Institutional injustice: Implications for system transformation emerging from the mental health recovery narratives of people experiencing marginalisation

Taking what you get or Getting what you Need: A Qualitative Study on Experiences with Mental Health and Welfare Services in Long-Term Recovery in First-Episode Psychosis

How people in long-term recovery (clinical and personal) in first-episode psychosis (schizophrenia and bipolar spectrum disorders) experience the mental health and welfare services they interact with is not frequently studied but has significant implications. We therefore aimed to explore which aspects of these services people with FEP evaluate as important for their long-term recovery. Twenty participants in clinical and/or personal recovery from two Norwegian long-term follow-up studies after FEP (TOP 10-year and TIPS 20-year) were sampled for this interview-based qualitative study. The research-team included service user experience. A deductive analysis based on personal accounts of recovery generated five service aspects. Few specific types of interventions were reported to promote recovery although medications, psychotherapy and employment support were mentioned. Participants valued services based in collaboration and that focused on their resources rather than limitations. The importance of long-term follow-up with a consistent aim was highlighted, as was the inclusion of caregivers and peers. Welfare services contributed to recovery by supporting basic needs and safety, but some experienced social exclusion when not participating in the labor market. This study is unique in exploring the role of services, including welfare, in long-term FEP recovery from service user perspectives. Participants evaluated that services played a more indirect role in long-term recovery by supporting their personal resources, although what they needed from services had frequently not been offered. Their expertise by experience contributes valuable knowledge. Better service coordination and consistent implementation of this knowledge are crucial to support recovery in FEP.

Humanism and Psychosis: Working With Patients Who Have Potential Medical Comorbidities Along With Mental Illness

Marginalized groups, such as Black participants experiencing homelessness and diagnosed with schizophrenia, often face significant barriers to care. Improvements in treatment can be achieved by incorporating patient views, addressing stigmas, avoiding medical jargon, respecting patient preferences, and demonstrating transparency and positive affect. We discuss one example in our case report where a newly unhoused woman with schizophrenia, highlighting the impact of medical mistrust, discrimination, and ineffective communication in mental health care. We retrospectively used the Brief Psychiatric Rating Scale (BPRS) score to assess the severity of the patient's psychiatric condition after her workup. The severity of the BPRS scale is graded as mild (31-40 total score), moderate (41-52 total score), and severe (above 52 total score). Using this scale and our case report, we aim to highlight the importance of emphasizing the rationale of the plan of care to patients, explaining their diagnoses, and reasoning of diagnostics without using medical jargon.

Discourses of compassion from the margins of health care: the perspectives and experiences of people with a mental health condition

BACKGROUND

Evidence supports the positive influence of compassion on care experiences and health outcomes. However, there is limited understanding regarding how compassion is identified by people with lived experience of mental health care.

AIM

To explore the views and experiences of compassion from people who have lived experience of mental health.

METHODS

Participants with a self-reported mental health condition and lived experience of mental health (n = 10) were interviewed in a community setting. Characteristics of compassion were identified using an interpretative description approach.

RESULTS

Study participants identified compassion as comprised three key components; 'the compassionate virtues of the healthcare professional', which informs 'compassionate engagement', creating a 'compassionate relational space and the patient's felt-sense response'. When all these elements were in place, enhanced recovery and healing was felt to be possible. Without the experience of compassion, mental health could be adversely affected, exacerbating mental health conditions, and leading to detachment from engaging with health services.

CONCLUSIONS

The experience of compassion mobilises hope and promotes recovery. Health care policymakers and organisations must ensure services are structured to provide space and time for compassion to flourish. It is imperative that all staff are provided with training so that compassion can be acquired and developed.

A Qualitative Exploration of Institutional Betrayals in Rural Communities: An Emerging Typology

To explore individuals' personal narratives of perceived betrayals and injustices committed by institutions, their representatives, or other authority figures and discern in what spheres of life they commonly manifest. 157 adults from largely rural, low-income communities in southern Appalachia participated in semi-structured qualitative interviews that asked them to describe key points in their life experiences, including high points, low points, and turning points. These were reviewed for episodes of institutional betrayals. Interview transcripts were analyzed using a grounded thematic analysis. Participants mentioned numerous instances of betrayals that occurred from interactions with institutions or their representatives. These were grouped into four categories: professional betrayals involving mistreatment from an employer, health care provider, or other authority figure; professional-organizational betrayals where a professional perpetrator was able to get support from a problematic organizational culture; corporate malfeasance involving misdeeds by business entities; and systemic injustices involving the sociopolitical architecture of society. The findings identified a range of institutional betrayal experiences that were unnecessary, unwanted, intentional, and harmful. They could be distinguished by the type of perpetrators and often led to notable harms, including unwanted system involvement and unemployment. Although participants seldom explicitly mentioned the rural setting in their descriptions of institutional betrayal, it is likely that limited options for health care providers, schools, and other institutions exacerbated some harms. Institutional betrayals need to be considered in people's trauma dosage, their cumulative lifetime burden of trauma.

