The conditions of possibilities for recovery: A critical discourse analysis in a Danish psychiatric context

"We are a rehabilitation unit, at least on paper" - Competing representations of recovery-oriented rehabilitation in dual diagnosis treatment policy and practice

Within dual diagnosis treatment, principles of recovery are increasingly acknowledged. Nevertheless, recovery-oriented rehabilitation often becomes an abstract concept, leaving professionals in various dilemmas. This article examines competing representations of recovery-oriented rehabilitation across Danish dual diagnosis treatment policy and practice from a post-structural, analytical perspective inspired by governmentality and problematization studies. The empirical foundation consists of a qualitative ethnographic study including conducting and examining 12 national policies relevant to contemporary Danish dual diagnosis treatment practice and 23 interviews with health/welfare professionals employed at a Danish in-patient, dual diagnosis rehabilitation unit. The analysis points to a complexity between three sets of competing representations reflected in 1) the conceptual relationship between rehabilitation and recovery, 2) perceptions of knowledge based on experience or evidence, and 3) ideals of optimization and emancipation. Finally, the article discusses convergences between the competing and, at times, conflictual ideals, attempting to explain the conceptual fluffiness, discrepancies, and dilemmas experienced by professionals in dual diagnosis treatment within broader epistemological and ideological debates in social sciences and humanities.

"I'm not an anxious person": end-of-life care workers constructing positive psychological states

BACKGROUND

Mental health is an issue of social and economic importance. Sociocultural and scholarly attention has largely focused on the negative aspects of mental health. That is, on mental disorders and illness and how they adversely impact our lives. In contrast, this paper forms part of a recent alternative empirical perspective in discourse-based research, by focusing on the positive aspects of mental health. In this article, we investigate how end-of-life care workers construct their positive psychological states.

METHODS

Our data are 38 audio-recorded and transcribed semi-structured interviews with end-of-life care workers from Hong Kong and the United Kingdom. We utilized thematic analysis to identify common categorial strands across the data and discourse analysis to identify the linguistic strategies that these interviewees used to talk about their mental health.

RESULTS

Our thematic analysis generated a superordinate theme across the interviews-namely, that of end-of-life care workers talking about their positive psychological states. We identify three generic ways that end-of-life care workers talked about these psychological states; by "foregrounding the positive," "reformulating the negative," and "dismissing the negative." Our analysis also explicates how interviewees connected social and organizational support to being a benefit to their psychological states.

CONCLUSIONS

Our work contributes to existing discourse-based and sociolinguistic research on mental health by turning their focus towards a consideration of its positive dimensions. We also identify recurrent linguistics strategies used by people to construct their mental health. Our analyses point to the importance of investigating mental health as a multidimensional concept that considers participants' own reflections on their mental health.

Health professionals' perceptions of user involvement in a mental health centre: A critical discourse analysis

The objective of this study was to investigate the engagement between healthcare professionals and users of mental healthcare at the individual level in a mental health hospital. A qualitative research design with purposive sampling was adopted. Five audio-recorded focus group interviews were conducted with nurses and other health professionals at a mental health hospital in Copenhagen and were explored using Fairclough's discourse analysis framework. This study shows how users can be subject to paternalistic control despite the official aim that user involvement be an integral part of the care and treatment offered. As evidenced in discussions by health professionals, the users were involved in plans based on conditions determined by the health professionals who were predominantly focused on treating diseases and enabling the users to live a life independent of professional help. Our results can contribute to dealing with the challenges of incorporating user involvement as an ideology in mental health hospitals.

Competing discourses as barriers to change in rehabilitation nursing: a discourse analysis

Introduction

The power of action research to create change by anchoring research results in practice was challenged in an action research project at a specialized rehabilitation unit for persons with acquired spinal cord injury. Despite the co-researchers' new insights, approaches, and actions supporting patient participation, it was not possible to change the basic conditions for the practicing of nursing. We aimed to raise awareness of the mechanisms that govern barriers by exploring these barriers as experienced by nurses in their effort to change their practice to improve patient participation.

Method

We used Fairclough's critical discourse analysis drawing on Foucault's practical systems; ethics (identity, relation to oneself), power (action, relation to others), and knowledge (representation, aspects of the world), which he combines with discourse-analytical concepts.

