The role of users of psychiatric services in service development – influence not power

Researchers' perspectives on public involvement in health research in Singapore: The argument for a community-based approach

Background

Singapore is becoming a world‐class research hub, promoting the advancement of patient care through translational clinical research. Despite growing evidence internationally of the positive impact of public involvement (PPI), in Singapore PPI remains unusual beyond patient participation as subjects in studies.

Objective

To explore health researchers' understandings of the principles, role and scope of PPI, and to identify barriers and opportunities for implementation in Singapore.

Design

Semi‐structured qualitative interviews between April and July 2018. Data were analysed using thematic framework analysis.

Results

Whilst most participants (n = 20) expressed a lack of experience of PPI, the interview process provided an opportunity for reflection through which it emerged as a beneficial strategy. Interviewees highlighted both utilitarian and ethical reasons for implementing PPI, particularly around increasing the relevance and efficiency of research. In addition to those challenges to PPI documented in the existing literature, participants highlighted others specific to the Singaporean context that make PPI at an individual level unlikely to be successful, including the socio‐political environment and prevailing social and professional hierarchies. They also identified asset‐based strategies to overcome these, in particular, a more community‐oriented approach.

Conclusion

The cultural reluctance of individuals to question perceived authority figures such as researchers may be overcome by adopting an approach to PPI that is closer to family and local community values, and which facilitates patients and the public collectively engaging in research. Further work is needed to explore the views of patients and the public in Singapore, and the implications for other Asian communities.

Contributory injustice in psychiatry

I explain the notion of contributory injustice, a kind of epistemic injustice, and argue that it occurs within psychiatric services, affecting (at least) those who hear voices. I argue that individual effort on the part of clinicians to avoid perpetrating this injustice is an insufficient response to the problem; mitigating the injustice will require open and meaningful dialogue between clinicians and service user organisations, as well as individuals. I suggest that clinicians must become familiar with and take seriously concepts and frameworks for understanding mental distress developed in service user communities, such as Hearing Voices Network, and by individual service users. This is especially necessary when these concepts and frameworks explicitly conflict with medical or technical understandings of users' experiences. I defend this proposal against three objections.

Patient family advisors' perspectives on engagement in health-care quality improvement initiatives: Power and partnership

BACKGROUND

Engagement of the public in defining and shaping the organization and delivery of health care is increasingly viewed as integral to improving quality and promoting transparent decision making. Meaningful engagement of the public in health-care reform is predicated on shifting entrenched power imbalances between health-care systems and those it claims to serve.

OBJECTIVES

To describe the expressions, forms and spaces of power from the perspectives of persons who participated as Patient/Family Advisors (PFAs) in Rapid Process Improvement Workshops (RPIWs) within Saskatchewan, Canada.

METHODS

Using a qualitative, interpretive approach, in-depth interviews were conducted with a purposive sample of 18 PFAs who had participated in at least one RPIW over the past year. Deductive thematic analysis was informed by Gaventa's model of power.

RESULTS

Motivations for serving as a PFA included a sense of obligation to contribute to the improvement of a public system, recognition of their rights as citizens within a publicly funded system and an opportunity to openly express their concerns where previous encounters had been very negative. The invited spaces of the RPIWs were created by policymakers to accord visible power to PFAs. Participation resulted in PFAs gaining new insights into the structure and operations of the system, affirmation of their right to advocate and recognition of the potential to claim spaces of power as consumers. Advisement on specific health-care initiatives using the vehicle of PFAs shaped and promoted new forms and spaces of power, representing one step in a very long road to full engagement of consumers in health care.

Encouraging user involvement in mental health services

This article summarises the current research evidence base on user involvement in mental health services from both policy and practical perspectives. We begin by examining the many meanings of the term ‘mental health service user’ and the policy imperatives for user involvement, to provide a context for later examples of good practice. We then discuss what is meant by ‘involvement’ and the reasons why user involvement is particularly important in mental health services. Finally, we describe some of the traditional barriers to involvement and a number of examples of positive practice across a range of different aspects of mental health service development and delivery.

User and carer involvement in mental health training

National policy in the UK emphasises the importance of involving service users and caregivers in all types of mental health provision. The training of mental health care and social service professionals has always relied on seeing patients, but the patients' role has usually been a passive one. This is now changing, and service users and carers are becoming active educators in professional training, benefiting both the teachers and those taught. Provision is still very variable and is dependent on local initiatives. Voluntary organisations are active in this field, and there are now two academic posts for service users in the UK. This article explores the current forms of service user training, its benefits and drawbacks, and makes recommendations for future work.