A systematic review of client’s perspectives on the cultural and racial awareness and responsiveness of mental health practitioners

Culturally and racially responsive practice continues to be a common challenge among Mental Health Practitioners (MHPs). To the authors’ knowledge, this systematic review was the first to collate and synthesize clients’ perspectives of MHPs’ cultural and racial awareness and responsiveness from around the world. Original studies that were published between 2010 and 2021 reporting on qualitative data about clients’ perspectives regarding MHPs’ cultural-racial awareness and responsiveness were included in the review. The studies’ key findings that addressed this review’s question were synthesized and analyzed using reflexive thematic analysis. This review found 48 papers that met inclusion criteria, which represented the views of 652 clients across 10 countries. Three major themes and eight subthemes were established that concerned characteristics of the MHP, the client, and the therapeutic alliance. The results of this review indicate individual and systemic factors that influence mental health access for people from culturally and racially marginalized groups. Ongoing training of MHPs, increased racial and cultural representation among MHPs, inclusive physical settings, and reduced discrimination by MHPs are among the key findings and directions based on the results of this review.

Psychiatry and/or recovery: a critical analysis

This perspective paper aims to present a personal viewpoint on the impact of psychiatric discourse on the principles of recovery in mental health care. Mental health services espouse these principles, yet psychiatric discourse remains the dominant model. A critical analysis will examine how psychiatry maintains this dominance. The aim is to examine how psychiatric discourse constructs both the nature of mental distress and its treatment, and how it maintains its power as the dominant authority and its relationship to recovery principles. The paper concludes that psychiatric discourse is the antithesis of recovery principles and that its authority is perpetuated through co-opting a medical explanatory model, claiming expertise in the ability to predict social risk, and maintaining a tightly controlled echo chamber. A way forward involves the dismantling of the hierarchical service delivery model based on psychiatric discourse and replacing it with a more horizontal service delivery model in which the lived experience of mental distress is central. Regular audit of services needs to prioritize recovery principles. The implications for mental health nursing are considered.

Decolonising medical knowledge - The case of breast cancer and ethnicity in the UK

National and global efforts have led to significant improvements in breast health and diagnosis, globally (Lukong, 2017). These achievements, however, are not even. Focusing on the case of breast cancer in the UK, we argue that enduring forms of medical racism leave Black women more vulnerable to advanced forms of the disease, explaining higher mortality rates and later-stage diagnosis. In particular, we show how a lack of dedicated policy, inadequate data collection, and a lack of representation conspire to place Black women at additional and unnecessary risk of worse breast cancer outcomes. We thus propose key recommendations to address the ethnic disparities in and make steps to decolonise breast cancer care. These are early screening for at-risk groups, community-led interventions, and more and better representation of Black women and their risks in breast cancer resources.

'Maybe I Shouldn't Talk': The Role of Power in the Telling of Mental Health Recovery Stories

Mental health 'recovery narratives' are increasingly used within teaching, learning and practice environments. The mainstreaming of their use has been critiqued by scholars and activists as a co-option of lived experience for organisational purposes. But how people report their experiences of telling their stories has not been investigated at scale. We present accounts from 71 people with lived experience of multiple inequalities of telling their stories in formal and informal settings. A reflexive thematic analysis was conducted within a critical constructivist approach. Our overarching finding was that questions of power were central to all accounts. Four themes were identified: (1) Challenging the status quo; (2) Risky consequences; (3) Producing 'acceptable' stories; (4) Untellable stories. We discuss how the concept of narrative power foregrounds inequalities in settings within which recovery stories are invited and co-constructed, and conclude that power imbalances complicate the seemingly benign act of telling stories of lived experience.