Results

Our discourse analysis of the empirical data at micro-level uncovers the nature of barriers to change in practice. In addition, our analysis at macro-level unveils how these practices are embedded in larger historical, societal, and institutional discourses. This identified two current discourses: a biomedical discourse and a biopsychosocial discourse. In the light of these two discourses, the nurses at micro-level saw themselves as strong agents for the best rehabilitation by acting in accordance with the biopsychosocial discourse. But they were unable to find the time and space to do so due to tasks, structures, and practices specified by an organization dominated by the biomedical discourse.

Mental Health Staff's Perspectives on Tapering of Antipsychotic Medication: A Focus Group Study

Contemporary practices of long-term antipsychotic maintenance treatment for schizophrenia are being challenged, and clinicians must consider the possibilities of reducing long-term maintenance use. However, research indicates that people with schizophrenia receive little support from mental health staff to reduce antipsychotic medication. This article reports a study which aimed to investigate interdisciplinary mental health staff's accounts of tapering of antipsychotic medication and to explore different positions that mental health staff assign to themselves and others. Six focus groups were conducted with 39 mental health staff from outpatient clinics, inpatient units, forensic mental health units, and community mental health services. The data analysis combined analyses of the interactions during focus groups and the thematic content. Results were considered from a discourse analytic perspective considering the function and consequence of accounts applied by the mental health staff. The mental health staff accounted for their perspectives on tapering from the following three distinctive positions: 1) No, patients will eventually realize that they need the medication, 2) Yes, but tapering means running a big risk of relapse in symptoms, and 3) Yes, we need to welcome risks to support personal recovery. Our findings indicated that there was reluctance among interdisciplinary mental health staff to let service users make decisions and limited possibilities for people with schizophrenia to have their request for tapering of their antipsychotic medication met by mental health staff.

Exploring the Evidence for the Paradigms of Recovery and Social Work Converging in Mental Health Service Delivery Worldwide: Reflections from an Irish Case Study

Recovery within mental health service delivery is no longer a new consideration in the Western world. However, it is well-documented how challenging its implementation and translation to practice and reality have been in contemporary mental health systems. In conjunction with this, mental health social work is continuously being challenged and debated in relation to its role, responsibilities, and identity in service delivery. This is largely the consequence of the continued dominance of the biomedical model in relation to service delivery. Yet, if we critically reflect on the philosophy and ethos of recovery, it becomes very clear that social work should be the key profession to lead the development and improvement of recovery-orientated services across the globe. To illustrate this argument, the authors first draw on empirical research undertaken by the lead author within the Republic of Ireland on how recovery is socially constructed within mental health service delivery. The key stakeholders involved in the Irish study included professionals, service users, family members, and policy influencers, with participants taking part in semi-structured interviews. Secondly, the authors reflect on some of the findings from this Irish study, presenting an argument for not only a more significant role for social work in an Irish mental health context but also making comparisons from an international perspective. This includes exploring the role of critical social work traditions for supporting services to move beyond a philosophy of recovery that has, to date, overlooked the intersectional injustices and inequalities faced by hard-to-reach populations. Finally, the authors conclude by providing some possibilities for how the paradigms of social work and recovery can and should continue to converge towards each other, opening a space for social work to become a more dominant perspective within mental health systems worldwide.

Mental Health, Discourse and Stigma

In this editorial to the special collection "Mental Health, Discourse and Stigma" we outline the concepts of mental, health, discourse and stigma as they are examined through sociolinguistic lenses. We examine the sociolinguistic approach to mental health and stigma and discuss the different theoretical frameworks and methodological approaches that have been applied in such contexts. Sociolinguistics views mental health and stigma as discursively constructed and constituted, i.e. they are both manifest, negotiated, reinforced or contested in the language that people use. We highlight existing gaps in sociolinguistic research and outline how it could enrich research in psychology and psychiatry and contribute to professional practice. Specifically, sociolinguistics provides well-established methodological tools to research the 'voices' of people with a history of mental ill health, their family, carers and mental health professionals in both online and off-line contexts. This is vital to develop targeted interventions and to contribute to de-stigmatization of mental health. To conclude, we highlight the importance of transdisciplinary research that brings together expertise in psychology, psychiatry and sociolinguistics.