Specialist registrars' views on the proposed reform of the Mental Health Act (1983)

AIMS AND METHOD

A postal questionnaire was sent to specialist registrars (SpRs) in the Wessex Region to evaluate senior trainees' reactions to information about the proposed changes in mental health legislation and to ascertain if the information had adversely affected their view of their future careers as consultants.

RESULTS

A high level of concern about the proposed changes and their potential impact on consultants was revealed. A majority of SpRs took a more negative view of their future career, especially those preparing a single Certificate of Completion of Specialist Training in general adult psychiatry, who were more likely to have adverse perceptions and to have thought of opting out.

SERVICE IMPLICATIONS

The legislative proposals have the potential for considerable impact on recruitment and retention of psychiatrists.

Service user involvement in mental health care: an evolutionary concept analysis

BACKGROUND

The concept of service user involvement is an evolving concept in the mental health-care literature.

OBJECTIVE

This study sought to explore and analyse the concept of service user involvement as used in within the field of mental health care.

METHODOLOGICAL APPROACH

An evolutionary concept analysis was conducted using a literature-based sample extracted from an electronic database search. One hundred and thirty-four papers met the inclusion criteria and were analysed to discover key attributes, antecedents and consequences of service user involvement and to produce a definition of the concept.

FINDINGS

Five key attributes of service user involvement within the context of mental health care were identified: a person-centred approach, informed decision making, advocacy, obtaining service user views and feedback and working in partnership.

DISCUSSION AND CONCLUSIONS

Clarity of the attributes and definition of the concept of service user involvement aims to promote understanding of the concept among key stakeholders including mental health professionals, service users and community and voluntary organizations. The findings of the research have utility in the areas of theory and policy development, research on service user involvement in mental health care and service user involvement in mental health practice. Directions for further research regarding the concept are identified.

An analysis of the Research Team-Service User relationship from the Service User perspective: a consideration of 'The Three Rs' (Roles, Relations, and Responsibilities) for healthcare research organisations

BACKGROUND

This article debates interview data from service users who engaged with the work of a Collaboration for Leadership in Applied Health Research and Care (CLAHRC). The evidence base, to date, concerning the nature of CLAHRC work at the frontline (i.e. What is it actually like to do CLAHRC work?) is meagre; thus, this article represents an original contribution to that literature. Further, this article analyses service users' participation in research - as members of the research team - and so contributes to the body of developing literature regarding involvement too.

OBJECTIVE

This article explores the nature of the Research Team-Service User relationship, plus associated roles, relations and responsibilities of collaborative health research.

DESIGN

Qualitative social science research was undertaken in a health-care research organization utilizing interview method and a medical sociology and organizational sociology theoretical framework for analysis. Data utilized originate from a larger evaluation study that focuses on the CLAHRC as an iterative organization and explores members' experiences.

RESULTS

There can be a disparity between initial expectations and actual experiences of involvement for service users. Therefore, as structured via 'The Three Rs' (Roles, Relations and Responsibilities), aspects of the relationship are evaluated (e.g. motivation, altruism, satisfaction, transparency, scope, feedback, communication, time). Regarding the inclusion of service users in health research teams, a careful consideration of 'The Three Rs' is required to ensure expectations match experiences.

User and researcher collaborations in mental health in low and middle income countries: a case study of the EMPOWER project

BACKGROUND

Increasing recognition has been given to the interaction of users and researchers in shaping the perspective and practice of mental health care. However, there remains very little evidence exploring how this interaction works, particularly in low and middle income countries. The aim of this study was to explore experiences of how users and researchers worked together to communicate research, using a case study of the EMPOWER project.

METHODS

The study followed a case-study approach. EMPOWER was a project that sought to strengthen the capacity of user organizations in India, Kenya, Nepal and Zambia by encouraging user-researcher collaborations to communicate research findings in the four countries. A qualitative research method was applied for this study, with semi-structured interviews conducted with seven people: two researchers, one communications developer, and four user group members (one from each of the four countries). Data were analyzed using thematic analysis.

RESULTS

The findings indicated positive perceptions of the collaboration between researchers and users. Key themes were partnership and support, the value of the personal experience of users and their knowledge of the target audiences, and empowerment. Key challenges related to differences in levels of education and technical knowledge and the lack of payments to users.

CONCLUSIONS

This exploratory study provides insight to help understand collaborative processes for communicating mental health research. It highlights many positive outcomes from the EMPOWER collaboration but also highlights the need for more in-depth research on this issue.