Experiences of racism and postpartum depression symptoms, care-seeking, and diagnosis

Postpartum depression (PPD) is common and disproportionately affects people of color. Experiences of emotional upset due to racism (EUR) may be an important predictor of PPD outcomes. Therefore, we aimed to determine if EUR during the 12 months before delivery was associated with PPD symptomology, asking for help for depression, and depression diagnosis among postpartum people of color (PPOC). We conducted a cross-sectional secondary data analysis among PPOC from 11 states and New York City using PRAMS data, 1/1/2015-12/31/2017. We assessed symptomology using an unvalidated PHQ-2. Logistic regression was performed without and with stratification by ethnicity (non-Hispanic PPOC vs Hispanic PPOC) to estimate whether EUR during 12 months before delivery was associated with (1) PPD symptoms, (2) asking for help for depression, and (3) depression diagnosis. Models adjusted for age, educational attainment, timely prenatal care, payment method, stress during pregnancy, and pre-pregnancy depression. Seventy-four thousand nine hundred nine (11.8%) PPOC reported EUR in the 12 months before delivery. After adjustment, EUR was associated with a 10.3 percentage point (%pt; 95% CI: 6.8, 13.8), 13.6%pt (95% CI: 8.8, 18.5), and 4.1%pt (95% CI: 1.4, 8.0) higher probability of positive PPD screening among all PPOC, non-Hispanic PPOC, and Hispanic PPOC, respectively. EUR was not associated with asking for help for depression but was associated with a higher prevalence of depression diagnosis among all PPOC (4.6%pt; 95% CI: 1.0, 8.4) and non-Hispanic PPOC (6.0%pt; 95% CI: 0.8, 11.2).Experiences of EUR are associated with an increased prevalence of PPD symptoms. Additional prospective research spanning the pre-pregnancy through postpartum periods is needed to examine the dynamic relationship between racism, symptomology, help-seeking, and diagnosis of depression.

A Systematic Review of Inequalities in the Mental Health Experiences of Black African, Black Caribbean and Black-mixed UK Populations: Implications for Action

BACKGROUND

Measurable differences in the experience and treatment of mental health conditions have been found to exist between different racial categories of community groups. The objective of this research was to review the reported mental health of Black African-Caribbean communities in the UK, determinants of mental health, and interventions to enhance their experiences of mental health services.

METHOD

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement was applied. To be included, papers must be published in a peer reviewed journal; report on adult populations (over 18) from any of Black African, Black Caribbean or Black mixed people in the UK; and assess (quantitative), or discuss (qualitative) mental health experiences, determinants of mental health, or interventions intended to enhance experiences of mental health services among the target population. The aims, inclusion criteria, data extraction, and data quality evaluation were specified in advance. Searches were conducted using EBSCO (PsychInfo; MEDLINE; CINAHL Plus; psychology and behavioural sciences collection). The search strategy included search terms relating to the aim. Risk of bias was assessed using a standard tool, records were organised using Endnote, and data were extracted and synthesised using Microsoft Excel.

RESULTS

Thirty-six studies were included, of which 26 were quantitative and six reported exclusively on Black participants. Black populations were less likely to access mental health support via traditional pathways due to stigma and mistrust of mental health services. Black Africans especially, sought alternative help from community leaders, which increased the likelihood of accessing treatment at the point of crisis or breakdown, which in turn increased risk of being detained under the Mental Health Act and via the criminal justice system.

DISCUSSION

Findings suggest a cycle of poor mental health, coercive treatment, stigma, and mistrust of services as experienced by Black communities. Evidence was limited by poorly defined ethnic categories, especially where Black populations were subsumed into one category. It is recommended that mental health services work collaboratively with cultural and faith communities in supporting Black people to cope with mental illness, navigate mental health pathways, and provide culturally appropriate advice. Protocol Registration Number PROSPERO CRD42021261510.

Older forensic mental healthcare patients in England: demographics, physical health, mental wellbeing, cognitive ability and quality of life

Background

Older individuals (e.g., 55 years and over) constitute a growing proportion of the forensic mental health patient population. As a group, they are vulnerable to health outcomes similar to other individuals with serious mental disorders of the same age; however, these concerns can be compounded by complex forensic-related care backgrounds and clinical presentations, lengthy periods of time spent in prison or psychiatric hospitals, substance use histories, and crime perpetration or victimisation. The healthcare needs and strengths of this group are not well understood.The aim of this study was to identify and describe the demographic, physical health, mental wellbeing, cognitive ability, and quality of life profiles of older forensic patients in community, low, medium, and high security settings in England.