Mental Health Recovery in Social Psychiatric Policies: A Reflexive Thematic Analysis

The realisation of recovery as an overarching goal of mental health care services has proven difficult to achieve in practice. At present, concepts of recovery are contested and unclear, which affects their implementation in psychiatric practices. We examined social psychiatric policies about recovery with the aim to explore their underlying assumptions about recovery. Relevant texts from the policies' knowledge bases were subjected to reflexive thematic analysis. We developed a central theme: "A clinical standardisation of the concept of recovery". The theme involved meaning clusters that encompassed conflicting and commonly shared assumptions about recovery across the text corpus. We discussed the findings from discourse analytical and governmentality perspectives. In conclusion, the policies' aim of providing clarity about recovery was circumvented by the very knowledge bases used to support their endeavours.

Perspectives on Recovery-Oriented Care in Mental Health Practices: Health Professionals Experiences

In several Western countries, mental health professionals work in accordance with the principles of recovery-oriented practices, but there is little research into what opportunities there are for fostering recovery-oriented practices in mental health settings. To investigate how central elements of recovery-oriented practices are reflected in health professionals experiences of care and treatment in mental health. Four focus group interviews with nurses and other health professionals are conducted and analysed using manifest content analysis to carry out a low-level analysis of the participants' experiences in mental healthcare. The study was designed in accordance with the ethical principles of the Helsinki Declaration (1) and Danish law (2). The participants gave informed consent after verbal and written information. The main theme, 'recovery-oriented practices framed within institutional structural conditions', was based on three subthemes: 1) users need help to find meaning during hospitalisation and find hope, 2) health professionals experience it as an obligation that users achieve personal recovery, and 3) user perspectives versus the mental health practices' structural logic. This study sheds light on health professionals experiences with a recovery-oriented practice. The health professionals believe in this as a positive approach and see it as an important obligation to help the user find their own aims and hopes. On the other hand, it can be difficult to work in recovery-oriented practices. It requires an active commitment from users; for many, this can be difficult to live up to.

Healthcare Professionals' Experiences with Patient Participation in a Mental Healthcare Centre: A Qualitative Study

INTRODUCTION

Patient participation is a cornerstone of the debate concerning healthcare professionals and patients of mental health centres. It constitutes an objective in government health policy in Scandinavia and other Western countries. However, little is known about the experiences of healthcare professionals in mental healthcare practices involving patients under their treatment and care.

OBJECTIVE

This study aimed to explore the experiences of healthcare professionals with patient participation in the context of a mental health centre.

METHODOLOGICAL DESIGN

Four focus group interviews with healthcare professionals reflected differing experiences with unfolding patient participation in clinical practices in four wards of a mental health centre. A content analysis developed and framed themes.

RESULTS

Patient participation was based on structural conditions, which shows that predetermined structural methods predominantly control involvement. The structural methods are seen as promoting participation from the patient's perspective. At the same time, the methods also enable taking account of the individual patient's wishes and needs for involvement.

DISCUSSION AND CONCLUSION

This study illuminates the meaning of patient participation in a mental health centre based on the social interactions among nurses and other healthcare professionals. The approach can contribute to dealing with the challenges of incorporating patient participation as an ideology for all patients in a psychiatric context, which is important knowledge for healthcare professionals.

Recovery-Oriented Practices in a Mental Health Centre for Citizens Experiencing Serious Mental Issues and Substance Use: As Perceived by Healthcare Professionals

INTRODUCTION

Recovery-oriented practices have become a means of promoting user recovery during hospitalisation, but we do not know much about the concrete means of practicing recovery-orientation for the most vulnerable users with serious mental difficulty and substance use.

AIMS

We investigated the concrete means of practicing recovery-orientation in care work and the elements, dimensions, outcomes, or steps of it in a special department of mental health centres.

METHOD

Focus group interviews were conducted with 16 health professionals with experience with users with serious mental difficulty and substance use. Qualitative content analysis was undertaken.

RESULTS

The main theme was "holistic recovery on structural terms" based on two themes and four subthemes. The first theme was "recovery based on an individual approach" with subthemes "detective-find hope" and "how to do recovery-oriented practice". The next theme was "recovery subject to structural framework" with subthemes "tension between different interests" and "symptoms as a barrier".

