigour of the current knowledge base and (iv) evaluate the extent to which service users and carers have been involved in the development and execution of this work. This paper reports only on service users' views.

DESIGN

Systematic review.

DATA SOURCES

Electronic and evidence-based databases, reference checking and hand searching of key academic journals, national policy and user/carer organisational websites.

REVIEW METHODS

Two reviewers independently undertook study eligibility judgements and data extraction. Eligible studies were sub-classified according to service setting (inpatient/residential, community/non-residential or mixed/unspecified). Each study was assessed against key quality criteria. Data were synthesised in a narrative format.

RESULTS

One hundred and thirty two studies were included in the review. The majority were small-scale academic studies biased towards white, adult service users. Few studies provided evidence of user collaboration. Service users regard mental health nursing as a multi-faceted role delivering practical and social support alongside more formal psychological therapies. Service users report inadequate information provision, poor inter-professional communication and a lack of opportunities for collaborative care. Service users perceive inpatient mental health nurses as particularly inaccessible.

CONCLUSIONS

UK-registered mental health nurses should be equipped with both therapeutic clinical skills and generic skills associated with relationship building, engagement and communication. Future research should be conducted in collaboration with service users and include clear and effective mechanisms for the dissemination and implementation of research findings. In particular, the views of children and adolescents, the elderly and black and minority ethnic groups, currently under-represented in research, should be examined.

"From the heart of my bottom": negotiating humor in focus group discussions

Reporting and analyzing interactional data collected during focus groups can be a significant challenge for qualitative health researchers. In this article, the authors explore the use of humor among focus group participants as one area of interaction and negotiation that is methodologically interesting and theoretically insightful. They explore discussions about service user involvement in medical education across eight focus groups consisting of medical educators, medical students, and service users. The findings suggest that humor can be used among focus group participants to maintain solidarity, navigate coping strategies, and negotiate power. Not only is humor useful when exploring new concepts, it can also be an indication of wider views that might not be explicit in an analysis of focus group members' comments alone. The authors urge qualitative health researchers to examine interactions among focus group participants, and their analysis of humor illustrates how this can be achieved.

More than just a place to talk: young people's experiences of group psychological therapy as an early intervention for auditory hallucinations

OBJECTIVES

Auditory hallucinations are extremely distressing, particularly when occurring during adolescence. They may be most responsive to psychological intervention during a three-year critical period following symptom-onset, but as yet no studies have investigated voices groups for young participants with adolescent-onset psychosis. The aim of the current study is to explore the experience of group-CBT amongst a group of young people experiencing distressing auditory hallucinations.

DESIGN

This project was planned and conducted in the tradition of idiographic, qualitative psychology. A small purposive sample was selected, and in-depth, open-ended interviews were conducted, in order to generate and explore rich, experiential accounts which are clearly situated and contextualized.

METHODS

Eight participants who had completed a cognitive behavioural group intervention were interviewed using a semi-structured interview schedule. The transcribed data were analysed according to the principles of Interpretative Phenomenological Analysis (IPA; Smith, Osborn, & Jarman, 1999).

RESULTS

Two superordinate themes emerged. The first describes experiential features of the respondents' accounts of group therapy. The second theme posits a cyclical relationship between four key factors: the content of the hallucinated voices, the participants' explanations for, and reactions to these voices, and thus, their ability to cope with them.

CONCLUSIONS

'Voices groups' are appreciated by young people with auditory hallucinations, as sources of therapy, information, and support. These results suggest a number of testable hypotheses about the efficacy of group treatment and its future development.