Methods

A cross-sectional quantitative study design was used. N=37 forensic patients aged 55 years and over completed six questionnaires. Data were also collected from patient records.

Results

Most patients were male and were diagnosed with psychosis. The most frequently committed index offence types were violent offences. Patients were prescribed 7.6 medications on average and had average anticholinergic effect on cognition scores of 2.4. Nearly half the sample had diabetes, with an average BMI score of 31.7 (indicating obesity). Possible cognitive impairment was identified in 65% of the sample. Patients' assessments of their recovery-related quality of life and mental wellbeing were comparable to published UK general population values. Assessments of quality of life were positively correlated with the ability to undertake everyday activities and cognitive performance.

Conclusions

We suggest that forensic services are well-placed to provide holistic mental and physical care to this group but that they should co-develop with patients a greater range of age-appropriate meaningful activities that are mindful of mobility issues and consider implementing more cognition-based and physical health interventions.

Development and delivery cost of digital health technologies for mental health: Application to the Narrative Experiences Online Intervention

BACKGROUND

The increasing development and use of digital health interventions requires good quality costing information to inform development and commissioning choices about resource allocation decisions. The Narrative Experiences Online (NEON) Intervention is a web-application that delivers recorded mental health recovery narratives to its users. Two randomized controlled trials are testing the NEON Intervention in people with experience of psychosis (NEON) and people experiencing non-psychosis mental health problems (NEON-O).

AIM

This study describes and estimates the cost components and total cost of developing and delivering the NEON Intervention.

MATERIALS AND METHODS

Total costs for the NEON Trial (739 participants) and NEON-O Trial (1,024 participants) were estimated by: identifying resource use categories involved in intervention development and delivery; accurate measurement or estimation of resource use; and a valuation of resource use to generate overall costs, using relevant unit costs. Resource use categories were identified through consultation with literature, costing reporting standards and iterative consultation with health researchers involved in NEON Intervention development and delivery. Sensitivity analysis was used to test assumptions made.

RESULTS

The total cost of developing the NEON Intervention was £182,851. The largest cost components were software development (27%); Lived Experience Advisory Panel workshops (23%); coding the narratives (9%); and researchers' time to source narratives (9%). The total cost of NEON Intervention delivery during the NEON Trial was £118,663 (£349 per NEON Intervention user). In the NEON-O Trial, the total delivery cost of the NEON Intervention was £123,444 (£241 per NEON Intervention user). The largest cost components include updating the narrative collection (50%); advertising (19%); administration (14%); and software maintenance (11%). Uncertainty in the cost of administration had the largest effect on delivery cost estimates.

CONCLUSION

Our work shows that developing and delivering a digital health intervention requires expertise and time commitment from a range of personnel. Teams developing digital narrative interventions need to allocate substantial resources to curating narrative collections.

IMPLICATIONS FOR PRACTICE

This study identifies the development and delivery resource use categories of a digital health intervention to promote the consistent reporting of costs and informs future decision-making about the costs of delivering the NEON Intervention at scale.

TRIAL REGISTRATION

NEON Trial: ISRCTN11152837, registered 13 August 2018, http://www.isrctn.com/ISRCTN11152837. NEON-O Trial: ISRCTN63197153, registered 9 January 2020, http://www.isrctn.com/ISRCTN63197153.

Management of a High-Performing Mental Health Recovery Research Group

A personal perspective is given on the processes involved in managing and sustaining a high-performing mental health recovery research group. The broader context of scholarship in the United Kingdom is outlined, in which academic productivity is commodified specifically in relation to peer-reviewed journal papers. Four leadership choices in developing a high-performing research group are discussed: optimal group size; sharing the workload; maintaining a programmatic focus; and performance expectations. Approaches to maximising innovation are identified, including emotional and intellectual engagement of team members, working with diverse stakeholders and convening communities of practice. We use a highly managed approach to publications from inception to acceptance, which is described in detail. The use of these approaches is illustrated in relation to the Recovery Research Team which was formed in 2009. Specific recovery-related issues covered include demonstrating the ability to develop a significant recovery research portfolio (our four current large [>UK£2 m] studies relate to recovery narratives, global mental health peer support work, digital interventions and Recovery Colleges); the positive implications of actively recruiting researchers with mental health lived experience; how performance issues are managed; our approach to involving lived experience co-authors in papers; and our decision to conduct mixed-methods rather than solely qualitative studies.