CONCLUSIONS

recovery-oriented practice is understood as an approach where health professionals emphasise forming relationships based on trust, being hopeful for the users' future, spending time with users, and respecting users' experiences and knowledge from their own life. There are cross-pressures between different interests. The desire to meet the users' perspectives and respect these perspectives but at the same time live up to mental health centre purposes to stabilise the users' health and achieve self-care.

Recovery-Oriented Cross-Sectoral Network Meetings between Mental Health Hospital Professionals and Community Mental Health Professionals: A Critical Discourse Analysis

Aims and objectives: In the medical field, we lack knowledge on how interprofessional collaboration across sectors is carried out. This paper explores how healthcare professionals and users perceive recovery-oriented cross-sectoral discharge network meetings between mental health hospital professionals and community mental health professionals and which discourses manifest themselves within the field of mental healthcare. Method: Ten professionals from a mental health hospital and eight community mental health professionals participated. In addition, five users with experience in mental health services in both sectors participated. Fairclough’s discourse analysis framework was used to explore their experiences. The study was designed following the ethical principles of the Helsinki Declaration and Danish law. Each study participant in the two intersectoral sectors gave their informed consent after verbal and written information was provided. The Consolidated Criteria for Reporting Qualitative Research checklist was used as a guideline to secure accurate and complete reporting of the study). Results: The healthcare professionals in both sectors are governed by steering tools, legislation and a strong biomedical tradition to solve illness-related problems, such that users must be offered treatment and support to achieve self-care as soon as possible. This can be seen as a reflection of, and a driving force in, a change in the wider social practice that Fairclough terms the ‘marketisation of discourse’—a social development in late modernity, whereby market discourse colonises the discursive practices of public institutions. The user of psychiatric and social services experiences a structured system that does not offer the necessary time for deep conversations. Users do not consider recovery as something that is only seen in relation to the efforts of the professionals, as recovery largely takes place independently of professionals. Recovery depends on users’ internal resources and a strong network that can support them on the journey. Conclusion: Healthcare professionals perceive recovery-oriented cross-sectoral discharge network meetings to reflect paternalistic and biomedical discourses. Users want to be seen more as whole persons and did not experience sufficient involvement in the intersectoral care. Relevance to clinical practice: Healthcare professionals need to be supported to seek clarity in the understanding and operationalisation of a recovery-oriented approach, if the agenda is to be truly adopted and strengthened.

Measuring judiciarization of people with mental illnesses

The judiciarization of the psychiatric subject is a two-sided process. It could anti-discriminate people with mental illnesses but, at the same time, it could potentially provoke pathologization of mental illnesses. Current methodologies proposed to measure this important and complicated process for people with mental illnesses do not allow analysis on multiple levels (the macro, meso, and micro). In this article, to fill this gap we propose a methodological strategy that helps to investigate judiciarization of people with mental illnesses on multiple levels at once. This approach is based on critical discourse analysis of legal documents and court decisions that feature people with the poor mental health. Namely, we suggest how to measure the level or degree of judiciarization, its geographical evenness, actors in the legal process, its dimensions (the law branches of its occurrence), and linguistic content. We applied this methodology in examining 1,243 legal documents and 327,311 court decisions that were issued by agents of the Russian law system. The research findings show that judiciarization levels in Russia have been rising over the years, moving away from stigmatizing those with mental illnesses and towards anti-discrimination. Our paper could be of interest to socio-legal researchers and social policy practitioners.

Recovery-Oriented Network Meetings in Mental Healthcare: A Qualitative Study

Recovery-oriented cross-sectoral collaboration is a cornerstone of the debate concerning health professionals and users of mental health services and constitutes an objective in government health policy in Scandinavia and other Western countries. Users do not find that professionals communicate with each other across specific sectors regarding plans that have been prepared. They often experience that they have to start over again every time they switch between treatment locations. The aim of this study is to develop a recovery-oriented model for network meetings. Health professionals and users with experience from mental health services participated in three workshops to discuss and achieve a plan for recovery-oriented network meetings. Knowledge was generated in dynamic research cycles that were experiential, presentational, propositional, and practical. Themes were developed and framed by a content analysis.Recommendations are presented as a narrative from all the participants involved. The overall theme was 'more focus on personal recovery' with subthemes such as 'CHIME as a recovery-oriented approach'. In addition, other themes were generated such as 'open dialogical meetings', with subthemes such as 'meeting structures' and 'open dialogues'. This study concludes recommendations to promote a recovery-oriented approach in cross-sectoral network meetings inspired by theoretical perspectives along with the experiences and knowledge of co-researchers.