Barriers to the participation of people with psychosocial disability in mental health policy development in South Africa: a qualitative study of perspectives of policy makers, professionals, religious leaders and academics

BACKGROUND

This paper outlines stakeholder views on environmental barriers that prevent people who live with psychosocial disability from participating in mental health policy development in South Africa.

METHOD

Fifty-six semi-structured interviews with national, provincial and local South African mental health stakeholders were conducted between August 2006 and August 2009. Respondents included public sector policy makers, professional regulatory council representatives, and representatives from non-profit organisations (NPOs), disabled people's organisations (DPOs), mental health interest groups, religious organisations, professional associations, universities and research institutions.

RESULTS

Respondents identified three main environmental barriers to participation in policy development: (a) stigmatization and low priority of mental health, (b) poverty, and (c) ineffective recovery and community supports.

CONCLUSION

A number of attitudes, practices and structures undermine the equal participation of South Africans with psychosocial disability in society. A human rights paradigm and multi-system approach is required to enable full social engagement by people with psychosocial disability, including their involvement in policy development.

Consumer participation in a youth mental health service

AIM

Consumer participation is increasingly being understood in both a policy and a practice context as an essential component of mental health service planning, delivery and evaluation. Existing models of participation benefit from adaptation to suit the early intervention context.

METHODS

This paper describes a unique programme of 'youth' consumer participation occurring at Orygen Youth Health (OYH)--an early intervention service in Melbourne, Australia. Flexibility and support are key components of the model. As well as supporting increased consumer-centredness of service delivery, the model aims to support the recovery of those involved in participation activities.

RESULTS

The programme described is comprehensive, multimodal, continues to evolve and is successful based on anecdotal feedback. However, there are no evaluation data to support its attainment of outcomes.

CONCLUSION

Consumer participation is an essential part of mental health service development, delivery and evaluation and must be incorporated into early intervention services. As programmes of participation evolve, comprehensive models of evaluation must be developed to acknowledge their outcomes.

Lone voices have an emotional content: focussing on mental health service user and carer involvement

PURPOSE

The purpose of this paper is to describe learning gained from involving service users and carers as researchers in an action research study. The researchers aimed to introduce self-directed support in mental health services--part of the government's personalisation agenda, which requires a move from current social care commissioning, where a person is matched to available services, to one where a person self-assesses, has an agreed support plan and then with appropriate help, purchases his or her own services to lead as independent a life as possible. This development is allied closely with the mental health service recovery approach.

DESIGN/METHODOLOGY/APPROACH

Three service users and two carers were recruited to work alongside the lead researcher. Service users were fully involved in the steering group - part of participatory action research project. Data were collected from: debriefing meetings with co-researchers between April and December 2007; a group interview held by the lead researcher; and participants' journal comments and self-reflections.

FINDINGS

The main areas in which service users and carers found involvement difficult were: overcoming professional language barriers; emotional impact; and power imbalances between themselves and professionals. Findings suggest that considerable improvement is required by mental health professionals and managers if service users and carers are successfully involved in projects.

RESEARCH LIMITATIONS/IMPLICATIONS

This is a small study within a larger action research project. Findings are not generalisable owing to the small sample; however, findings are supported by the service-user involvement literature.

ORIGINALITY/VALUE

Few studies explore participation effects on service users and carers from their perspective. This research provides insights into what needs to be addressed to improve service user and carer involvement to improve mental health services.

Understanding consumer participation in mental health: Issues of power and change

Consumer participation occurs in all Victorian public mental health services. Area mental health services employ consumer consultants to enhance consumer participation across the network. Ongoing support of management is essential to the success of consumer participation. This project aimed to explore understandings of consumer participation from a manager's perspective. Semistructured interviews were conducted with seven participants in this qualitative, interpretive study. The thematic analysis revealed the complexities around defining consumer participation and demonstrated the difficulties and possible reasons as to why there is no real clarity between managers, service providers, and consumers as to what consumer participation should look like. Power and change were the primary themes. Power and the overwhelming consensus that the medical model and those working within it hold the most power was strongly represented in this study. Legislation and workplace settings were seen as considerable factors adding to the disempowerment of consumers within an already disempowering mental health system. Change was the other main theme that emerged, with culture and attitudes of the old 'institutionalized' thinking that still pervades some pockets of mental health services being seen as the major barriers to change. The role of the consumer consultant was a prominent subtheme, with their role in training and the education of workers seen as an essential and positive way to progress consumer participation. These findings demonstrate that managers consider there to be hope for consumers, brought about by collective action and lobbying, and through consumer participation in less-restrictive parts of the service (community settings).