Service users and carers' experiences of a psychosis service

This paper presents the findings of a survey, which examined how people with psychosis and their carers had experienced local mental health services. The research was conducted prior to the establishment of an early intervention service and other service improvements in the region. The results suggest that the mental health service is improving overall for individuals with psychosis and their carers. The experiences of recent service users and carers seem more positive than those whose first contact with the services occurred during the 1970s and 1980s. Both service users and their carers report feeling largely supported by mental health professionals and voluntary support agencies, and feel included in the treatment approach. However, a number of important issues were highlighted. These include (i) the need for public education (which may help to reduce the delay which currently occurs between people seeking support and receiving treatment); (ii) improved access to alternative treatments, such as psychosocial therapies (in conjunction with pharmacological treatment); the provision of appropriate psychiatric facilities; and (iii) the inclusion of an early intervention treatment approach. The survey provides descriptive information from one NHS trust, which shows support for larger scale research findings and government recommendations.

Emerging empirical evidence on the ethics of schizophrenia research

Many challenging ethical questions come with the scientific efforts to understand the nature and treatment of schizophrenia. The empirical study of ethical aspects of schizophrenia research has sought to clarify and resolve many of these questions. In this article we provide an overview of the existing data-based literature on schizophrenia research ethics and outline directions for future inquiry. We examine 5 broad categories of inquiry into the ethics of schizophrenia research: (1) Scientific designs (eg, placebo-controlled studies and medication-free intervals, prodromal and high-risk research, and genetics research); (2) informed consent and decision-making capacity, including assessment of decisional abilities, as well as intervention studies; (3) understanding and perceptions of risk and benefit (including the therapeutic misconception); (4) influences on research participation (including voluntarism, altruism, and other motivations); and (5) key participant safeguards, such as protocol review and participant advocates. We discuss how empirical work in each of these areas answers certain questions and raises new ones. Finally, we highlight important gaps in our understanding of ethically relevant aspects of schizophrenia research and offer a specific research agenda for empirical ethics.

Concepts of recovery: competing or complementary?

PURPOSE OF REVIEW

Within the last 5 years, concepts of recovery have taken center stage in psychiatry as the overarching goal of mental health services. In the course of this shift towards recovery, clinicians and consumers (and many others) have struggled to make the concept of recovery both measurable and meaningful. The clinical concept of recovery has focused upon the remission of symptoms and restoration of functioning. A rehabilitation model of recovery has been a more subjective and consumer-oriented concept that focuses on the full lives that are lived within the context of enduring disability.

RECENT FINDINGS

A review of the literature addressing the concepts of recovery over the last 2 years demonstrates that authors are rarely explicit about the perspective of recovery from which they are writing. Almost all of the representative papers, however, struggled with how best to define, measure and validate recovery in its broadest terms. Several authors reviewed the history of recovery and offered conceptual discussions of either their first-person experiences or implications for mental health practice. Other authors, regardless of their perspective on recovery, sought to more concretely define criteria for recovery, for the purposes of recovery measure development or more rigorous research of the concept.

SUMMARY

As authors struggle to reconcile these often competing concepts of recovery, we suggest that both concepts are useful for different purposes and populations and that the synthesis of the two will offer a broader perspective on life with, after, or despite mental illness.

Depression and the perpetuation of an incapacitated identity as an inhibitor of return to work

The aim of the current study was to conduct a qualitative investigation of attitudes to work among people diagnosed with clinical depression. It was of particular interest to understand the role played by illness in attitudes to recovery. The economic and social burden of adult depression on society is becoming increasingly apparent. It has been argued that recovery from mental illness of this kind is most appropriately understood in 'functional terms' (i.e. 'getting on with life beyond illness'). One important goal in this process is return to work. Accordingly, in-depth semi-structured interviews were conducted with 19 people formally diagnosed with clinical depression. These interviews were the analyzed using Interpretative Phenomenological Analysis: a method of investigation and analysis concerned with making sense of participant experiences and accounts of their ill-health. This process identified three master themes, only one of which is the focus of this paper. This theme pertains to the unwitting role that can be played by the health care system in reinforcing the 'sick role' and in so doing providing a continued justification for an 'off-work' identity. Consequently, this study provides an unusually penetrating insight into the way depression can, through institutional practices, become inextricably part of someone's identity, with important implications for functional recovery.