Recovery-oriented intersectoral care between mental health hospitals and community mental health services: An integrative review

BACKGROUND

Recovery-oriented intersectoral care is described as an aim in mental healthcare to create a holistic framework for planning that provides integration of treatment and rehabilitation. Existing studies show that nurses and other professionals do not take responsibility for the collaborative element of intersectoral care between mental health hospitals and community mental health services. The users of mental healthcare do not experience their patient journey as a cohesive process when they are discharged from a mental health hospital to community mental health services.

AIM

The integrative review aims to examine the professionals' experience with recovery-oriented intersectoral care between mental health hospitals and community mental health services.

DESIGN

Since the aim was to review user experience, we chose an integrative review as an obvious choice for design.

ETHICAL APPROVAL

Not applicable.

FINDINGS

Seven studies met the inclusion criteria. The interactive inductive and deductive analysis generated four themes, which clarify the experience of professionals with recovery-oriented intersectoral care between the mental health hospitals and community mental health services, namely 'structurally routine care', 'unequal balance of power between the sectors', 'bureaucracy as a barrier to recovery-oriented intersectoral care' and 'flexible mental healthcare approaches'.

CONCLUSION

This review achieves specific knowledge of recovery-oriented intersectoral care. The studies included show that recovery-oriented intersectoral care is not clearly defined. It is challenging to transfer intersectoral care to an organisation with different structural and linguistic barriers.

Conceptualizing patient participation in psychiatry: A survey describing the voice of patients in outpatient care

BACKGROUND

While increasingly discussed in somatic care, the concept of patient participation remains unsettled in psychiatric care, potentially impeding person-centred experiences.

OBJECTIVE

To describe outpatient psychiatric care patients' conceptualization of patient participation.

DESIGN

An exploratory survey.

SETTING AND PARTICIPANTS

Patients in four psychiatric outpatient care units.

VARIABLES

Patients conceptualized patient participation by completing a semi-structured questionnaire, including optional attributes and free text. Data were analysed using statistics for ordinal data and content analysis for free text.

RESULTS

In total, 137 patients (69% of potential respondents) completed the questionnaire. The discrete items were favoured for conceptualizing patient participation, indicating a primary connotation that participation means being listened to, being in a reciprocal dialogue, learning about one's health care and managing one's symptoms. Additional free-text responses acknowledged the attributes previously recognized, and provided supplementary notions, including that patient participation is about mutual respect and shared trust.

DISCUSSION

What patient participation is and how it can be facilitated needs to be agreed in order to enable preference-based patient participation. Patients in outpatient psychiatric care conceptualize participation in terms of both sharing of and sharing in, including taking part in joint and solo activities, such as a reciprocal dialogue and managing symptoms by yourself.

CONCLUSION

While being a patient in psychiatric care has been associated with a lack of voice, an increased understanding of patient participation enables person-centred care, with the benefits of collaboration, co-production and enhanced quality of care.

PATIENT CONTRIBUTION

Patients provided their conceptualization of patient participation in accordance with their lived experience.

Part I: Dynamics of Recovery: A Meta-Synthesis Exploring the Nature of Mental Health and Substance Abuse Recovery

Recovery-oriented care has become a leading vision across countries. To develop services and communities in more recovery-oriented directions, enhanced understandings of recovery in terms of personal and social contexts are important prerequisites. The aim of this study is to explore the nature and characteristics of the experiences of recovery. The method used is a form of qualitative meta-synthesis that integrates the findings from multiple qualitative studies published by one research group. Twenty-eight empirical papers with a focus on recovery as personal and contextual experiences were included in this meta-synthesis. Five meta-themes were developed: (a) being normal, (b) respecting and accepting oneself, (c) being in control, (d) recovery as intentional, and (e) recovery as material and social. The themes describe how recovery encompasses dynamics between personal experiences and contextual dimensions. This meta-synthesis consolidated an understanding of recovery as dynamics of the self and others, and as dynamics of the self and material resources. This understanding of recovery suggests the need to work not only with the person, but also with families, networks, social systems, and local communities, thus developing mental health and substance abuse services in more collaborative, open-ended, and context-sensitive directions.