Social representations and professional knowledge: The representation of mental illness among mental health practitioners

The closing decades of the twentieth century saw a dramatic shift from institutional to community-based care for the mentally ill. This paper describes a study of the social representation of mental illness by mental health professionals working in Britain and France during this time of major policy change. Such professionals play a vital social role in translating policy directives into practical work with laypeople, yet their representations are relatively under-researched. Data in this study derive from semistructured interviews on the nature of mental ill-health and mental health work conducted with a multidisciplinary sample of professionals (N=60). Consonant with community care policies, analysis suggests that professionals conceptualize mental ill-health and its treatment in social rather than medical terms. However, uncertainty characterizes many aspects of their representations. This is associated with eclectic working practices combining multiple strategies derived from diverse theoretical traditions. The changing policy context appears to have augmented this representational uncertainty. Psychodynamic perspectives are more influential amongst French practitioners compared with their British counterparts. The study highlights how social representations held by 'intermediary' groups reflect their interface between scientific and lay spheres. The role of power and the function of social representations in reconciling sources of tension and ambiguity associated with this unique social position are discussed.

Health researchers' attitudes towards public involvement in health research

OBJECTIVE

To investigate health researchers' attitudes to involving the public in research.

BACKGROUND

Public involvement in research is encouraged by the Department of Health in the UK. Despite this, the number of health researchers actively involving the public in research appears to be limited. There is little research specifically addressing the attitudes of health researchers towards involving the public: how they interpret the policy, what motivates and de-motivates them and what their experiences have been to date.

DESIGN

A qualitative research design, using semi-structured telephone interviews.

SETTING AND PARTICIPANTS

Fifteen purposively sampled UK-based University health researchers were the participants. Interviews were conducted over the telephone.

FINDINGS

The participants suggested varying constructions of public involvement in research. Arguments based on moral and political principles and consequentialist arguments for involving the public in research were offered and most participants highlighted the potential benefits of involving the public. However, feelings of apprehension expressed by some participants imply that a number of researchers may still be uncomfortable with involving the public, as it presents a different way of working.

Improving acute psychiatric hospital services according to inpatient experiences. A user-led piece of research as a means to empowerment

This paper has been undertaken by people with experience with mental health issues and mental health care systems. The aim of the research was to explore psychiatric inpatients' strategies for coping with mental ill health and in what ways acute inpatient psychiatric hospital services are facilitative to the individual attempting recovery. Ten focus groups were facilitated and data were analysed through systematic content analysis. Findings revealed that the main areas of concern for inpatients were: information, communication, relationships, activities, self-help, patient involvement in care treatment plans, and the physical environment. The authors also make a case to improve the status of user-led research as a means to understand the needs of mental health service users.

The participation of mental health service users in Ontario, Canada: a Canadian Application of the Consumer Participation Questionnaire

BACKGROUND

Ontario mental health policy calls for the participation of service users in mental health organizations, but no studies have examined the extent to which this is occurring.

AIMS

This study measures the extent to which service users participate in Ontario, Canada community mental health organizations and measures the attitudes toward service user participation in planning and in employment.

METHODS

Members of the Ontario Federation of Community Mental Health and Addictions Programs were invited to participate in a modified form of the Consumer Participation Questionnaire, created by Kent and Read (1998) for New Zealand.

RESULTS

Participation in Ontario community mental health organizations was present in this order: planning, membership on boards of directors, attendance at staff training, policy, staff hiring, and teaching at staff training. Compared with New Zealand, the prevalence of participation was higher in Ontario, but attitudes toward participation were similar. The role with the highest prevalence of participation, planning, was the same for both locations.

CONCLUSIONS

An updated New Zealand study is called for, as is a more continuous method that includes various voices for measuring participation.

'Listen to my madness': understanding the experiences of people with serious mental illness

This article explores the salience of disability theory for understanding the experiences of people with serious mental illness. Drawing on data from a focus group study, we suggest that users experience both impairment (as embodied irrationality) which can, in itself, be oppressive, and also have to manage their lives within a largely disabling society. We outline some of the strategies adopted by users to manage their situation and ensure they access and receive health services, and illustrate how these are a result of the complex relationship between disability and impairment. We suggest that using a framework of the social model of disability provides a useful way of understanding and making sense of the experience of users with serious mental illness.