User Involvement in the Handover between Mental Health Hospitals and Community Mental Health: A Critical Discourse Analysis

INTRODUCTION

This study aimed to explore how healthcare professionals and users could perceive user involvement in the handover between mental health hospitals and community mental healthcare, drawing on the discourse analysis framework from Fairclough.

METHODS

A qualitative research design with purposive sampling was adopted. Five audio-recorded focus group interviews with nurses, users and other health professionals were explored using Fairclough's discourse analysis framework. Ethical approval: The study was designed following the ethical principles of the Helsinki Declaration and Danish Law. Each study participant in the two intersectoral sectors gave their informed consent after verbal and written information was provided.

RESULTS

This study has shown how users can be subject to paternalistic control despite the official aims that user involvement should be an integral part of the care and treatment offered. As evidenced in discussions by both health professionals and the users themselves, the users were involved in plans with the handover on conditions determined by the health professionals who were predominantly focused on treating diseases and enabling the users to live a life independent of professional help.

CONCLUSIONS

Our results can contribute to dealing with the challenges of incorporating user involvement as an ideology in the handover between mental health hospitals and community mental health. There is a need to start forming a common language across sectors and, jointly, for professionals and users to draw up plans for intersectoral care.

Recovery-Oriented Intersectoral Care in Mental Health: As Perceived by Healthcare Professionals and Users

This study aimed to explore how mental health professionals and users perceive recovery-oriented intersectoral care when comparing mental health hospitals and community mental healthcare. Methodological design: Five audio-recorded focus group interviews of nurses, other health professionals and users were explored using manifest and latent content analysis. Ethical issues and approval: The study was designed in accordance with the ethical principles of the Helsinki Declaration and Danish law. Each study participant in the two intersectoral sectors gave their informed consent after verbal and written information was provided. Findings: From the health professionals’ perspective, the main theme informed by subthemes and categories was formulated: ‘Recovery-oriented intersectoral care requires more coordination and desire for collaboration’. Two subthemes were subsequently formulated: ‘The users´ perspective of the centre’ and ‘Need for a common agenda and understanding of recovery-oriented intersectoral care’. From the users´ perspective, the main theme was formulated as: ‘Recovery-oriented intersectoral care in tension between medical- and holistically oriented care’. This theme was informed by two subthemes: ‘The users´ perspective is not in focus’ and ‘A trusting relationship and a holistic approach brings coherence’. Conclusions: This study reveals that health professionals want to work in a recovery-oriented manner in intersectoral care, but several challenges appear which make achieving this aim difficult. A common understanding of recovery and how it should be carried out in intersectoral care does not exist. Care decisions are primarily made paternalistically, where the users’ and relatives’ voices are ignored. In an attempt to create coherence across sectors, intersectoral network meetings have been established with health professionals from both sectors. However, the meetings are characterised by a lack of a clear purpose regarding the meeting structure and content, and users are only minimally involved. Our results can contribute to dealing with the challenges of incorporating recovery-oriented intersectoral care as an ideology in all psychiatric and municipal contexts and is, therefore, important for health professionals and users.

Healthcare Professionals' and Users' Experiences of Intersectoral Care between Hospital and Community Mental Healthcare

This paper explores healthcare professionals’ and users’ experience of coherent intersectoral care between hospital mental healthcare and community mental healthcare. A total of 20 healthcare professionals, primarily nurses, and 14 users with a range of mental illnesses participated in nine focus group interviews (FGIs). Participants were encouraged in the FGIs to reflect upon their experience of coherency in intersectoral care. The analysis of FGIs was informed by a phenomenological-hermeneutic approach in a research group from 2016–2019. The Consolidated Criteria for Reporting Qualitative Research checklist was used as a guideline to ensure complete and accurate reporting of the study. The analysis led to the generation of several themes from a professional perspective and from a user perspective, addressed barriers to coherent intersectoral care. The healthcare professionals experienced barriers such as a lack of common language and knowledge of partners. The users did not feel involved and lacked coherence in their recovery processes and, as such, intersectoral care was often experienced as being lost in a maze.